New HTN guidelines advocate for early Tx

The new ACC/AHA* hypertension guidelines reinforce previous recommendations to lower blood pressure (BP) early and aggressively, with a greater emphasis on lifestyle interventions, the link between BP and cognitive function, and pregnancy.

The target BP level for adults remains below 130/80 mm Hg, but antihypertensive medication should be started sooner – in addition to lifestyle intervention – in those with hypertension and diabetes, chronic kidney disease or an elevated 10-year risk of cardiovascular disease.

“High BP is the most common and most modifiable risk factor for heart disease,” said Dr Daniel Jones, MD, dean and professor emeritus of the University of Mississippi School of Medicine in Jackson, Mississippi, US, who chaired the guidelines committee.

“By addressing individual risks earlier and offering more tailored strategies across the lifespan, we aim to help clinicians manage hypertension early and reduce the toll of heart disease, kidney disease, type 2 diabetes, and dementia among patients.”

The guidelines, which replace the 2017 iteration, also encourage the use of the PREVENT (Predicting Risk of CVD EVENTs) calculator – introduced in 2023 – for risk assessment instead of the long-established pooled cohort equations (PCE) to support clinical decisions for primary prevention. [Hypertension 2025;doi:10.1161/HYP.0000000000000249]

PREVENT can estimate both 10- and 30-year risks of MI, stroke, and heart failure, supporting early discussions on prevention options for a diverse range of patients. Several studies have now validated the tool, both in patients with high and low lipoprotein(a), and have demonstrated its ability to predict heart failure.

Salient changes

Jones said one of the key changes in the guidelines is an “encouragement”—rather than a more explicit recommendation—to help patients achieve a systolic BP of <120 mm Hg (Class 2b; Level B Evidence).

In 2017, the guidelines made headlines by lowering the recommended BP level from 140 mm Hg to 130 mm Hg—primarily based on the SPRINT data. [N Engl J Med 2015;373:2103-2116] That threshold still applies, but several studies, including STEP, ESPRIT, and BPROAD, have demonstrated benefits from even lower levels. [N Engl J Med 2021;385:1268-1279; Clin Hypertens 2025 May 1:31:e20]

“One of the strongest pieces of evidence that has accumulated is that [lowering BP] not only prevents heart disease and stroke but also reduces the risk of cognitive dysfunction and dementia,” said Jones.

While the definitions of normal and elevated BP, as well as stage 1 and 2 hypertension, remain unchanged since 2017, Jones highlighted a shift in the new guidelines. Specifically, patients with systolic BP of 130–139 mm Hg who do not have a high 10-year risk of events and have not yet experienced an event should start medication if BP is not controlled after 3-6 months of lifestyle modification (Class 1; Level B Evidence).

For all adults with stage 2 hypertension, initiation of antihypertensive drug therapy with 2 first-line agents of different classes in a single-pill, fixed-dose combination is preferred over 2 separate pills to improve adherence and reduce time to achieve BP control.

The guidelines also highlight the importance of early intervention, primarily through lifestyle changes outlined in the AHA’s Life’s Essential 8. [Circulation 2022; 146(5):e18-e43] These include the following:

·       Limiting sodium intake to less than 2,300 mg daily, with an ideal target of 1,500 mg by checking food labels and increasing potassium consumption

·       Consuming either no alcohol or no more than one or two drinks per day for women and men, respectively

·       Managing stress through exercise and using techniques such as meditation, breathing control, or yoga

·       Achieving or maintaining a healthy weight, with a goal of at least a 5 percent reduction in body weight for adults with overweight or obesity

·       Following a heart-healthy eating pattern, such as the DASH diet

·       Increasing physical activity to at least 75–150 mins each week, including aerobic exercise and/or resistance training

·       Home BP monitoring to help confirm office diagnosis of hypertension, track progress, and personalize care.

For the first time, the authors place a great emphasis on the accurate measurement of BP, with the patient sitting, feet on the floor, and arm resting on the table.

The guidelines also incorporated studies showing a link between hypertensive disorders of pregnancy and cardiovascular disease later in life. [J Am Coll Cardiol 2024;84:2264-2274]

“High BP during pregnancy predicts high BP for the rest of your life and increases the chance of heart disease and stroke,” pointed out Jones. Although much of this information has already been highlighted in obstetric guidelines, “we know that in many rural areas, early stages of pregnancy are managed by primary care physicians and not by obstetricians. We’re trying to get good information in the hands of primary care clinicians to manage those patients.”

Similarly, the guidelines also highlight the connection between hypertension and cognitive decline, including dementia. “Intensively lowering BP reduces the risk of dementia,” Jones said. “However, by the time a patient reaches a geriatrician or a neurologist with memory problems, the damage has already been done.”

The guidelines also recommend screening for primary aldosteronism in patients with resistant hypertension, regardless of whether they have hypokalaemia. Testing the ratio of urine albumin to creatinine is also advised for all patients with high blood pressure — which was previously considered an optional test.

The ACC/AHA hypertension guidelines were published in collaboration with 11 other organizations. Jones said they want to send a clear message to primary care doctors who primarily manage hypertension in the early stages of adulthood to ensure patients are screened and high BP is controlled.