New ACC/AHA Hypertension Guidelines Still Urge Early Treatment but With Some Twists

New US hypertension guidelines, the first since 2017, released today reinforce prior recommendations that prioritize lowering blood pressure early and aggressively, with special emphasis on lifestyle interventions, the connection between BP and cognitive function, and pregnancy.

Importantly, the recommendations also prioritize the newer PREVENT risk calculator instead of the long-used pooled cohort equations (PCE).

The document, led by the American College of Cardiology (ACC) and American Heart Association (AHA) in collaboration with 11 other organizations, was published jointly in JACC, Circulation, and Hypertension. It replaces the 2017 iteration.

“High blood pressure is the most common and most modifiable risk factor for heart disease,” chair of the guideline writing committee Daniel W. Jones, MD (University of Mississippi Medical Center, Jackson), said in a press release. “By addressing individual risks earlier and offering more tailored strategies across the lifespan, the 2025 guideline aims to aid clinicians in helping more people manage their blood pressure and reduce the toll of heart disease, kidney disease, type 2 diabetes, and dementia.”

To TCTMD, Jones stressed the importance of numerous societies being involved in the effort, not only the ACC/AHA but also the American Academy of Physician Associates, American Association of Nurse Practitioners, American College of Clinical Pharmacy, American College of Preventive Medicine, American Geriatrics Society, American Medical Association, American Society of Preventive Cardiology, Association of Black Cardiologists, National Medical Association, Preventive Cardiovascular Nurses Association, and the Society of General Internal Medicine.

“We had a very broad viewpoint represented in the committee,” Jones said. While deep discussions were had about the evidence and how to apply it, there also was “certainly a strong consensus,” he added. “All of the guideline writers signed off on the guideline and every supporting organization signed off on the guideline, which we think is quite remarkable and really healthy.”

Some notable changes in the current document are its “encouragement”—rather than a more explicit recommendation—to help patients achieve a systolic BP of less than 120 mm Hg (Class 2b; Level of Evidence B), Jones explained. In 2017, the guidelines made waves by dropping the recommended level from 140 mm Hg to 130 mm Hg—largely based on SPRINT data. That threshold remains, but several studies, including STEP, the China Rural Hypertension Control Project (CRHCP), and ESPRIT, have now suggested that patients can benefit from even lower levels.

“One of the really good pieces of evidence that accumulated was that [lowering BP] not only prevents heart disease and stroke, but reduces the risk for cognitive dysfunction and dementia,” he said. “That’s really an important finding.”

While the definitions of normal and elevated BP, as well as for stage 1 and 2 hypertension, remain the same as they did in 2017, Jones pointed to a shift in these latest guidelines. Specifically, its authors urge, patients with systolic BP between 130 and 139 mm Hg who don’t have a high 10-year risk of events and have not yet had an event should begin medication if lifestyle therapy has not controlled their BP after 3 to 6 months (Class 1; Level of Evidence B).

For risk stratification, the PREVENT calculator, introduced in 2023, is now recommended above the long-used PCE for atherosclerotic cardiovascular disease to aid in the clinical decision-making process for primary prevention. Several studies have now validated the tool, shown its promise in patients with both high and low lipoprotein(a), and demonstrated its ability to even predict heart failure. Notably, research has also shown that PREVENT reclassifies many patients into a lower-risk category compared with the PCEs.

“The pooled cohort equation was based on patient data from 20 years ago, basically, and this has a larger database and is more contemporary data,” Jones said. “It’s more precise in its prediction, both at the group level and also at the individual level.”

The guidelines also stress the importance of early intervention, primarily through lifestyle changes outlined in the AHA’s Life’s Essential 8:

• Limiting sodium intake to less than 2,300 mg per day, moving toward an ideal limit of 1,500 mg per day by checking food labels and increasing potassium
• Consuming either no alcohol or no more than one or two drinks per day for women and men, respectively
• Managing stress with exercise, as well as incorporating techniques like meditation, breathing control, or yoga
• Maintaining or achieving a healthy weight, with a goal of at least a 5% reduction in body weight in adults who have overweight or obesity
• Following a heart-healthy eating pattern, such as the DASH diet
• Increasing physical activity to at least 75 to 150 minutes each week including aerobic exercise and/or resistance training
• Home BP monitoring for patients to help confirm office diagnosis of high blood pressure and to monitor, track progress, and tailor care

Another aspect of the document Jones highlighted is its incorporation of studies showing a link between hypertensive disorders of pregnancy and later cardiovascular disease.

“This is basically new information in the blood pressure guidelines that’s been available to obstetricians and gynecologists through their international organizations,” he said. The writing group chose to add this content because of the increase in understanding of blood pressure’s relevance in pregnancy (ie, preeclampsia and eclampsia) as well as the knowledge that there can be long-term implications, said Jones. “If blood pressure is high during pregnancy, then it imposes an increased risk of high blood pressure further down the road and an increased risk of heart disease and stroke.”

While much of this has already been emphasized in obstetric guidelines, “we know that in many rural areas in America, early stages of pregnancy are managed by primary care clinicians and not necessarily by obstetricians,” Jones continued. “We’re just trying to get good information in the hands of primary care clinicians to manage those patients.”

Similarly, that’s why the ACC/AHA guidelines draw attention to hypertension’s relationship with cognitive decline and dementia. “By the time a patient gets to a geriatrician or a neurologist with memory problems, the damage has been done,” he said.

Jones stressed: “We’re trying to get a clear message to primary care clinicians, who are the ones who primarily deal with hypertension in the earlier stages of adulthood, and to encourage them to be more aggressive in managing blood pressure, to get blood pressure lower, and to be sure that all of their patients are screened and that everybody’s blood pressure’s controlled.”