The Hypertension Editors’ View of the 2025 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults

This issue of Hypertension features the 2025 ACC/AHA Guideline for the Diagnosis and Treatment of Hypertension, developed by the Joint Committee on Clinical Practice Guidelines in collaboration with major stakeholders in healthcare and hypertension management.¹ This document is essential reading for physicians and health care providers who care for patients with hypertension and related conditions, as it not only updates state-of-the-art evidence-based care, but also explores emerging concepts in the pathophysiology of the disease. Several important and unique aspects of this Guideline warrant emphasis, particularly in terms of risk assessment, treatment recommendations, and implementation. The 2025 ACC/AHA Guideline replaces the 2017 iteration, with some new and some revised recommendations from the previous version.

One of the major new recommendations in the 2025 Guideline is the emphasis on screening for hyperaldosteronism in all patients with resistant hypertension, regardless of their serum potassium levels. This reflects the growing evidence that up to one-third of patients with resistant hypertension have hyperaldosteronism and could benefit from targeted interventions, including surgical procedures or pharmacological therapies that interrupt the aldosterone pathway. Guidelines for diagnosing hyperaldosteronism have been published elsewhere,^{2, 3} and initial screening typically involves measuring aldosterone, renin and potassium levels. Interestingly the 2024 European Society of Cardiology Guideline for the management of elevated blood pressure and hypertension,⁴ and the 2025 Endocrine Society primary aldosteronism clinical practice guideline,² recommend that all patients with hypertension, not just those with resistant forms, be screened for hyperaldosteronism. This broader approach highlights the underdiagnosis of the condition and its known contribution to poorly controlled and resistant hypertension.

Another important new recommendation relates to renal denervation (RDN) as a therapeutic option in patients with resistant hypertension. Patients who are being considered for RDN need to be evaluated by a multidisciplinary team with expertise in resistant hypertension and RDN. Patients need to be informed of the potential procedural risks and decisions need to be shared between patients and their physician in selecting RDN as an alternative to medical therapy.

The latest Guideline also includes new recommendations focused on specific patient groups, including those with acute intracerebral hemorrhage, pregnancy, hypertensive emergencies, and severe hypertension in non-pregnant, non-stroke patients. Readers are directed to the full text for further details.¹

A major update in the 2025 Guideline is the emphasis that treating patients with hypertension involves ‘risk management’. In the new Guideline the Predicting Risk of cardiovascular disease EVENTs (PREVENT) calculator is employed, which replaces the widely used Pooled Cohort Equation (PCE). Estimating risk with the PREVENT calculator helps in determining whether pharmacological treatment should be initiated for patients with Stage 1 hypertension (systolic pressures between 130 to 140 mmHg). The PREVENT score calculator offers several advantages over the PCE,⁵ including the incorporation of body mass index (BMI), a broader age range (39 – 70 years), and more detailed estimates of renal function. These changes reflect the increased recognition of renal dysfunction as a significant cardiovascular risk factor and highlight the need for earlier intervention in patients with compromised renal health. Notably, the PREVENT score calculator does not include race as a determinant, addressing longstanding concerns about the equity and appropriateness of race-based metrics in clinical care. Likewise, recommendations for treatment of self-identified black race patients are absent in the new Guideline, simplifying therapeutic decisions. According to the 2025 Guideline, patients with stage 1 hypertension and a 10-year cardiovascular risk of less than 7.5%, as defined by PREVENT, should initially be treated with lifestyle modifications for 3 to 6 months. Conversely, patients with a risk greater than 7.5% should receive pharmacological therapy in conjunction with lifestyle changes. The PREVENT risk calculator thus identifies those who require immediate drug therapy and helps guide timing for ultimate pharmacological therapy for those with stage 1 hypertension. An important new recommendation is that combination drug therapy be initiated for stage II hypertension (BP ≥ 140/90 mmHg).

Lifestyle modifications remain a cornerstone of hypertension management, with the Guideline stressing their importance for both hypertensive and non-hypertensive individuals. A new recommendation focuses on potassium-based salt substitutes and a potassium-rich diet, especially in patients on a high salt diet, and who do not have chronic kidney disease. Other lifestyle modifications include limiting sodium intake, engaging in regular physical activity, achieving or maintaining a near-normal body weight, and reducing or eliminating alcohol consumption. In patients with severe obesity, weight loss can be particularly effective in controlling blood pressure and may require interventions such as GLP-1 receptor agonists or bariatric surgery. The new Guideline highlights the increasingly recognized role of these interventions in managing both obesity and hypertension.

The first-line medications for treating hypertension remain largely unchanged from the 2017 guideline. These include thiazide-like diuretics, dihydropyridine calcium channel blockers, and either ACE inhibitors or angiotensin receptor blockers. The 2017 Guideline did not specify the dihydropyridine class of calcium channel antagonists, thus their specification in the 2025 Guideline reflects an important refinement. The 2025 Guideline emphasizes use of single-pill combinations, which have been shown to improve medication adherence and simplify treatment regimens.⁶ While the polypill—a combination of antihypertensive agents and other cardiovascular drugs (e.g. beta blockers and aspirin), is not specifically mentioned in the Guideline, it remains a promising option for secondary prevention of cardiovascular disease and improved compliance.

Effective implementation of the latest Guideline requires a team-based care approach. Thus, treatment of hypertension is no longer the sole responsibility of individual physicians. Instead, it involves collaboration among a multidisciplinary team that includes pharmacists, dietitians, nurses, physician extenders, and community health workers. The Guideline advocates for partnerships with community leaders, health departments, and organizations such as churches to improve public awareness, facilitate blood pressure screenings, and promote adherence to treatment protocols. Moreover, the use of home blood pressure monitoring is strongly encouraged, as it provides valuable insights into the effectiveness of treatment, engages patients in their care, and offers actionable data for the healthcare team. Home blood pressure devices should be validated.

Despite the advances in knowledge reflected by the new Guideline, significant challenges remain in implementing these in clinical practice effectively. Many patients are still not prescribed first-line medications, fail to achieve target blood pressure levels, or have undiagnosed underlying conditions such as hyperaldosteronism. For example, there are clearly huge numbers of subjects that should be screened for hyperaldosteronism, yet only a small fraction of these individuals is currently evaluated. Resource constraints are a significant barrier, as hypertension management is not a lucrative area of healthcare, making it difficult to fund the teams of screeners, nurses, and pharmacists needed to implement the guidelines. Additionally, some physicians believe they can manage hypertension adequately without adopting multidisciplinary approaches, leading to suboptimal care. Addressing these barriers will require greater education, outreach, and investment in hypertension screening and management infrastructure.

Certain topics were notably absent from the 2025 Guidelines, reflecting gaps in current knowledge and clinical application. For example, despite decades of research into the genetic underpinnings of hypertension, little progress has been made in translating genetic findings into diagnostic or therapeutic tools.⁷ Similarly, while the gut microbiome has garnered substantial interest in the hypertension field,⁸ its clinical relevance remains speculative, and further research is needed to determine whether microbiome analysis or manipulation will become part of routine care. Finally, the Guideline does not yet incorporate several promising new drug classes, including aldosterone synthase inhibitors, non-steroidal mineralocorticoid receptor antagonists, endothelin receptor antagonists, and small interfering RNA therapies. These emerging treatments have the potential to reshape hypertension management and will likely influence future updates to the Guideline. In this regard, the Guideline writing committee will evaluate evidence from new clinical trials and update their recommendations when appropriate without waiting for the next Guideline. Ideally these updates will be published and highlighted in Hypertension.

The 2025 ACC/AHA Hypertension Guideline represents a significant step forward in the diagnosis and management of hypertension. It emphasizes the importance of individualized risk assessment, the adoption of team-based care, and lifestyle interventions as foundational elements of treatment. However, challenges in implementation and gaps in research highlight the need for ongoing efforts to improve hypertension care and prevent its devastating consequences. With proper treatment and adherence, most patients can achieve target blood pressure levels. For those who do not, additional evaluation and more advanced interventions will be essential to optimize outcomes.