Hypertension Management Guidelines

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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

This guideline, published in Circulation (2025;152:e114–e218; DOI: 10.1161/CIR.0000000000001356), is a collaborative report from numerous US medical and health associations. It provides comprehensive recommendations for the prevention, detection, evaluation, and management of high blood pressure in adults.

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Aim and Methods of the 2025 Guideline

This 2025 guideline replaces the 2017 version. It is based on an extensive literature search from December 2023 to June 2024, incorporating studies published since February 2015. The guideline is structured as a dynamic document for all clinicians managing hypertension.

Top Take-Home Messages

1. Hypertension Significance: High BP is the leading modifiable risk factor for various cardiovascular diseases, stroke, dementia, kidney disease, and mortality. The general treatment goal is <130/80 mm Hg.

2. Community Collaboration: Clinicians should partner with community leaders and health systems to implement screenings and guideline-based management for improved BP control.

3. Multidisciplinary Care: Team-based care (physicians, pharmacists, nurses, etc.) is vital for addressing patient needs and overcoming barriers to hypertension control.

4. BP Classification:

   • Normal: <120/80 mm Hg

   • Elevated: 120-129 mm Hg systolic and <80 mm Hg diastolic

   • Stage 1 Hypertension: 130-139 mm Hg systolic or 80-89 mm Hg diastolic

   • Stage 2 Hypertension: \ge140 mm Hg systolic or \ge90 mm Hg diastolic

5. Lifestyle Changes: Strongly recommended for prevention and treatment, including healthy weight, DASH diet, sodium reduction (<2300 mg/day, ideally <1500 mg/day), increased potassium, physical activity, stress management, and limited alcohol intake.

6. Medication Initiation Criteria: Recommended for all adults with BP \ge140/90 mm Hg. Also for selected adults with BP \ge130/80 mm Hg if they have clinical CVD, previous stroke, diabetes, CKD, or a \ge7.5\% 10-year predicted CVD risk (PREVENT™).

7. Medication After Lifestyle: For adults with BP \ge130/80 mm Hg and \<7.5\% 10-year CVD risk (PREVENT), medication is recommended if BP remains \ge130/80 mm Hg after a 3-6 month trial of lifestyle modification.

8. Stage 2 Hypertension Initial Therapy: Preferred initiation with two first-line agents of different classes in a single-pill, fixed-dose combination.

9. Home Blood Pressure Monitoring (HBPM): An important tool when combined with team interactions and standardized protocols. Cuffless devices are not recommended yet due to precision and reliability concerns.

10. Severe Hypertension (Non-pregnant): BP >180/120 mm Hg without acute target organ damage should be managed promptly in an outpatient setting with oral antihypertensives.

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What is New: Key Recommendation Changes from 2017 to 2025

• Terminology: "Hypertensive urgency" is now "Severe hypertension."

• Primary Aldosteronism Screening: Recommended for resistant hypertension regardless of hypokalemia (COR 1). Antihypertensive medications (excluding MRAs) should continue during initial screening (COR 1).

• Potassium-based Salt Substitutes: Useful for elevated BP/hypertension, except in CKD or with potassium-retaining drugs (COR 2a).

• BP Treatment Threshold (Non-CVD, Diabetes/CKD/High Risk): Initiation recommended at BP \ge130/80 mm Hg for 10-year CVD risk \ge7.5\% (PREVENT) (COR 1).

• BP Treatment Threshold (Non-CVD, Low Risk): Initiation recommended if BP remains \ge130/80 mm Hg after 3-6 months of lifestyle intervention (COR 1).

• Diabetes & Hypertension: ACEi or ARB recommended for CKD (eGFR <60 mL/min/1.73 m^2 or albuminuria \ge30 mg/g) and considered for mild albuminuria to delay kidney disease progression (COR 1).

• CKD & Hypertension: RAASi (ACEi or ARB, not both) recommended for eGFR <60 mL/min/1.73 m^2 with albuminuria \ge30 mg/g (COR 1).

• Acute Intracerebral Hemorrhage (ICH): Immediately lower SBP to 130 to <140 mm Hg for at least 7 days if presenting SBP is 150-220 mm Hg, but stop if SBP <130 mm Hg (COR 2a). Careful titration to avoid SBP variability is beneficial (COR 2a).

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What is New: Key Recommendation Changes (Continued)

• Acute ICH (Harm): SBP should not be lowered below 130 mm Hg for SBP >220 mm Hg presentations (COR 3 Harm).

• Acute Ischemic Stroke (Harm): Lowering SBP <140 mm Hg after successful endovascular reperfusion can worsen long-term functional outcome (COR 3 Harm).

• Mild Cognitive Impairment & Dementia: SBP goal of <130 mm Hg recommended (COR 1).

• Hypertension and Pregnancy:

  • Pregnant individuals with SBP \ge160 mm Hg or DBP \ge110 mm Hg need antihypertensive medication within 30-60 minutes to lower BP to <160/110 mm Hg (COR 1).

  • Pregnant individuals with chronic hypertension should aim for BP <140/90 mm Hg (COR 1).

  • Low-dose aspirin is recommended to reduce preeclampsia risk (COR 1).

• Hypertension and Pregnancy (Harm): Atenolol, ACEi, ARB, direct renin inhibitors, nitroprusside, or MRA are contraindicated due to fetal harm (COR 3 Harm).

• Resistant Hypertension: More detailed evaluation for secondary causes, including medication review, is beneficial (COR 1). All patients considered for RDN need evaluation by a multidisciplinary team (COR 1). Shared decision-making is crucial for RDN (COR 1).

• Severe Hypertension (Non-pregnant/Non-stroke, Hospitalized): Intermittent use of additional IV or oral antihypertensives to acutely reduce BP is not recommended without acute target organ damage (COR 3 Harm).

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Preamble: Guideline Development and Intended Use

ACC/AHA guidelines translate scientific evidence into clinical practice recommendations to improve cardiovascular health, developed without commercial support. They apply to patients with or at risk of CVD, primarily in the US, and aim to improve care quality without replacing clinical judgment.

Methodology and Modernization

Guideline methodology is continuously updated based on published standards. Modifications include a modular recommendation format with hyperlinked references. Cost-value assessments are performed when feasible. Recommendations are dynamically updated with new evidence; "full revision" and "focused update" designations are being phased out.

Selection of Writing Committee Members and Relationships with Industry

The writing committee comprises diverse experts. ACC and AHA have strict policies to ensure unbiased development. Appendix 1 details members' relationships with industry.

Evidence Review and Evidence Review Committees

Recommendations are evidence-based, focusing on RCTs but including other studies. An independent evidence review committee is commissioned for crucial clinical questions requiring systematic review; these recommendations are marked "SR."

Guideline-Directed Medical Therapy

GDMT includes clinical evaluation, diagnostic testing, pharmacological, and procedural treatments. Dosage confirmation with product inserts and evaluation for contraindications/interactions are crucial. Recommendations are limited to US-approved drugs/devices.

Introduction

1.1. Methodology and Evidence Review

Recommendations are evidence-based. A literature review from December 2023 to June 2024 covered studies in English from February 2015 onwards, using databases like MEDLINE, EMBASE, and Cochrane. Key search terms included "hypertension," "blood pressure," and "cardiovascular disease." Additional studies up to January 2025 were considered. Evidence tables are available online.

1.2. Organization of the Writing Committee

The committee included diverse specialists (cardiologists, nephrologists, neurologists, nurses, pharmacists, patient advocates) representing multiple professional organizations. One member with relevant industry relationships was removed before final approval.

1.3. Guideline Review and Approval

Reviewed by a peer review committee appointed by the Joint Committee and approved by governing bodies of ACC and AHA, and endorsed by collaborating organizations.

1.4. Scope of the Guideline

This guideline replaces the 2017 version. It excludes recommendations for BP management in patients with CCD, HF, AF, valvular heart disease, aortic disease, or PAD, as these are covered in other guidelines (Table 2). It emphasizes risk-based approaches for antihypertensive therapy initiation. The PREVENT equations are recommended over PCEs for 10-year CVD risk estimation due to their contemporary data, diverse sample, and inclusion of kidney function and social risk factors. PREVENT estimates total CVD (MI, stroke, HF), while PCEs estimate ASCVD (MI, stroke).

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1.5. Class of Recommendations and Level of Evidence

COR reflects recommendation strength (benefit vs. risk), and LOE rates scientific evidence quality (data type, quantity, consistency) (Table 3).

Definitions and Classification of BP

2.1. Definition of High BP

BP is categorized as normal, elevated, stage 1, or stage 2 hypertension (Table 4) to guide clinical and public health decisions, reflecting increasing CVD risk across these levels. This classification aids in prevention and treatment strategies. The relationship with out-of-office BP monitoring (ABPM, HBPM) is also discussed. Normal BP is <120/80 mm Hg, Elevated is 120-129 SBP and <80 DBP, Stage 1 is 130-139 SBP or 80-89 DBP, and Stage 2 is $\ge140$ SBP or $\\ge90$ DBP. Adults with SBP and DBP in two categories are designated to the higher category.

Evaluation and Diagnosis

Hypertension is the most prevalent modifiable CVD risk factor and a leading cause of death and disability. US prevalence was 46.7% from 2017-2020. BP levels increase with age. Lifetime risk for hypertension is 80-90%, with earlier onset in men and Black/Hispanic individuals. Awareness, treatment, and control rates remain low, with disparities by age and race/ethnicity. Hypertension often co-occurs with other risk factors (smoking, obesity, diabetes, CKD), leading to amplified CVD risk. Higher BP is linearly associated with fatal and nonfatal cardiovascular events; each 20 mm Hg SBP or 10 mm Hg DBP increase doubles risk. Earlier BP control is crucial as vascular damage can occur even with normal BP levels.

3.1. Patient Evaluation

3.1.1. Accurate Measurement of In-Office BP

Standardized methods are recommended for accurate in-office BP measurement. Oscillometric devices are preferred over auscultatory methods, especially automated office BP (AOBP). Proper patient preparation, positioning, environment, and validated devices with appropriate cuff size are crucial. Multiple readings are necessary for clinical decisions. Regular training and competency checks for staff are vital.

3.1.2. Patient Evaluation, Including Laboratory Tests and Other Diagnostic Procedures

For newly diagnosed hypertension, a comprehensive history, physical exam, and routine lab tests (CBC, electrolytes, creatinine, lipid profile, glucose/HbA1c, TSH, urinalysis, urine albumin-to-creatinine ratio) and 12-lead ECG are recommended (Table 6). This evaluation helps identify causes, estimate CVD risk, and detect target organ damage. Baseline tests should be repeated annually or sooner if needed.

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3.1.3. Out-of-Office BP Monitoring

Out-of-office BP monitoring (ABPM or HBPM) provides crucial information beyond office BP, improving accuracy and precision for true BP levels. ABPM offers mean, daytime, nighttime BP, nocturnal dipping, early-morning surge, and variability. HBPM provides mean BP over days/weeks and variability across days.

3.1.4. ABPM and HBPM

ABPM or HBPM are recommended to confirm hypertension and monitor medication titration. HBPM is practical for longitudinal management, especially with co-interventions. Validated devices and correct cuff size are essential. Table 7 provides BP thresholds. Out-of-office BP monitoring has stronger CVD outcome prediction than office BP, but ABPM's superiority over HBPM for risk prediction is unclear.

3.1.4.1. Cuffless BP Devices

Cuffless BP devices are currently not recommended for diagnosis or management of high BP. Limitations include variable sensor technologies, validation approaches, and inconsistent agreement with cuff-based methods.

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3.2. Patient Diagnosis

3.2.1. Causes of Hypertension

Hypertension results from a complex interplay of behavioral, environmental, hormonal, and genetic factors. Key contributors include high sodium, low potassium, alcohol overuse, weight gain, obesity, insulin resistance, sleep disturbances, psychosocial stressors, and environmental toxins. BP is highly heritable, but genetic variants explain less than 10% of variance, highlighting environmental and gene-environment interactions. (Table 8)

3.2.2. White-Coat Hypertension and Masked Hypertension, and White-Coat Effect and Masked Uncontrolled Hypertension

Out-of-office BP monitoring differentiates hypertension types (Table 9). ABPM is the reference standard for white-coat and masked hypertension diagnosis, while HBPM is preferred for white-coat effect and masked uncontrolled hypertension. Untreated office SBP \ge130 mm Hg or DBP \ge80 mm Hg (but not \ge160/100 mm Hg) warrants out-of-office BP to exclude white-coat hypertension (COR 2a). Out-of-office monitoring is useful for white-coat/masked hypertension to exclude progression to sustained hypertension (COR 2a) and for apparent treatment-resistant hypertension to exclude white-coat effect (COR 2a).

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3.2.3. Secondary Forms of Hypertension

Screening for secondary hypertension is recommended when clinically suspected to identify specific causes and targeted therapy (COR 1). Secondary causes are found in 5-25% of adults. Common forms include primary aldosteronism and obstructive sleep apnea (OSA). Screening for primary aldosteronism is recommended in resistant hypertension, even without hypokalemia (COR 1). Referral to a specialist is reasonable for positive screening tests (COR 2a).

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3.2.3.1. Primary Aldosteronism

Screening for primary aldosteronism is recommended in patients with hypertension and resistant hypertension, hypokalemia (spontaneous or diuretic-induced), OSA, adrenal mass, or family history of early-onset hypertension/stroke (<40 years) (COR 1). Plasma aldosterone, renin activity, and their ratio are recommended for screening (COR 1). Most antihypertensive medications (except MRAs) should be continued before initial screening (COR 1). Referral to a specialist is recommended for positive screening (COR 1).

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3.2.3.2. Renal Artery Stenosis

Medical therapy is recommended for atherosclerotic renal artery stenosis to reduce kidney and CVD morbidity (COR 1). Revascularization may be considered if medical management fails (COR 2a). For nonatherosclerotic renal artery stenosis (e.g., fibromuscular dysplasia), revascularization is also reasonable (COR 2b).

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3.2.3.3. Obstructive Sleep Apnea

In adults with hypertension and OSA who are overweight/obese, weight loss interventions combined with CPAP can reduce SBP (COR 2a). For resistant hypertension and moderate-to-severe OSA, CPAP treatment can reduce BP (COR 2a).

Prevention Strategies

Lifestyle behaviors are crucial for preventing hypertension, even for those with a genetic predisposition. Recommended primordial prevention strategies include all therapies listed in Section 5.1 ("Lifestyle and Psychosocial Approaches"), such as weight loss, DASH diet, sodium reduction (<2300 mg/day, ideally <1500 mg/day), potassium intake (3500-5000 mg/day), aerobic and resistance exercise (\ge150 min/week moderate activity, \ge2 days/week resistance), and stress management. Alcohol intake, even small amounts, is associated with higher SBP.

BP Management

5.1. Lifestyle and Psychosocial Approaches

Lifestyle modifications are critical for controlling BP and preventing CVD events. These include:

• Weight Loss: >5\% body weight reduction (or >3 kg/m^2 BMI) is recommended for overweight/obese adults (COR 1). Aim for 1 mm Hg BP reduction per 1 kg weight loss.

• Diet and Nutrients: Heart-healthy eating patterns like the DASH diet are recommended (COR 1). Reduced sodium intake (<2300 mg/day, ideally <1500 mg/day) is also recommended (COR 1). Potassium-based salt substitutes can be useful, except in CKD or with potassium-retaining drugs (COR 2a). Moderate potassium supplementation (<80 mmol/day), preferably from diet, is recommended, with caution in CKD or with potassium-reducing drugs (COR 1).

• Alcohol: Abstinence or reduction to \le1 drink/day for women and \le2 drinks/day for men is advised (COR 1).

• Physical Activity: Structured exercise (aerobic and/or resistance training: \ge150 min/week moderate activity, \ge2 days/week resistance) is recommended (COR 1).

• Stress Reduction: Transcendental meditation (COR 2b) and other stress management techniques like breathing control or yoga (COR 2b) may be reasonable as adjuncts.

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5.2. Medical Management

Thiazide-type diuretics (hydrochlorothiazide, chlorthalidone, indapamide) are grouped under one term. While generally interchangeable, thiazide-like diuretics are preferred for resistant hypertension due to greater efficacy.

5.2.1. Initiation of Pharmacologic BP Treatment in the Context of Overall CVD Risk

Antihypertensive therapy benefits are maximized by prioritizing high-risk individuals using absolute risk estimation. A risk-based strategy is more effective and efficient than a BP-alone strategy.

5.2.2. BP Treatment Threshold and the Use of CVD Risk Estimation to Guide Drug Treatment of Hypertension

• All Adults with Hypertension: Initiate medications if average SBP \ge140 mm Hg or DBP \ge90 mm Hg (COR 1).

• Hypertension with Clinical CVD: Initiate medications if average SBP \ge130 mm Hg or DBP \ge80 mm Hg (COR 1).

• Hypertension without Clinical CVD but High Risk: Initiate medications if average SBP \ge130 mm Hg or DBP \ge80 mm Hg, for those with diabetes, CKD, or \ge7.5\% 10-year CVD risk (PREVENT) (COR 1).

• Hypertension without Clinical CVD and Low Risk: If average SBP remains \ge130 mm Hg or DBP \ge80 mm Hg after 3-6 months of lifestyle intervention, initiate medications (COR 1).

Figure 6 provides a summary of risk-based thresholds for BP treatment initiation. The PREVENT equations are the most accurate and generalizable risk prediction tool for US adults aged 30-79 years.

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5.2.3. Initial Medication Selection for Treatment of Primary Hypertension

Thiazide-type diuretics, long-acting dihydropyridine CCB, ACEi, or ARB are recommended as first-line therapy due to their favorable profiles for BP lowering, CVD prevention, and tolerability (COR 1).

5.2.4. Choice of Initial Monotherapy Versus Initial Combination Drug Therapy

• Stage 2 Hypertension (SBP \ge140 mm Hg and DBP \ge90 mm Hg): Initiate two first-line agents of different classes, ideally in a single-pill combination (SPC) (COR 1).

• Stage 1 Hypertension (SBP 130-139 mm Hg and DBP 80-89 mm Hg): Initiate a single first-line antihypertensive drug, with titration as needed (COR 2a).

• Avoid Harm: Simultaneous use of ACEi, ARB, and/or renin inhibitor is not recommended due to harm (COR 3: Harm).

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5.2.5. Antihypertensive Medication Adherence Strategies

• Once-Daily Dosing: Beneficial for improving adherence (COR 1).

• Single-Pill Combinations (SPCs): Effective for improving adherence by reducing pill burden (COR 1).

• Reminder Aids and Education: Medication reminder aids and educational interventions are useful (COR 2a).

5.2.6. Medication Interactions

Knowledge of pharmacology and drug-drug interactions is essential. Important pharmacokinetic interactions involve the CYP3A4 pathway (e.g., verapamil, diltiazem). Pharmacodynamic interactions can be beneficial (e.g., RAS blocker with a thiazide diuretic) or harmful (e.g., ACEi and ARB combined).

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5.2.7. BP Goal for Patients With Hypertension

• High CVD Risk: SBP goal of <130 mm Hg, with encouragement for <120 mm Hg, is recommended to reduce CVD events and mortality (COR 1).

• Not High CVD Risk: SBP goal of <130 mm Hg, with encouragement for <120 mm Hg, may be reasonable to prevent further BP elevation (COR 2b).

• High CVD Risk: DBP target of <80 mm Hg is recommended to reduce CVD events and mortality (COR 1).

• Not High CVD Risk: DBP target of <80 mm Hg may be reasonable to reduce CVD events (COR 2b).

5.2.8. Electrolyte Imbalances

Electrolyte assessment is crucial at diagnosis and 2-4 weeks after initiating/titrating diuretics, ACEi, ARB, and MRA. Hypokalemia from diuretics and hyperkalemia from RASi/MRA are common. Hyponatremia can occur with diuretics. Combined use of ACEi and ARB increases AKI risk. Strategies include dietary changes, supplementation, and complementary drug combinations.

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5.2.9. Kidney Dysfunction/Injury

Estimated GFR should be measured 2-4 weeks after initiating/titrating antihypertensives. An expected $\\le30\% dip in eGFR with RAASi is generally benign. Persistent $\gt30\% decline warrants nephrologist referral to rule out AKI, CKD progression, or renal artery stenosis. Diuretic-induced kidney dysfunction may indicate hypovolemia.

5.3. Comorbidities

Hypertension-related target organ damage (e.g., LVH, HF, CKD, stroke, dementia) is prevalent and increases CVD risk. Hypertension control is key to preventing organ damage.

5.3.1. Diabetes

• T2D and Hypertension: Initiate treatment at SBP \ge130 mm Hg (goal <130 mm Hg, encourage <120 mm Hg) and DBP \ge80 mm Hg (goal <80 mm Hg) to reduce CVD morbidity and mortality (COR 1).

• Drug Classes: All first-line classes are effective (COR 1).

• ACEi/ARB: Recommended for CKD (eGFR <60 mL/min/1.73 m^2 or albuminuria \ge30 mg/g) and considered for mild albuminuria to delay kidney disease progression (COR 1).

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5.3.2. Obesity and Metabolic Syndrome

• Incretin Mimetics (e.g., GLP-1 receptor agonists): May be effective for lowering BP as an adjunct to weight management in overweight/obese adults (BMI \ge27 kg/m^2) (COR 2b).

• Bariatric Surgery: May be effective at lowering BP in individuals with obesity (BMI \ge35.0 kg/m^2) (COR 2b).

5.3.3. Chronic Coronary Disease

Reducing SBP to <130 mm Hg lowers cardiovascular risk. ACEi, ARB, and BB reduce CVD events and mortality. BBs should be continued if patients are on them. If needed, CCB, thiazide-type diuretics, and/or MRA can be added.

5.3.4. Prevention of HF in Adults With Hypertension

• SBP Target: Treating SBP to <130 mm Hg is recommended to lower HF risk (COR 1).

• DBP Target: Treating DBP to <80 mm Hg is recommended to lower HF risk (COR 1).

5.3.4.1. HF With Reduced Ejection Fraction (HFrEF)

Uptitration of HF GDMT is recommended for BP control. A goal SBP <130 mm Hg should be attained. Dihydropyridine CCBs can be used; nondihydropyridine CCBs are not recommended.

5.3.4.2. HF With Preserved Ejection Fraction (HFpEF)

Diuretics are crucial for volume overload. RAASi (MRA or ARNi, or ARB) are indicated for SBP <130 mm Hg. SGLT2i are frequently used. BBs are only for specific comorbidities.

5.3.5. Atrial Fibrillation

Hypertension is the highest attributable risk for AF. Optimal BP control reduces MACE (including stroke). Lifestyle modifications may decrease AF recurrence. ACEi or ARB may reduce AF incidence/recurrence. MRAs reduce AF burden. General hypertension guidelines (goal BP <130/80 mm Hg) apply.

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5.3.6. Valvular Heart Disease

Uncontrolled hypertension with aortic stenosis/regurgitation is linked to worsening symptoms, HFrEF, and death. Antihypertensive medications control BP. ACEi or ARB are associated with reduced mortality after TAVR and reductions in cardiovascular events with chronic aortic regurgitation. No specific optimal BP targets for chronic aortic regurgitation.

5.3.7. Aortic Disease

Hypertension is a major risk factor for AD (aneurysm, dissection). Intensive BP management (<130/80 mm Hg) is crucial. BBs are recommended, with data often extrapolated from acute aortic syndrome.

5.3.8. Hypertension Treatment in Patients With CKD

• SBP Goal: For CKD (eGFR <60 mL/min/1.73 m^2 or albuminuria \ge30 mg albumin/g creatinine), target SBP <130 mm Hg to decrease all-cause mortality (COR 1).

• RAASi: For CKD (eGFR <60 mL/min/1.73 m^2 with albuminuria \ge30 mg/g), RAASi (ACEi or ARB, not both) is recommended to decrease CVD and delay kidney disease progression (COR 1).

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5.3.8.1. Hypertension After Kidney Transplantation

Hypertension is common post-transplant. Optimal BP goals or drug choices lack robust trial data. Continued immunosuppression can increase hypertension risk. Insufficient evidence for specific recommendations, but masked hypertension is prevalent.

5.3.9. Cerebrovascular Disease

BP management in stroke is complex due to diverse causes. Recommendations depend on stroke acuity, type, and therapeutic goals.

5.3.9.1. Acute Intracerebral Hemorrhage (ICH)

• SBP Reduction (150-220 mm Hg): Beneficial to immediately lower SBP to 130 to <140 mm Hg for at least 7 days, stopping if SBP <130 mm Hg (COR 2a).

• Careful Titration: Smooth, nonlabile, and sustained BP control is beneficial for functional outcomes (COR 2a).

• SBP Reduction (Harm >220 mm Hg): SBP should not be lowered below 130 mm Hg for patients presenting with SBP >220 mm Hg (COR 3: Harm).

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5.3.9.2. Acute Ischemic Stroke

• Hypotension/Hypovolemia: Correct to maintain organ perfusion (COR 1).

• IV Thrombolytics: Lower BP to SBP <185 mm Hg and DBP <110 mm Hg before and maintain below 180/105 mm Hg for 24 hours (COR 2a).

• Endovascular Treatment: Maintain BP at \le180/105 mm Hg during and for 24 hours post-procedure (COR 2a).

• BP \ge220/120 mm Hg (No Thrombolysis/Endovascular): May be reasonable to lower BP by 15% in first 24 hours (COR 2b).

• BP <220/120 mm Hg (No Thrombolysis/Endovascular): No benefit in initiating/reinitiating treatment within 48-72 hours (COR 3: No Benefit).

• Post-Reperfusion SBP <140 mm Hg (Harm): Can worsen long-term functional outcome (COR 3: Harm).

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5.3.9.3. Secondary Stroke Prevention

• Drug Choice: Thiazide-type diuretics, ACEi, or ARB are recommended for lowering BP and reducing recurrent stroke/ICH risk (COR 1).

• BP Goal: Office SBP/DBP goal of <130/80 mm Hg is recommended to reduce recurrent events (COR 1).

• No Prior Hypertension, BP \ge130/80 mm Hg: Antihypertensive medication can be beneficial (COR 2a).

5.3.9.4. Mild Cognitive Impairment and Dementia

• SBP Goal: SBP <130 mm Hg is recommended to prevent mild cognitive impairment and dementia (COR 1).

5.3.10. Peripheral Artery Disease (PAD)

Hypertension is the most common risk factor for PAD. Treatment to a BP goal of <130/80 mm Hg is optimal to reduce MACE. ACEi or ARB should be first-line agents.

5.4. Plan of Care for Hypertension

Team-Based Care

• Uncontrolled Hypertension: Team-based care is recommended for achieving and maintaining BP control (COR 1).

• Evidence-Based Plan: An evidence-based care plan utilizing HBPM and responsive to SDOH is recommended (COR 1).

Framework in Clinical Practice to Improve Hypertension Control

• Integrated Treatment Model: Accurate BP measurement, prompt treatment, patient engagement, and ongoing HBPM review are recommended (COR 1).

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Follow-Up After Initial BP Evaluation and Initiation of Antihypertensive Therapy

• Uncontrolled Hypertension: Monthly follow-up evaluations are needed until control is achieved (COR 1).

Health Information Technology (HIT)

• Uncontrolled Hypertension: HIT (synchronous/asynchronous communication) is beneficial for improving BP control, access to care, and adherence (COR 1).

• Undiagnosed/Uncontrolled Hypertension: EHR and patient registries are beneficial for screening and identification (COR 1).

• Telehealth Interventions: Useful for reducing BP and improving office BP control (COR 2a).

5.5. Hypertension and Pregnancy

• Planning/Pregnant: Labetalol and extended-release nifedipine are preferred agents (COR 1). Low-dose aspirin (81 mg/day) is recommended to reduce preeclampsia risk (COR 1).

• Severe Range (SBP \ge160 mm Hg or DBP \ge110 mm Hg): Antihypertensive medication to lower BP to <160/110 mm Hg within 30-60 minutes (COR 1).

• Chronic Hypertension: Antihypertensive therapy to achieve BP <140/90 mm Hg (COR 1).

• Avoid Harm: Atenolol, ACEi, ARB, direct renin inhibitors, nitroprusside, or MRA are contraindicated (COR 3: Harm).

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5.5.1. Gestational Hypertension

Defined as de novo hypertension after 20 weeks' gestation without new proteinuria/organ damage. Associated with increased maternal/fetal adverse events. ACOG recommends severe-range gestational hypertension be managed similarly to preeclampsia with severe features.

5.5.2. Preeclampsia and Eclampsia, Including Preeclampsia Superimposed on Chronic Hypertension

Preeclampsia is an HDP with hypertension and proteinuria or organ dysfunction. Magnesium sulfate and antihypertensives are mainstays. Low-dose aspirin can reduce preeclampsia risk.

5.5.3. Short- and Long-Term Follow-Up of Pregnancy-Associated Hypertension

Individualized postpartum BP measurement and medication titration. HBPM, team-based care, and telehealth may improve outcomes. History of HDP increases future CKM risk. Annual BP measurement is encouraged for those whose BP normalizes. HDP are sex-specific risk enhancers for primary CVD prevention.

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5.6. Resistant Hypertension and Renal Denervation

Resistant Hypertension

• Detailed Evaluation: Recommended for secondary causes and removal of interfering medications (COR 1).

• MRA Addition: Recommended for uncontrolled resistant hypertension despite optimal first-line therapy (ACEi/ARB + CCB + thiazide-like diuretic, eGFR \ge45 mL/min/1.73 m^2) (COR 1).

• Alternative Agents: If MRA is not tolerated/contraindicated, amiloride, BBs, alpha-blockers, central sympatholytic drugs, dual endothelin receptor antagonists, or direct vasodilators are reasonable (COR 2a).

Renal Denervation (RDN)

• Adjunct Treatment: May be reasonable for carefully selected patients with resistant hypertension (office SBP 140-180 mm Hg and DBP \ge90 mm Hg, eGFR \ge40 mL/min/1.73 m^2) who have failed or cannot tolerate drug therapy (COR 2b).

• Multidisciplinary Team: All patients considered for RDN should be evaluated by a multidisciplinary team (COR 1).

• Shared Decision-Making: Benefits and risks should be discussed with patients (COR 1).

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6. Complications of Management

6.1. Management of Orthostatic Hypotension (OH)

• Improved BP Control: Recommended to reduce OH risk (COR 1).

• Asymptomatic OH with Intensive Therapy: SBP goal <130 mm Hg is reasonable due to CVD and mortality benefit (COR 2a).

• Symptomatic OH Assessment: Reasonable to detect other chronic conditions when initiating or adding medication with a SBP goal of <130 mm Hg (COR 2a).

6.2. Hypertensive Emergencies and Severe Hypertension in Nonpregnant and Nonstroke Patients

• Hypertensive Emergency (BP >180/120 mm Hg + Acute Target Organ Damage): ICU admission for continuous monitoring and parenteral therapy (COR 1).

• Compelling Conditions (e.g., Acute Aortic Syndrome): SBP should be reduced to <140 mm Hg, or <120 mm Hg in aortic dissection, within the first hour (COR 1).

• No Compelling Condition: SBP should be reduced by \le25\% within the first hour; then to <160/100 mm Hg within 2-6 hours; then cautiously to 130-140 mm Hg over 24-48 hours (COR 1).

• Hospitalized Severe Hypertension (No Acute Organ Damage): Intermittent use of additional IV or oral antihypertensives to acutely reduce BP is not recommended (COR 3: Harm).

6.2.1. Medications for Hypertensive Emergencies

Treatment depends on rapid recognition and specific condition. Tables 26 and 27 list preferred agents and considerations.

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6.3. Sexual Dysfunction

Frequently reported in hypertension; more by women. Linked to vascular issues and common risk factors. Diuretics and BBs (except nebivolol) may contribute to erectile dysfunction; ARBs have a favorable profile. Phosphodiesterase-5 inhibitors are safe for erectile dysfunction, but caution is needed with CYP3A4 inhibitors, grapefruit juice, alcohol, and nitrates.

6.4. Patients Scheduled for Surgical Procedures

• Chronic BB Use: BBs should be continued perioperatively (COR 1).

• Most Medications: Reasonable to continue most antihypertensives perioperatively (COR 2a).

• ACEi/ARB Discontinuation: May be considered preoperatively to prevent hypotension (COR 2b).

• High BP (>180/110 mm Hg): Deferring elective surgery may be considered to minimize complications (COR 2b).

• Abrupt BB/Clonidine Discontinuation: Potentially harmful due to rebound hypertension (COR 3: Harm).

• New BB on Surgery Day: Should not be started due to increased postoperative mortality risk (COR 3: Harm).

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7. Evidence Gaps and Future Directions

While advancements have been made, key knowledge gaps remain, indicating areas for future research:

• Hypertension Control Rates: Most US adults with hypertension are not controlled. Research is needed on effective screening methods and implementation strategies for BP control within and outside healthcare.

• Younger Adults: Clarify BP targets and treatment decisions for younger adults, especially for diastolic hypertension and low short-term CVD risk. Studies should include CVD endpoints beyond academic centers and evaluate target organ damage.

• Accurate BP Measurement: Trials comparing attended vs. unattended AOBP methods are needed. Continued research on accurate wearable and cuffless devices, HBPM, ABPM, and other novel approaches is crucial. Studies comparing home and ambulatory BP for CVD risk are needed to reduce disparities.

• Interventions and Adherence: Further studies on HBPM combined with interventions to achieve/maintain BP control using health technology and minimize nonadherence are required.

• Social Determinants of Health (SDOH): More research is needed at the intersection of BP, race/ethnicity, and SDOH, focusing on underinsured/uninsured populations. BP treatment thresholds and targets need clarification for different subpopulations to ensure equitable application.

• Genetic and Environmental Factors: Further studies are needed on genetic and epigenetic factors in BP, using risk estimates that consider environmental and behavioral influences.

• Sleep Apnea Treatment: Evidence for BP lowering from sleep apnea treatment is limited; this is an area for research.

• Stress Management: Early promising studies need testing across a broader patient range, especially with adverse SDOH.

• Medication Combinations: Additional trials comparing combinations of medications (separate vs. SPCs) are needed to improve adherence and effectiveness.

• Pregnancy and Hypertension: Safety and effectiveness of antihypertensive therapies, contraception options, and prophylactic aspirin therapy need further study in pregnant individuals or those planning pregnancy.

• Severe Hypertension and Perioperative Management: Trials are challenging in these areas; pragmatic study designs may be helpful.

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Appendix 1. Writing Committee Relationships With Industry and Other Entities

This appendix transparently lists all reported relationships between committee members and industry or other entities during the guideline development. These relationships are categorized (Employment, Consultant, Speakers Bureau, Ownership/Partnership/Principal, Personal Research, Institutional/Organizational/Other Financial Benefit, Expert Witness) and specify if they are 'RELEVANT' or 'NOT RELEVANT' to the document. Significant interests (\ge5\% ownership or >5\% gross income from entity) are noted. One member was removed due to policy regarding relevant RWI balance.

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Appendix 2. Reviewer Relationships With Industry and Other Entities

Similar to Appendix 1, this section provides a transparent list of all reported relationships with industry and other entities for the peer review committee members at the time of peer review. Categories and significance notation are consistent with Appendix 1.