Cardiovascular · Topic 35 of 48

Hypertension

Cardiovascular · hypertension (2025 AHA/ACC)

Hypertension

Hypertension starts at 130/80 and the goal is below 130/80; PREVENT risk decides how fast stage 1 gets drugs, and stage 2 starts with two.

Key numbers

Hypertension starts at 130/80≥ 130/80 mmHg

Treat to below 130/80< 130/80 mmHg

Start drugs by stage and PREVENT riskPREVENT ≥ 7.5%

01 · Defined byHypertension starts at 130/80

Adult BP categories: normal < 120/80; elevated 120–129 and < 80; stage 1 hypertension 130–139 or 80–89; stage 2 ≥ 140 or ≥ 90 mmHg. If systolic and diastolic differ, the higher category applies.

02 · The numberTreat to below 130/80

The treatment goal for most adults, including older adults, is BP < 130/80 mmHg; patients with 10-year PREVENT CVD risk ≥ 7.5% should be encouraged toward systolic < 120 mmHg when tolerated.

03 · The ruleStart drugs by stage and PREVENT risk

Start medication at ≥ 140/90; at ≥ 130/80 with CVD, diabetes, CKD or 10-year PREVENT risk ≥ 7.5%; and at ≥ 130/80 in lower-risk adults after 3–6 months of lifestyle change fails.

What it is

Core idea

Resistant: above goal on three drugsResistant hypertension = BP above goal despite adherence to 3 optimally dosed drugs of different classes including a diuretic (or needing 4 drugs); exclude white coat effect and nonadherence, then add a mineralocorticoid antagonist (spironolactone).

Diagnosis & monitoring

Work-up

Reassess monthly until at goalIf BP is not at goal within 1 month, check adherence and tolerability, then raise the dose or add a first-line drug from another class; recheck labs at least yearly.

Baseline labs: UACR, metabolic panel, lipids, A1c, ECGAt diagnosis order urinalysis with urine albumin-to-creatinine ratio, a metabolic panel (creatinine, potassium, calcium), lipids, glucose or A1c, TSH and an ECG.

Management

Orders

First line: thiazide, ACEi/ARB, or dihydropyridine CCB must knowFirst-line drug classes are thiazide-type diuretics (chlorthalidone or indapamide preferred), ACE inhibitors or ARBs, and long-acting dihydropyridine calcium channel blockers; beta-blockers are not first-line without a compelling indication.

Stage 2: start two drugs, one pill must knowStage 2 hypertension starts with two first-line drugs of different classes — an ACE inhibitor or ARB plus a thiazide or CCB — ideally as one single-pill combination; stage 1 may start with one.

Average 2–3 properly measured readingsDiagnose on the average of 2–3 office readings on separate occasions: seated 5 minutes, arm supported at heart level, correct cuff size, no caffeine, exercise or tobacco for 30 minutes before.

CKD or albuminuria: ACE inhibitor or ARBWith CKD (eGFR < 60 or albuminuria ≥ 30 mg/g), including diabetic kidney disease, use an ACE inhibitor or ARB — never both together.

Heart failure or post-MI: guideline-directed classesCompelling indications: heart failure — ACE inhibitor or ARB, beta-blocker, mineralocorticoid antagonist; post-MI — ACE inhibitor, beta-blocker, spironolactone or eplerenone; angina — beta-blocker or CCB.

Screen resistant hypertension for primary aldosteronismScreen every patient with resistant hypertension for primary aldosteronism (aldosterone and renin) whether or not potassium is low — and anyone with unexplained hypokalemia or sleep apnea; keep non-MRA antihypertensives during initial testing.

Older adults: thiazide or CCB for systolic hypertensionOlder adults share the < 130/80 goal when tolerated; thiazide-type diuretics and dihydropyridine CCBs suit isolated systolic hypertension, and frail older patients tolerate diastolic BP down to 60–65 mmHg.

Red flags & don'ts

Avoid harm

Pregnancy: no ACEi, ARB or MRA avoidACE inhibitors, ARBs, mineralocorticoid antagonists and nitroprusside are avoided in pregnancy; labetalol and extended-release nifedipine are first-line, aiming for < 140/90 in chronic hypertension (CHAP trial).

White coat or masked hypertension?

Commonly confused

Office BP	High
Home or ambulatory BP	Normal
More common in	Older adults, women, children
Cardiovascular risk	Somewhat above normotension; 3–4× risk of sustained hypertension later
How to detect	Home or ambulatory monitoring

Teach & follow up

Patient education

Sodium under 1,500 mg; more potassiumLifestyle for everyone: sodium < 1,500 mg/day (or cut ≥ 1,000 mg), more dietary potassium, DASH-type diet, weight loss, exercise, alcohol ≤ 2 drinks/day (men) or ≤ 1 (women).

More detail

Reference

Show 8 reference facts

Secondary hypertension (about 15%) is most often primary aldosteronism; also consider sleep apnea, CKD, renal artery stenosis, pheochromocytoma (plasma free metanephrines for paroxysms), thyroid disease and coarctation (weak, delayed femoral pulses).

A systolic goal < 130 mmHg is now a class 1 recommendation to prevent mild cognitive impairment and dementia.

Potassium-based salt substitutes help people who salt food at home, but use caution in CKD or with drugs that raise potassium.

Renal denervation is an option for selected patients with uncontrolled or resistant hypertension after multidisciplinary review; its effect on cardiovascular events is not yet proven.

Severe hypertension (> 180/120) without acute target-organ damage — formerly hypertensive urgency — is managed with oral medications and close follow-up, not rapid IV lowering (see Hypertensive Urgency & Emergency).

Every 10-mmHg fall in systolic BP lowers coronary disease about 17%, stroke 27%, heart failure 28% and all-cause mortality 13%.

A between-arm systolic difference > 15 mmHg warrants evaluation of the upper-extremity vasculature.

White coat hypertension (10–20% of adults; more common in older adults, women and children) triples to quadruples the risk of later sustained hypertension; masked hypertension (10–30%) is more common in men, Black adults and diabetes.

Pearl

Diagnose at 130/80, treat to below 130/80 — and start stage 2 with two drugs in one pill.

Sources · Merck Manual Professional — Hypertension (updated to the 2025 AHA/ACC guideline, Feb 2026) · ACC — New in Clinical Guidance: High Blood Pressure Focus of New ACC/AHA Guideline (Oct 2025) · UIC Drug Information Group — Overview of the 2025 Hypertension Guidelines (Dec 2025) · U.S. Pharmacist — ACC/AHA Hypertension Guideline Update (Mar 2026) · Jones DW et al. 2025 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. Hypertension 2025;82(10):e212–e316 · Healio — Top 10 prevention takeaways from the 2025 high blood pressure guideline (Sep 2025) · ACC — ACC Releases New Guidance For Managing Resistant Hypertension (2026 Expert Consensus Decision Pathway, Oct 2026) · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).