Abstract
The publication of the recent hypertension guidelines (the combined efforts of the AHA, ACC, AANP, AAPA, ABC, ACCP, ACPM, AGS, AMA, ASPC, NMA, PCNA, and SGIM), 1 was meant for updating the last published AHA document of 2017. It naturally raises everyone’s curiosity in finding out what the newer updates have got to convey in this 105-page document. What is the impact on our current practice?
These guidelines re-emphasized the need for a methodical and accurate clinical measurement of blood pressure (BP) in clinics. There is an eight-point list of dos and don’ts with a simple picture. Home-based monitoring supplements office measurements (Class-1/evidence: level A recommendation). Of course, the document did not elaborate about the validity of the available home BP devices in detail. But this document advised not to rely much on cuffless devices.
Normal BP is defined as <120/80 mm Hg. There is a continuous association with elevated BP and cardiovascular (CV) risk for coronary artery disease, stroke, heart failure, and atrial fibrillation. The term hypertensive urgency is no longer recommended. It is replaced by the term “severe hypertension.” The latest categorization of stages of hypertension is shown in Table 1.
The target for BP reduction in general is to reduce it to less than 130/80 mm Hg, but those with higher CV risk need a more aggressive target of less than 120 mm Hg.
The Predicting Risk of Cardiovascular Disease EVENTs (PREVENT) was developed by the American Heart Association in 2023 score. This was validated in over 6.5 million American adults who were cardiovascular disease (CVD) free. This estimates the 10-year and 30-year risk of CVD, including atherosclerotic CVD (ASCVD) and heart failure. 2
PREVENT™ equations are now recommended in place of pooled cohort equations (PCEs) as the former include measures of renal parameters. Among those without clinical CV disease, a PREVENT™ derived 10-year CVD risk >7.5% calls for pharmacological intervention when systolic blood pressure (SBP) is >130 mm Hg or average diastolic blood pressure (DBP) >80 mm Hg. Thus, the threshold to start BP medication in diabetes and chronic kidney disease (CKD) patients is lower than that for those who have a lesser predicted risk. Some authors have questioned the lack of race as a determinant in this scoring system. It is possible that the PREVENT score may lead to undertreatment of certain hypertension patients.
To prevent cognitive decline and dementia, a target of <130 mm Hg SBP is specifically recommended. There is now more robust evidence for this new recommendation. The single-pill combination drugs are to be preferred with stage 2 (Class-1).
Reduced salt intake (ideal-less than 1,500 mg/day) and alcohol consumption (less than one drink per day for women and two per day for men) are essential steps for proper BP control. Potassium-based salt substitutes used through home-cooking are acceptable, except in patients with CKD or those on drugs that may cause hyperkalemia. Weight optimization recommendations incorporate the use of glucagon-like peptide-1 (GLP-1) medications and bariatric surgery as evidence-based strategies.
In those with resistant hypertension, screening for primary aldosteronism must be done irrespective of the presence of hypokalemia at presentation. This is a shift from the earlier practice.
In adults with acute spontaneous intracerebral hemorrhage (ICH) who present with SBP of 150-220 mm Hg, they should be promptly treated to control the SBP levels. During therapy, it should be aimed to lower the levels to the 130-140 mm Hg range for about 7 days, but the therapy has to be stopped or lowered if levels fall below these levels. During acute ischemic stroke, those who are undergoing endovascular treatment, lowering SBP <140 mg in the first 24-48 h is labeled as a harmful step, and it is advised to avoid such a situation.
Renal denervation therapy (RDN) is emerging stronger, and the experience is increasing, but long-term and robust reduction is not been reported. It falls to a 2b recommendation for want of persuasive evidence. A multidisciplinary team with expertise should evaluate the need for RDN.
Chronic hypertension during pregnancy is defined as a BP reading of more than 140 mm Hg of SBP/more than 90 mm Hg of diastolic, or both, before 24 weeks of gestation. Guidelines for the management of chronic hypertension during pregnancy have been updated. Those with two readings of more than 160 mm Hg SBP or more than 120 mm Hg, it is advisable to reduce these figures within 30 min of detection to prevent adverse effects.
Testing for the urine albumin-to-creatinine ratio is advised for all hypertensive patients during evaluation.
Cut-offs and Categories of Hypertension in Adults as per American Heart Association (AHA) 2025 Guidelines.
In summary, we can say that these latest guidelines emphasize early detection, personalized, and preventive treatment. Lifestyle modifications remain paramount at all stages of hypertension management.
