The American College of Cardiology (ACC) and American Heart Association (AHA) recently updated their guidelines for the management of high blood pressure in adults. As the most common modifiable risk factor for the development of heart disease, appropriate management can greatly improve patients' lives.

High blood pressure is defined as a systolic and/or diastolic elevation of blood pressure 130/80 mm Hg or higher on at least 2 separate occasions. Most often there is no known cause — primary hypertension, but for some patients high blood pressure may be a symptom of another condition — secondary hypertension. The goal of treatment is to keep blood pressure below 130/80 mm Hg. This can be accomplished with lifestyle modification, medication, and in some cases medical procedures like renal denervation. 

The ACC/AHA guidelines reviewed in this article are comprehensive. Today we will only explore some of the major changes and key takeaways from 2017 to 2025 in the management of high blood pressure. We encourage you to view the full recommendations on our website or by using the links below.

Guidelines Referenced
Major Changes and Key Takeaways (2017-2025)
  • Secondary Forms of hypertension (HTN): Primary Aldosteronism
    • The 2025 update adds obstructive sleep apnea (OSA) to the list of conditions in which to screen for primary aldosteronism.
  • Secondary Forms of HTN: OSA
    • There are new recommendations for adults with OSA and overweight or obesity that weight loss interventions combined with continuous positive airway pressure (CPAP) can help to lower blood pressure.
    • CPAP may also be useful in lowering blood pressure in adults with resistant hypertension with moderate-to-severe OSA.
  • Blood Pressure Treatment Threshold
    • The treatment threshold when it comes to estimated 10-year cardiovascular disease (CVD) risk was lowered from less than 10% in the 2017 recommendations to 7.5% or more in the updated 2025 guidelines.
  • Blood Pressure Goals
    • 130/80 continues to be the goal blood pressure for adults with hypertension, but the new guidelines encourage further blood pressure improvement to a systolic blood pressure (SBP) less than 120.
  • Comorbidities: Obesity and Metabolic Syndrome
    • There are two new recommendations for adults with hypertension who also have overweight or obesity. First, certain medications used for weight management may help to lower blood pressure.
    • Second bariatric surgery in adults with hypertension and obesity combined with behavioral interventions and medications may also help to lower blood pressure.
  • Hypertension and Pregnancy
    • In the updated guidelines there was a change to the preferred medications for treating HTN in women who are pregnant or planning to become pregnant. Labetalol and nifedipine ER are preferred and methyldopa was removed from the preferred medications.
    • The update also added medications to the list of drugs that should not be used in women with HTN who are pregnant or planning to become pregnant— medications added are atenolol, nitroprusside, and MRAs.
    • There were also new recommendations for the use of low dose aspirin, treatment of pregnant women with blood pressure of 160/110 or higher, and pregnant women with chronic HTN.
  • Resistant HTN and Renal Denervation
    • Resistant HTN and renal denervation were not addressed in the previous version of this guideline.
    • The updated guideline includes recommendations for the evaluation and treatment of resistant hypertension and considerations for additional medication in adults with uncontrolled resistant hypertension.
    • New recommendations were made for the selection of patients with resistant hypertension who may be considered for renal denervation.
  • Complications of Management: Orthostatic Hypotension (OH)
    • OH was not addressed in the 2017 recommendation.
    • The 2025 guidelines adds new recommendations for improving blood pressure control to lower the risk of OH, blood pressure goals for adults with HTN and OH, and evaluation for other chronic conditions in adults with symptomatic OH.
Item20172025
Secondary HTN: Primary AldosteronismIn adults with hypertension, screening for primary aldosteronism is recommended in the presence of any of the following concurrent conditions: resistant hypertension, hypokalemia (spontaneous or substantial, if diuretic induced), incidentally discovered adrenal mass, family history of early-onset hypertension, or stroke at a young age (<40 years).In adults with hypertension, screening for primary aldosteronism is recommended in the presence of any of the following conditions to increase rates of detection, diagnosis, and specific targeted therapy: resistant hypertension (regardless of whether hypokalemia is present), hypokalemia (spontaneous or diuretic induced), OSA, incidentally discovered adrenal mass, family history of early-onset hypertension, or stroke at a young age (<40 years).
Secondary HTN: Obstructive Sleep ApneaIn adults with hypertension and obstructive sleep apnea, the effectiveness of continuous positive airway pressure (CPAP) to reduce BP is not well established.In adults with hypertension and OSA who have overweight or obesity, weight loss interventions when combined with CPAP treatment can be effective in reducing SBP.
Blood Pressure Treatment Threshold and the use of CVD Risk Estimation to Guide Drug Treatment of HTNUse of BP-lowering medication is recommended for primary prevention of CVD in adults with no history of CVD and with an estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk <10% and an SBP of 140 mm Hg or higher or a DBP of 90 mm Hg or higher.

Adults with an elevated BP or stage 1 hypertension who have an estimated 10-year ASCVD risk less than 10% should be managed with nonpharmacological therapy and have a repeat BP evaluation within 3 to 6 months.

Adults with stage 1 hypertension who have an estimated 10-year ASCVD risk of 10% or higher should be managed initially with a combination of nonpharmacological and antihypertensive drug therapy and have a repeat BP evaluation in 1 month.		In adults with resistant hypertension and moderate-to-severe OSA, CPAP treatment can be useful in reducing BP.

In all adults with hypertension, initiation of medications to lower BP is recommended when average SBP is ≥140 mm Hg to reduce the risk of cardiovascular events and total mortality.

In adults with hypertension without clinical CVD but with diabetes or chronic kidney disease (CKD) or at increased short-term CVD risk (i.e., estimated 10-year CVD risk ≥7.5% based on PREVENT), initiation of medications to lower BP is recommended when average SBP is ≥130 mm Hg to reduce the risk of CVD events and total mortality.

In adults with hypertension without clinical CVD but with diabetes or CKD or at increased 10-year CVD risk (i.e., ≥7.5% based on PREVENT), initiation of medications to lower BP is recommended when average DBP is ≥80 mm Hg to reduce the risk of CVD events and total mortality.

In adults with hypertension without clinical CVD and with estimated 10-year CVD risk <7.5% based on PREVENT, initiation of medications to lower BP is recommended if average SBP remains ≥130 mm Hg after a 3- to 6-month trial of lifestyle intervention to prevent target organ damage and mitigate further rise in BP.

In adults with hypertension without clinical CVD and with estimated 10-year CVD risk <7.5% based on PREVENT, initiation of medications to lower BP is recommended if average DBP ≥80 mm Hg after a 3- to 6-month trial of lifestyle intervention to prevent target organ damage and mitigate further rise in BP.
BP Goal for Patients with HTNFor adults with confirmed hypertension and known CVD or 10-year ASCVD event risk of 10% or higher, a BP target of less than 130/80 mm Hg is recommended.

For adults with confirmed hypertension, without additional markers of increased CVD risk, a BP target of less than 130/80 mm Hg may be reasonable.		In adults with confirmed hypertension who are at increased risk for CVD, an SBP goal of at least <130 mm Hg, with encouragement to achieve SBP <120 mm Hg, is recommended to reduce the risk of cardiovascular events and total mortality.

In adults with confirmed hypertension who are not at increased risk for CVD, an SBP goal of <130 mm Hg, with encouragement to achieve SBP <120 mm Hg, may be reasonable to reduce risk of further elevation of BP.

In adults with confirmed hypertension who are at increased risk for CVD, a DBP target of <80 mm Hg is recommended to reduce the risk of cardiovascular events and total mortality.

In adults with confirmed hypertension who are not at increased risk for CVD, a DBP target of <80 mm Hg may be reasonable to reduce the risk of cardiovascular events.
Comorbidities: Obesity and Metabolic SyndromeNot addressed
In adults with hypertension who also have overweight or obesity with a BMI ≥27 kg/m2, incretin mimetics (eg, GLP-1RA) when used for weight management may be effective as an adjunct to lower BP.

In adults with hypertension who have obesity with a BMI ≥35.0 kg/m2, bariatric surgery (when considered for weight loss) in combination with behavioral interventions and antihypertensive therapies may be effective at lowering BP.
Hypertension and Pregnancy
Women with hypertension who become pregnant, or are planning to become pregnant, should be transitioned to methyldopa, nifedipine, and/or labetalol during pregnancy.

Women with hypertension who become pregnant should not be treated with ACE inhibitors, ARBs, or direct renin inhibitors.
For individuals with hypertension who are planning a pregnancy or who become pregnant, labetalol and extended release nifedipine are preferred agents to treat hypertension and minimize fetal risk.

Individuals with hypertension who are planning a pregnancy or who become pregnant should be counseled about the benefits of low-dose (81 mg/day) aspirin to reduce the risk of preeclampsia and its sequelae.

Pregnant individuals with SBP ≥160 mm Hg or DBP ≥110 mm Hg confirmed on repeat measurement within 15 minutes should receive antihypertensive medication to lower BP to <160/<110 mm Hg within 30 to 60 minutes to prevent adverse events.

Pregnant individuals with chronic hypertension (defined as prepregnancy hypertension or SBP 140 to 159 mm Hg and/or DBP 90 to 109 mm Hg prior to 20 weeks’ gestation) should receive antihypertensive therapy to achieve BP <140/90 mm Hg to prevent maternal and perinatal morbidity and mortality.

Individuals with hypertension who are planning a pregnancy or who become pregnant should not be treated with atenolol, ACEi, ARB, direct renin inhibitors, nitroprusside, or MRA to avoid fetal harm.
Resistant HTNNot addressed
In adults with resistant hypertension, a more detailed evaluation for secondary causes, to include careful review of all medications and removal of those with interfering effects on BP, is beneficial for lowering BP and simplifying treatment.

In adults with uncontrolled resistant hypertension despite optimal treatment with first-line antihypertensive therapy (ie, a combination of ACEi or ARB plus CCB and thiazide-like diuretic [chlorthalidone or indapamide] and with an eGFR of ≥45 ml/min/1.73 m2), addition of a MRA is recommended to control BP.

In adults with uncontrolled resistant hypertension who cannot tolerate MRA or have contraindications for MRA, addition of the the following agent classes (amiloride, BB, alpha blocker, central sympatholytic drug, dual endothelin receptor antagonist, direct vasodilator) is reasonable to control BP.
Renal DenervationNot addressedIn carefully selected patients with systolic and diastolic hypertension (office SBP 140 to 180 mm Hg and DBP ≥90 mm Hg) and eGFR ≥40 mL/min/1.73 m2 who have resistant hypertension despite optimal treatment, or intolerable side effects to additional antihypertensive drug therapy, renal denervation (RDN) may be reasonable as an adjunct treatment to BP medications and lifestyle modification to reduce BP.

All patients with hypertension who are being considered for RDN should be evaluated by a multidisciplinary team with expertise in resistant hypertension and RDN.

For patients with hypertension for whom RDN is contemplated, the benefits of lowering BP and potential procedural risks compared with continuing medical therapy should be discussed as part of a shared decision-making process to ensure patients choose the therapy that meets their expectations.
Management of Orthostatic HypotensionNot addressed
In adults with hypertension, improved BP control is recommended to reduce the risk for OH.

In adults receiving intensive BP-lowering therapy with asymptomatic OH, treatment with a goal of SBP <130 mm Hg is reasonable due to increased CVD and mortality benefit.

In adults with hypertension initiating treatment or adding medication with a goal of SBP <130 mm Hg, assessment for symptomatic OH is reasonable to detect other chronic conditions.
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