Blood Pressure Guidelines Updates 2025

The American Heart Association (AHA) and the American College of Cardiology (ACC) released new high blood pressure (BP) guidelines for adults in August 2025.  Many updates and changes have occurred, although the definitions of normal, elevated, and stage 1 and 2 hypertension are the same.   The new guidelines focus on the latest scientific data and emphasize earlier treatment and tighter control of BP.  The heart, brain, and kidneys all benefit from starting blood pressure treatment earlier and having lower targets.

The message now is much stronger than the last 2017 guidelines and is focused on lowering the target BP.  For example, for people with hypertension with a heightened cardiovascular risk the goal is to achieve “at least “ less than 130 mm HG (the top number) with encouragement to achieve less than 120 mm Hg.   For those with hypertension who are not at increased risk of CVD, the same goal “ may be reasonable” to forestall their BP from climbing higher.   The new language is stronger because the evidence clearly states that 120 is better for reducing heart disease and stroke and kidney disease.

The determination of whether someone has reached their target BP is determined on at least 2 readings during a visit with the clinician, not on a single measurement.

Earlier treatment is a big emphasis in the new guidelines.  People with stage 1 hypertension who don’t have clinical cardiovascular disease and who also have a low 10 year risk should use lifestyle changes to lower BP, but they should start medication if they’re not at that goal in 3-6 months.  For those non clinicians reading this, cardiovascular disease, also known as heart disease, refers to the following 4 entities: coronary artery disease (CAD) which is also referred to as coronary heart disease (CHD), cerebrovascular disease, peripheral artery disease (PAD), and aortic atherosclerosis. CAD results from decreased heart muscle perfusion that causes angina (chest pain) due to ischemia (insufficient blood flow) and can result in myocardial infarction (MI), and/or heart failure.  It accounts for one-third to one-half of all cases of cardiovascular disease.  Cerebrovascular disease is the entity associated with strokes, also termed cerebrovascular accidents, and transient ischemic attacks (TIAs). Peripheral arterial disease (PAD) is arterial disease predominantly involving the limbs that may result in claudication (pain, cramping, or a tired sensation in the legs that occurs with walking and is relieved by rest). Aortic atherosclerosis is the entity associated with thoracic and abdominal aneurysms.

The 2017 guideline also advised treating stage 1 hypertension with medication only for secondary prevention of recurrent cardiovascular events or for primary prevention in people with a heightened 10 year risk.   The new update also recommends immediate medication initiation for people with stage 1 hypertension who don’t have clinical CVD but do have diabetes or chronic kidney disease.

For people with stage 2 hypertension or higher, one drug is not enough, and the new guidelines advise a single pill combination of two drugs.

To determine cardiovascular risk and to make decisions about treatment options and goals, the new guidelines have adopted the  AHAs new PREVENT (Predicting Risk of CVD Events) risk calculator that was released in 2023.  This is a simple online tool to determine CVD risk.  With PREVENT, a 10 year predicted CVD risk of 7.5% or higher defines increased risk.

The new BP guidelines assert that lowering BP was a reasonable strategy to prevent cognitive decline and dementia.  The message: bring down BP to below 130 mm Hg and prevent mild cognitive impairment and dementia.  Higher blood pressure causes damage to small blood vessels in areas of the brain responsible for cognitive function.

Another new area to this update is with laboratory testing.  The first is the addition of urine albumin to creatinine ratio as part of the standard workup for all people with high BP.  This can allow earlier detection of chronic kidney disease.  Another new recommendation is to screen more patients for primary aldosteronism.  This is a condition that leads to hypertension and low potassium levels. The plasma aldosterone to renin ratio test is recommended for people with resistant hypertension or obstructive sleep apnea.  Clinicians can also screen patients with stage 2 hypertension to increase detection.

Lastly, some salt, alcohol, weight, exercise, and stress management guidelines. Salt:  the new guideline advises a low sodium diet for all patients with or without hypertension.  The goal is to reduce dietary sodium intake to less than 2300 mg/day (about 1 tsp) but better yet, to less than 1500 mg/day which is about two-thirds of a tsp.   Potassium rich salt substitutes should be considered which not only lowers the level of sodium in the diet, but increases the level of potassium, both of which are helpful in lowering BP. Alcohol: The ideal amount of alcohol is…… none!!!!  The update advises that all people with elevated BP abstain from drinking. This is because both systolic (the top number) and diastolic (the bottom number) increase over time with any amount of baseline alcohol intake.  The recommendations note that reducing alcohol intake has a bigger BP reduction for those who drink more (more than 1 drink per day for women and more than 2 drinks per day for men).  Weight:  If overweight or obese, the goal is to lower at least 5% of the body width or reduce the body mass index by at least 3.

And yes, the new blood pressure guidelines from 2025 strongly include diet, exercise, and stress management as key components of prevention and treatment. The guidelines emphasize incorporating a heart-healthy diet (like the DASH diet), regular physical activity (a minimum of 30 minutes aerobic activity 5 days/week and stress-reducing activities alongside or before medication.

Here is a brief overview of the 2025 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults.

Key Highlights:

• Classification:

Normal <120/<80

Elevated 120–129/<80

Stage 1 130–139/80–89

Stage 2 ≥140/90.

• Diagnosis: Stress standardized office technique of 2 elevated BP readings; confirm with home or ambulatory BP monitoring.
• Treatment thresholds:
  • Stage 2 (≥140/90): Initiate pharmacotherapy.
  • Stage 1 (130–139/80–89): Start meds if cardiovascular disease, diabetes, chronic kidney disease stroke, or 10‑year risk ≥7.5%; otherwise, trial lifestyle changes first.
• Target: <130/80 mm Hg for most adults, individualized for frailty, institutional care, or pregnancy.
• Lifestyle: DASH diet, sodium reduction, weight control, physical activity, limited alcohol, improved sleep/stress.
• Pharmacologic therapy: First‑line agents are thiazide‑like diuretics, ACEi/ARB, or calcium channel blockers. Single‑pill combinations encouraged for Stage 2 or multi‑drug needs.
• Renin/aldosterone recommendations: The guideline emphasizes screening for primary aldosteronism in patients with resistant hypertension, hypokalemia, or adrenal incidentalomas.
• Special populations: ACEi/ARB preferred in proteinuric CKD; avoid ACEi/ARB in pregnancy; individualized goals for older/frail adults.
• Systems approach: Team‑based care, community screening, and use of the PREVENT risk calculator to guide initiation at Stage 1.

A side note about herbal therapies to lower blood pressure (if lifestyle changes are insufficient), the BP targets and goals are the same.  If we can lower BP to the desired levels with magnesium, grape seed extract, olive leaf, hawthorn, garlic, CoQ10 and perhaps even Indian snake root (a potentially toxic herb) combinations, those products may be adequate for many people.

Ok, you’ve got this!!!!!