Table 2.
Comparison of AHA 2017, AHA 2025, and ESC 2024 hypertension guidelines, with a focus on patients with diabetes
| AHA/ACC 2017 | AHA/ACC 2025 | ESC 2024 | |
|---|---|---|---|
| Hypertension definition | ≥ 130/80 mmHg | ≥ 130/80 mmHg | ≥ 140/90 mmHg |
| Elevated BP / prehypertension | 120–129/<80 mmHg | 120–129/<80 mmHg | 130–139/85–89 mmHg (lifestyle intervention only) |
| BP treatment initiation for diabetes | ≥ 130/80 mmHg with cardiovascular risk or organ damage | ≥ 130/80 mmHg with cardiovascular risk or organ damage | ≥ 140/90 mmHg; 130–139/80–89 mmHg if high CV risk (lifestyle first, meds if insufficient) |
| BP target in treated diabetics | < 130/80 mmHg | < 130/80 mmHg (individualized in frail/older adults) | 130–139/70–79 mmHg (lower systolic for younger/high-risk, relax in older/frail) |
| Preferred first-line agents | ACEi or ARB (especially with albuminuria) | ACEi or ARB (with albuminuria/CKD); Thiazide-like diuretics and CCBs as add-on | ACEi or ARB; CCB or diuretics as add-on; combination therapy encouraged |
| Intensive therapy evidence | ACCORD-BP, SPRINT (non-diabetic included) | ACCORD-BP, meta-analyses support intensive control (< 130 mmHg) | ACCORD-BP, meta-analyses; recommend less aggressive in elderly/frail |
| Lifestyle modification emphasis | DASH diet, sodium restriction, weight loss, physical activity | DASH-like diet, sodium restriction, weight loss, exercise, alcohol moderation, smoking cessation | Similar: DASH, sodium restriction, weight management, exercise, alcohol moderation, smoking cessation |
| Home/ambulatory BP monitoring | Recommended for white-coat/masked hypertension | Strongly recommended, including ABPM for nighttime BP | Recommended, especially for masked/white-coat hypertension |
| Hypotension / adverse events caution | Individualize in elderly/frail | Individualized targets to avoid hypotension, falls, AKI | Strong emphasis on safety in older adults, frail, CKD, autonomic neuropathy |
| Integration with CV risk management | Lifestyle + pharmacologic therapy integrated with glycemic and lipid control | Strong emphasis on multimodal risk reduction (BP, lipids, glucose, lifestyle) | Similar, risk-based approach, slightly more conservative BP targets |
Key takeaways:
• Both AHA 2017 and 2025 use 130/80 mmHg as diagnostic and treatment thresholds, whereas ESC 2024 retains a higher threshold for initiation (140/90 mmHg)
• AHA 2025 reinforces individualized therapy, particularly in older or frail patients
• All guidelines emphasize ACEi/ARB in diabetes, lifestyle interventions, and use of combination therapy if targets are not achieved
• Home and ABPM monitoring are highlighted in 2025 more strongly than in 2017, reflecting an emphasis on precise BP control and identification of masked hypertension
• ESC guidelines remain more conservative, prioritizing safety in the elderly while recognizing the value of earlier intervention in high-risk patients