The American College of Cardiology (ACC) and the American Heart Association (AHA) recently updated their guidelines for the prevention, detection, evaluation, and management of high blood pressure in adults. High blood pressure is the most common modifiable risk factor for the development of heart disease. Adults diagnosed with hypertension who have treated blood pressure to less than 120/80 mmHg still have twice the risk for cardiovascular disease compared to adults without hypertension.
In this article we will review some of the changes in the recent AHA/ACC recommendations for the evaluation and management of high blood pressure, focusing on how these changes affect nursing practice. In each section we will compare the recommendations from 2017 with the current 2025 recommendations followed by implementation techniques for nursing practice that align with these recommendations.
to be able to better anticipate the needs of providers and patients. We encourage you to review the full guideline found at the links below for more important information on this topic as this only represents a small portion of this comprehensive guideline.
Guidelines Referenced
- 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults
- Published: November 2017
- Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults
- Published: August 2025
- Full-Text
Major Changes
Blood Pressure Goal
- There is a change in the blood pressure goal for adults with hypertension encouraging further lowering beyond 130/80 mmHg to reach a systolic blood pressure (SBP) of less than 120 mmHg.
| Comparison of Recommendations | ||
|---|---|---|
| Type | 2017 AHA/ACC Recommendation | 2025 AHA/ACC Recommendation |
| BP Goal for Patients with HTN | For 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. | 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. |
| 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 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. | ||
Practice Change Encouragement of a lower SBP goal of less than 120 mmHg is recommended for adults with hypertension.
Nursing Intervention Patient counseling and coaching should encourage patients to work to achieve an SBP of less than 120 mmHg. To do this patients should be advised to: Exercise regularly. Eat a healthy diet, low in sodium. Limit alcohol consumption. Avoid smoking and tobacco use. Manage stress. Maintain a healthy weight. Get good quality sleep. Take antihypertensive medications as prescribed. Monitor blood pressure at home.
Secondary Hypertension
- Up to 25% of adults with hypertension have hypertension due to another underlying condition — secondary hypertension.
- Secondary hypertension is more suspicious in adults who have:
- Stage 2 hypertension
- Treatment resistant hypertension
- Sudden onset hypertension
- Increased BP in patients with previously controlled hypertension on drug therapy
- Onset of hypertension before the age of 30 years
- Diastolic hypertension in older adults
- Target organ damage.
| Frequently Used Medications/Substances That May Cause High Blood Pressure | |
| Agent | Possible Management Strategy/Patient Education |
| Alcohol | Options include abstinence or limit alcohol to ≤1 drink daily for women and ≤2 drinks daily for men |
| Caffeine | Limit caffeine intake to <300 mg/dAvoid more than 1 cup daily in patients with severe uncontrolled hypertension |
| Decongestants (eg, phenylephrine, pseudoephedrine) | Use for shortest duration possible and avoid in severe or uncontrolled hypertensionProvider may consider alternative therapies (eg, nasal saline, intranasal corticosteroids, antihistamines) |
| Herbal supplements (eg, Ma Huang, ephedra, St. John’s wort [with MAO inhibitors, yohimbine]) | Avoid use |
| Black licorice | Avoid use |
| NSAIDs; acetaminophen | Education may include avoiding NSAIDs when possible and limiting acetaminophen to less than 4 g/d |
| Recreational drugs (eg, “bath salts” [MDPV], cocaine, methamphetamine, etc) | Discontinue or avoid use |
| Sudden withdrawal of central-acting sympatholytic drugs such as clonidine and tizanidine | Make sure to note the use or sudden discontinuation of these drugs |
| Amphetamines (eg, amphetamine, methylphenidate dexmethylphenidate, dexamfetamine, lisdexamfetamine, dextroamphetamine) | Provider may want to discontinue or decrease dose and consider behavioral therapies or nonstimulants (such as guanfacine) for ADHD instead of amphetamines |
| Antidepressants (eg, MAOIs, SNRIs, TCAs) | Eating high tyramine foods when taking MAOIs can cause a hypertensive crisis.Avoid tyramine-containing foods with MAOIs like aged cheeses, processed meats, smoked fish, soy products, avocados, bananas, grapes, raisins |
| Atypical antipsychotics (eg, risperidone, olanzapine) | Provider may prefer behavior therapy or lifestyle modification over use of atypical antipsychotics in patients with hypertension. |
| Immunosuppressants (eg, cyclosporine) | Provider may wish to change medication to tacrolimus, which may be associated with fewer effects on BP |
| Oral contraceptives | Provider may recommend low-dose (eg, 20-30 mcg ethinyl estradiol) agents or a progestin-only form of contraception.Provide education on other forms of birth control where appropriate (eg, barrier, abstinence, nonhormonal IUD) |
| Systemic corticosteroids (eg, dexamethasone, fludrocortisone, methylprednisolone, prednisone, prednisolone) | Provider may want to consider alternative modes of administration (eg, inhaled, topical) when feasible |
| Angiogenesis inhibitor (eg, bevacizumab) and tyrosine kinase inhibitors (eg, sunitinib, sorafenib) | Provider will usually try to avoid or limit use when possible |
| Androgen deprivation therapy such as CYP 17 inhibitors (eg, abiraterone, orteronel) or androgen receptor antagonist (eg, enzalutamide) | Provider will usually try to avoid or limit use when possible |
| Causes of Secondary Hypertension | ||
| Cause | Signs and Symptoms | Physical Exam Findings |
| Obstructive sleep apnea | Snoring, gasping during sleep, daytime sleepiness | Obesity, large neck |
| Chronic kidney disease | Urinary frequency, hematuria, nocturia, urinary incontinence | Abdominal mass or large palpable kidneys, Skin pallor |
| Primary aldosteronism | Hypertension and hypokalemia, muscle cramps, weakness, adrenal mass, or OSA | Arrhythmias, especially atrial fibrillation |
| Drug or alcohol induced | See table: Frequently Used Medications/Substances that may cause high blood pressure | Tremor, tachycardia, sweating, acute abdominal pain |
| Renovascular hypertension | Resistant hypertension; hypertension of abrupt onset or worsening or increasingly difficult to control; flash pulmonary edema (atherosclerotic); early-onset hypertension, especially in women (fibromuscular hyperplasia) | Abdominal systolic-diastolic bruit, bruits over other arteries |
| Hypothyroidism | Dry skin; cold intolerance; constipation; hoarseness; weight gain | Periorbital edema; coarse skin; cold skin; slow movement; goiter |
| Hyperthyroidism | Warm, moist skin; heat intolerance; nervousness; tremulousness; palpitations, insomnia; weight loss; diarrhea; proximal muscle weakness | Lid lag; fine tremor of the outstretched hands; warm, moist skin, goiter, thyroid nodule |
| Pheochromocytoma/ paraganglioma | BP lability, headache, sweating, palpitations, piloerection; positive family history of pheochromocytoma/ paraganglioma; adrenal incidentaloma | Café-au-lait spots; neurofibromas, orthostatic hypotension |
| Aortic coarctation (undiagnosed or repaired) | Young adult with hypertension (age <30 y) | BP higher in upper extremities than in lower extremities; absent femoral pulses; continuous murmur over patient’s back, chest, or abdominal bruit; left thoracotomy scar (postoperative) |
| Cushing syndrome | Rapid weight gain, especially with central distribution; proximal muscle weakness; depression; hyperglycemia | Central obesity, “moon” face, dorsal and supraclavicular fat pads, wide (1 cm) violaceous striae, hirsutism |
| Primary hyperparathyroidism | Hypercalcemia | Usually none |
| Congenital adrenal hyperplasia | Hypertension and hypokalemia; incomplete masculinization in men and primary amenorrhea in women | Signs of masculinization in females or incomplete masculinization in males |
| Mineralocorticoid excess syndromes | Early-onset hypertension; resistant hypertension; hypokalemia or hyperkalemia | Arrhythmias (with hypokalemia) |
| Acromegaly | Acral features, enlarging shoe, glove, or hat size; headache, visual disturbances; diabetes | Acral features; large hands and feet; frontal bossing |
Primary Aldosteronism
- The goal of screening for primary aldosteronism in patients with hypertension is to increase detection and diagnosis so treatment targeting the underlying cause of hypertension can be initiated.
- Obstructive sleep apnea (OSA) was added to the list of conditions in which screening for primary aldosteronism is indicated.
| Comparison of Recommendations | ||
|---|---|---|
| Type | 2017 AHA/ACC Recommendation | 2025 AHA/ACC Recommendation |
| Secondary HTN: Primary Aldosteronism | In 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 massFamily 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)OSAIncidentally discovered adrenal massFamily history of early-onset hypertension or Stroke at a young age (<40 years). |
Practice Change Patients with high blood pressure should be asked about OSA so that appropriate patients are screened for primary aldosteronism.
Nursing Interventions Identify at-risk patients to be screened for primary aldosteronism. 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). Those identified for screening should be prepared for testing of aldosterone-to-renin ratio (ARR):Testing should be performed in the morning with the patient in a seated position. Patients should eat an unrestricted sodium diet for at least a few days before testing (low-sodium diets can cause a false-negative result).Patients should not fast before the test, but should also not eat a heavy meal the morning of the test. Some medications, like mineralocorticoid receptor antagonists (MRAs) may need to be stopped because they can alter test results. Depending on the results of screening, additional testing may be needed.
Obstructive Sleep Apnea
- For adults with high blood pressure who also have OSA and overweight or obesity new guidance recommends a combination of weight loss interventions and the use of continuous positive airway pressure (CPAP) to lower blood pressure.
- New evidence has emerged suggesting that CPAP may lower blood pressure in adults with OSA and overweight and obesity, as well as, in adults with resistant hypertension.
| Comparison of Recommendations | |||
|---|---|---|---|
| Type | 2017 AHA/ACC Recommendation | 2025 AHA/ACC Recommendation | |
| Secondary HTN: Obstructive Sleep Apnea | In 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 continuous positive airway pressure (CPAP) treatment can be effective in reducing SBP. | |
| In adults with resistant hypertension and moderate-to-severe OSA, CPAP treatment can be useful in reducing BP. | |||
Practice Change In patients with OSA, weight loss interventions and the use of CPAP can help lower blood pressure.
Nursing Intervention Patient education should include: Lifestyle modification techniques to promote weight loss. Use of CPAP as prescribed can help lower blood pressure, especially in patients with resistant hypertension. Identify barriers for CPAP use and help patients to find ways of overcoming these. Some common barriers are discomfort with mask and/or pressure settings. Patients should be advised that changes to the mask fit and sometimes pressure setting may be possible to make CPAP more comfortable. Encourage patients to talk with their CPAP prescriber about any concerns they have with being able to use their CPAP.
Comorbidities—Obesity and Metabolic Syndrome
- The 2025 AHA/ACC guideline included 2 new recommendations for weight management techniques for adults with hypertension who have overweight and obesity that may help lower blood pressure:
- Incretin mimetic medications—help regulate blood sugar by mimicking the action of incretin hormones.
- Bariatric surgery.
| Comparison of Recommendations | ||
|---|---|---|
| Type | 2017 AHA/ACC Recommendation | 2025 AHA/ACC Recommendation |
| Comorbidities: Obesity and Metabolic Syndrome | Not 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. | ||
Practice Change Incretin mimetic medications and bariatric surgery for weight loss may help lower blood pressure.
Nursing Interventions Nursing care for patients starting or currently taking incretin mimetic medications should include: Monitoring vital signs to include blood pressure and monitor for transient increases in heart rate. Encouraging adequate hydration and healthy diet/lifestyle. Monitoring for hypoglycemia. Instructing patients on how to self-administer the medication—injection technique and rotating the injection site. Reinforce the importance of self-monitoring.
Nursing Interventions For patient considering bariatric surgery nurses may: Counsel patients on the risks and benefits of surgery including necessary dietary restrictions, portion control, hydration, and the long-term need for vitamins and supplements. Mental health counseling may be beneficial to make sure patients are ready for the lifestyle changes necessary after bariatric surgery. Stress the importance of continuing antihypertensives. Monitor vital signs. Coordinate care with specialists.
Acute Intracerebral Hemorrhage (ICH)
- The 2025 AHA/ACC guidelines recommend more aggressive blood pressure lowering after ICH for patients presenting with SBP between 150 and 220 mmHg.
- Immediate lowering of SBP to 130 to <140 mmHg for a minimum of 7 days.
- Antihypertensives should be stopped if SBP is <130 mmHg.
- Elevated blood pressure is associated with greater hematoma expansion, neurologic worsening, and death after an ICH.
| Comparison of Recommendations | ||
|---|---|---|
| Type | 2017 AHA/ACC Recommendation | 2025 AHA/ACC Recommendation |
| Intracerebral Hemorrhage | In adults with ICH who present with SBP greater than 220 mm Hg, it is reasonable to use continuous intravenous drug infusion and close BP monitoring to lower SBP. | In adults with acute spontaneous ICH requiring acute BP lowering, careful titration to ensure smooth, nonlabile, and sustained control of BP, avoiding peaks and large variability in SBP, can be beneficial for improving functional outcomes. |
| Immediate lowering of SBP to less than 140 mm Hg in adults with spontaneous ICH who present within 6 hours of the acute event and have an SBP between 150 mm Hg and 220 mm Hg is not of benefit to reduce death or severe disability and can be potentially harmful. | For adult patients with acute spontaneous intracerebral hemorrhage (ICH) who present with SBP between 150 and 220 mm Hg, it can be beneficial to immediately lower SBP to 130 to <140 mm Hg for at least 7 days after ICH to improve functional outcomes but stop antihypertensive medications if SBP <130 mm Hg. | |
| For adult patients with acute spontaneous ICH who present with SBP >220 mm Hg, SBP should not be lowered below 130 mm Hg to reduce adverse events. | ||
Practice Change Be prepared for orders to quickly lower blood pressure to SBP 130 to <140 mmHg in patients with ICH presenting with SBP between 150-220 mmHg and maintaining SBP at 130 to <140 mmHg for at least 7 days.
- Usually providers will not want a patient's SBP to drop below 130 mmHg, especially in patients who presented with very high SBP (greater than 220 mmHg).
- Nurses should make sure desired blood pressure parameters are clear and any lower limits are identified with instruction on what to do if the patient approaches this lower limit.
Nursing Interventions In patients with an ICH nurses should carefully monitor blood pressure and intracranial pressure (ICH). Strategies that may be implemented include: Continuous blood pressure monitoring, with smooth lowering of BP that avoids large variability. Performing frequent neurologic assessments. Watching for signs of increased intracranial pressure. Minimizing stimuli. Positioning the patient with the head of the bed elevated 30 degrees and avoiding hip flexion which can increase intra-abdominal and intra-thoracic pressure. Managing other aggravating factors like fever or seizures.
Complications of Management—Orthostatic Hypotension
- Orthostatic hypotension (OH) was not addressed in the previous AHA/ACC guideline.
- Improving blood pressure control can actually lower the risk of OH. Adults on antihypertensives with asymptomatic OH should have a goal SBP of less than 130 mmHg.
- Antihypertensive therapy may unmask underlying orthostatic hypotension, especially in older adults.
| Comparison of Recommendations | ||
|---|---|---|
| Type | 2017 AHA/ACC Recommendation | 2025 AHA/ACC Recommendation |
| Management of Orthostatic Hypotension | Not 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. | ||
Practice Change Adults should be asked about symptoms of orthostatic hypotension when starting and/or adjusting antihypertensives.
Nursing Interventions Obtain orthostatic blood pressures to assess for changes associated with position. Provide education on techniques to minimize symptoms of orthostatic hypotension and avoid potential injury from falls/fainting. This includes: Changing positions gradually. Maintaining adequate hydration. Increasing sodium intake. Using compression therapy to improve circulation. Teaching counter-maneuvers that can be used to increase blood flow when moving to a standing position, like crossing the legs and contracting the abdominal muscles when standing. Avoiding activities that make OH worse, like alcohol, standing for too long, or extreme heat.
That’s it for this article on nursing considerations for adults with high blood pressure. We thank you for reading and encourage you to sign up for alerts to stay informed on the latest published guidelines and articles.
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