AHA, ACC update guideline on prevention, treatment of hypertension
The 2025 joint guideline from the American Heart Association (AHA) and the American College of Cardiology (ACC) emphasizes prevention, early treatment to reduce cardiovascular disease risk, lifestyle modification, and use of a risk calculator to determine when to start medication.
A new joint guideline on hypertension advises earlier focus on lifestyle modification and medications, as well as use of the new PREVENT risk calculator to estimate a patient's cardiovascular risk.
The AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults reinforces the importance of healthy lifestyle behaviors, such as reducing salt intake, eating a nutritious diet, being physically active, maintaining or achieving a healthy weight, and managing stress. It was published by JACC and Circulation on Aug. 14.
New recommendations include that for adults with or without hypertension, potassium-based salt substitutes can be useful to prevent or treat elevated blood pressure and hypertension, particularly for patients in whom salt intake is related mostly to food preparation or flavoring at home. The guideline also newly recommends that patients with resistant hypertension be screened for primary aldosteronism regardless of whether hypokalemia is present and that they continue most antihypertensive medications prior to initial screening to minimize barriers to or delays in screening.
The guideline also offered revised recommendations on when to initiate drug treatment of hypertension, based on the PREVENT risk assessment tool:
- In adults with hypertension without clinical cardiovascular disease (CVD) but with diabetes or chronic kidney disease or at increased 10-year CVD risk (i.e., at least 7.5% based on PREVENT), initiation of medications to lower blood pressure (BP) is recommended when average systolic BP is 130 mm Hg or above and average diastolic BP is 80 mm Hg or above to reduce the risk of CVD events and total mortality.
- In adults with hypertension without clinical CVD and with estimated 10-year CVD risk less than 7.5% based on PREVENT, initiation of medications to lower BP is recommended if average systolic BP remains 130 mm Hg or above or average DBP remains 80 mm Hg or above after a three- to six-month trial of lifestyle intervention to prevent target organ damage and mitigate further increases in BP.
The new guideline recommends two important changes to laboratory testing for initial evaluation. The ratio of urine albumin and creatinine, which was recommended as an optional test in the 2017 guideline, is now recommended for all patients with high blood pressure. The guideline also now recommends an expansion of the indication for the plasma aldosterone-to-renin ratio test in more patients, including those with obstructive sleep apnea.
The guideline maintains the recommendation to begin treatment with two medications at once, preferably in a combination pill, for people with stage 2 hypertension (≥140/90 mm Hg). The guideline also suggests possible addition of newer therapies such as glucagon-like peptide-1 medications for some patients with hypertension and overweight or obesity.
The new guideline replaces the 2017 guideline and was prepared by a volunteer writing committee on behalf of the American Heart Association and the American College of Cardiology Joint Committee on Clinical Practice Guidelines.