Clinical Update

ADAPTED FROM:

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

AHA Clinical Update PPTX

Table 1. CLASS (STRENGTH) OF RECOMMENDATION
CLASS 1 (STRONG) Benefit >>> Risk
LEVEL (QUALITY) OF EVIDENCE‡
LEVEL A
Applying Class of Suggested phrases for writing recommendations:
• Is recommended
• High-quality evidence‡ from more than 1 RCT
• Meta-analyses of high-quality RCTs
Recommendation • Is indicated/useful/effective/beneficial
• Should be performed/administered/other
• One or more RCTs corroborated by high-quality registry studies

and Level of • Comparative-Effectiveness Phrases†:

− Treatment/strategy A is recommended/indicated in preference to
LEVEL B-R
• Moderate-quality evidence‡ from 1 or more RCTs
(Randomized)

Evidence to
treatment B
• Meta-analyses of moderate-quality RCTs
− Treatment A should be chosen over treatment B
LEVEL B-NR (Nonrandomized)
Clinical Strategies, CLASS 2a (MODERATE)
Suggested phrases for writing recommendations:
Benefit >> Risk
• Moderate-quality evidence‡ from 1 or more well-designed, well-

Interventions,
executed nonrandomized studies, observational studies, or registry
• Is reasonable
studies
• Can be useful/effective/beneficial
• Meta-analyses of such studies
Treatments, or • Comparative-Effectiveness Phrases†:
− Treatment/strategy A is probably recommended/indicated in preference to LEVEL C-LD (Limited Data)

Diagnostic Testing
treatment B
− It is reasonable to choose treatment A over treatment B • Randomized or nonrandomized observational or registry studies
with limitations of design or execution

in Patient Care CLASS 2b (Weak)

Suggested phrases for writing recommendations:
Benefit ≥ Risk • Meta-analyses of such studies
• Physiological or mechanistic studies in human subjects
• May/might be reasonable LEVEL C-EO (Expert Opinion)
• May/might be considered
• Usefulness/effectiveness is unknown/unclear/uncertain or not well-established • Consensus of expert opinion based on clinical experience.

CLASS 3: No Benefit (MODERATE) Benefit = Risk COR and LOE are determined independently (any COR may be paired with any LOE).
A recommendation with LOE C does not imply that the recommendation is weak. Many
Suggested phrases for writing recommendations: important clinical questions addressed in guidelines do not lend themselves to clinical
• Is not recommended trials. Although RCTs are unavailable, there may be a very clear clinical consensus that a
particular test or therapy is useful or effective.
• Is not indicated/useful/effective/beneficial
• Should not be performed/administered/other * The outcome or result of the intervention should be specified (an improved
clinical outcome or increased diagnostic accuracy or incremental prognostic
information).
CLASS 3: Harm (STRONG) Risk > Benefit
† For comparative-effectiveness recommendation (COR 1 and 2a; LOE A and B only),
Suggested phrases for writing recommendations: studies that support the use of comparator verbs should involve direct
comparisons of the treatments or strategies being evaluated.
• Potentially harmful
• Causes harm ‡ The method of assessing quality is evolving, including the application of
standardized, widely-used, and preferably validated evidence grading tools; and
• Associated with excess morbidity/mortality for systematic reviews, the incorporation of an Evidence Review Committee.
• Should not be performed/administered/other COR indicates Class of Recommendation; EO, expert opinion; LD, limited data; LOE, Level
of Evidence; NR, nonrandomized; R, randomized; and RCT, randomized controlled trial.

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Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults.Circulation.
Definition and Classification of Blood Pressure

Blood Pressure Category SBP DBP

COR RECOMMENDATIONS
Normal < 120 mmHg and < 80 mmHg

In adults, BP should be
Elevated 120 to 129 mmHg and < 80 mmHg categorized as normal,
elevated, or stage 1 or
Hypertension 1 stage 2 hypertension
to prevent and treat
Stage 1 Hypertension 130 to 139 mmHg or 80 to 89 mmHg high BP.

Stage 2 Hypertension ≥ 140 mmHg or ≥ 90 mmHg

Abbreviations: BP indicates blood pressure; DBP, diastolic blood pressure; and SBP, systolic blood pressure.
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 Best Practices for Accurate
In-Office Blood Pressure Measurement
Avoid caffeine, exercise, Use a BP device that has been validated
and smoking for at least for accuracy (validatebp.org). COR RECOMMENDATIONS
30 minutes before.
Use the correct cuff size When diagnosing and
on a bare arm. managing high BP in adults,
The patient’s arm
should be supported standardized methods are
at heart level.
1 recommended for the
accurate measurement and
Take 2 or more BP documentation of in-office BP.
Patient should be measurements at
relaxed, sitting in a chair least 1-minute apart.
(feet flat, legs uncrossed,
and back supported) for When measuring in-office BP
at least 5 minutes. in adults, it is reasonable to
BP measurement should be
done in a temperature-
2a use the oscillometric method
Neither patient nor with an automated device
controlled room.
clinician should talk during over the auscultatory method.
the rest or measurement.
No use of phones.

Abbreviation: BP indicates blood pressure.

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Essential Laboratory Tests and Diagnostic Procedures
• When hypertension is suspected or confirmed, laboratory and
diagnostic procedures are a standard part of the evaluation. Routine Diagnostic Studies
• This information will provide a baseline and will inform • Complete blood count
management decisions including the need for additional
testing. • Serum sodium, potassium, calcium
• These tests should be repeated at least annually to monitor for • Serum creatinine with estimation
potential adverse effects of therapies including kidney disease of GFR
progression and changes in predicted CVD risk.
• Lipid profile
• Additional diagnostic evaluation should be considered when
secondary causes of hypertension are suspected. • Fasting blood glucose or
Hemoglobin A1c
COR RECOMMENDATIONS • Thyroid-stimulating hormone
For adults who are diagnosed with hypertension, laboratory tests • Urinalysis
(ie, complete blood count, serum electrolytes, serum creatinine, lipid • Urine albumin to creatinine ratio;
1 profile, glucose or Hgb A1c, thyroid-stimulating hormone, urinalysis, urine protein to creatinine ratio
and urine albumin to creatinine ratio) and diagnostic procedures
(12-lead ECG) should be performed to optimize management. • Electrocardiogram

Abbreviations: CVD indicates cardiovascular disease; ECG, electrocardiogram; and Hgb, hemoglobin.
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From Clinic to Home: Blood Pressure Monitoring

COR RECOMMENDATIONS

In adults with suspected hypertension, out- Corresponding Ambulatory and Home Blood
of-office BP measurements by either ABPM Values Measurement to Office Values
1 or HBPM are recommended to confirm the
diagnosis of hypertension. Daytime Nightime 24-Hour
Office HBPM
ABPM ABPM ABPM
In adults who are taking antihypertensive (mmHg) (mmHg)
(mmHg) (mmHg) (mmHg)
medication, HBPM is recommended for
monitoring the titration of BP-lowering 120/80 120/80 120/80 100/65 115/75
1 medication, along with co-interventions
130/80 130/80 130/80 110/65 125/75
such as patient education, telehealth
counseling, and clinical interventions. 140/90 135/85 135/85 120/70 130/80
3: In adults, the use of cuffless BP devices is 160/100 145/90 145/90 140/85 145/90
No not recommended for the diagnosis or
Benefit management of high BP.

Abbreviations: ABPM indicates ambulatory blood pressure monitoring; BP, blood pressure; and HBPM, home blood pressure monitoring.
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Hypertension Causes, from Lifestyle to Genetics

Dietary Intake Factors Non-Dietary Factors

• Higher sodium intake • Genetics variants

• Lower potassium • Overweight/obesity
intake • Lower physical
• Lower calcium/ activity/fitness
magnesium intake • Sleep disturbances
• Lower diet quality (related to duration,
(lower intake of fruits/ quality, regularity
vegetables, plant and/or disordered
proteins, fiber) breathing)
• Alcohol intake • Psychosocial
stressors
• Air pollution

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White-coat and Masked Hypertension
• White-coat hypertension: BP is high in the office
setting and normal or elevated outside of the office
setting
• Masked hypertension: BP is high outside of the
office setting and normal or elevated in the office
setting
• ABPM is preferred for excluding white-coat and
masked hypertension among individuals not taking
antihypertensives.
• Adults with in-office BP ≥160/100 mmHg should be
promptly started on antihypertensives
• Studies have shown that individuals with white-
coat and masked hypertension compared to those
with sustained normotension are more likely to
have sustained hypertension on follow-up.
Abbreviations: ABPM indicates ambulatory blood pressure monitoring; BP, blood pressure;
DBP, diastolic blood pressure; and SBP, systolic blood pressure.
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White-coat and Masked Hypertension
COR RECOMMENDATIONS
In adults with untreated office SBP ≥130 mm Hg or DBP ≥80 mm Hg, and without office SBP ≥160 mm Hg or DBP
2a ≥100 mm Hg, it is reasonable to exclude white-coat hypertension using out-of-office BP monitoring before a
diagnosis of hypertension is made.
In adults with white-coat hypertension, out-of-office BP monitoring is reasonable to exclude transition to a
2a diagnosis of sustained hypertension.
In adults with apparent treatment resistant hypertension on office BP, it is reasonable to exclude white-coat
2a effect, a form of pseudoresistance, using out-of-office BP monitoring
In adults who are taking antihypertensive medication and have elevated office BP (office SBP ≥130 mm Hg or DBP
2a ≥80 mm Hg), but do not have resistant hypertension or office SBP ≥160 mm Hg or DBP ≥100 mm Hg, it is
reasonable to exclude white-coat effect using out-of-office BP monitoring
In adults with untreated office SBP <130 mm Hg and DBP <80 mm Hg, it may be reasonable to exclude masked
2b hypertension using out-of-office BP monitoring
In adults who are taking antihypertensive medication and have office SBP <130 mm Hg and DBP <80 mm Hg, it
2b may be reasonable to exclude masked uncontrolled hypertension using out-of-office BP monitoring

Abbreviations: ABPM indicates ambulatory blood pressure monitoring; BP, blood pressure;
DBP, diastolic blood pressure; and SBP, systolic blood pressure.
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Secondary Forms of Hypertension
Does the patient have any of the following conditions? COR RECOMMENDATIONS
• Drug-resistant/induced HTN • Onset of diastolic HTN in older adults
• Abrupt onset of HTN (ages ≥65 y) In adults with hypertension, screening for
• Onset of HTN at <30 y • Unprovoked or excessive hypokalemia specific forms of secondary hypertension is
• Exacerbation of previously controlled HTN • Insomnia or daytime sleepiness 1 recommended when clinical suspicion is
• Disproportionate target organ damage • Concomitant adrenal nodule present to increase rates of detection,
for degree of HTN • History of early-onset stroke
diagnosis, and specific targeted therapy.
• Accelerated/malignant HTN • Family history of primary aldosteronism
In adults with resistant hypertension,
Yes No
screening for primary aldosteronism is
recommended regardless of whether
Screen for primary aldosteronism and 1 hypokalemia is present to increase rates of
other secondary forms of HTN
detection, diagnosis, and specific targeted
therapy.
Screening not
Positive screening test? No In adults who a positive screening test for a
indicated
Yes
form of secondary hypertension, referral to
2a clinician who has expertise in that form of
hypertension is reasonable for diagnostic
Refer to clinician with specific
secondary HTN expertise confirmation and treatment.

Abbreviation: HTN indicates hypertension.

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Blood pressure management:
Lifestyle and psychosocial approaches

Weight Diet Alcohol Exercise and Stress

OVERWEIGHT WITH OR
WITH OR WITHOUT HTN WITH OR WITHOUT HTN
OR OBESE WITHOUT HTN

Class 1
Class 1 Class 1 Class 1
Class 1 Class 2a Alcohol
Weight loss Class 1 Moderate Structured Class 2b
Na+ intake Salt substitutes Abstinence
goal ≥5% Heart-healthy dietary K+ exercise Stress reduction
<2.3 g/d or
eating pattern intake program (i.e., meditation,
K+ based ≤1 drink/d
Each ↓ 1Kg, BP (i.e., DASH) 3.5-5 g/d (Aerobics and/or yoga)
Ideally, <1.5 g/d * ≤2 drinks/d
↓1/1 mmHg * Resistance)

*Monitor potassium in those at risk for hyperkalemia

Abbreviations: BP indicates blook pressure; DASH, Dietary Approaches to Stop Hypertension diet Kg, kilograms; and HTN, hypertension.

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Use of Risk Based Thresholds for Initiation of BP Treatment
Initiate anti-hypertensive medications to lower BP
BP Level-Only
Does the patient have an and reduce CVD risk for primary or secondary
Yes
average BP ≥140/90 mm Hg? prevention of CVD
COR 1

No
Initiate anti-hypertensive medications to lower BP
Risk-Based Does the patient have existing clinical CVD and reduce CVD risk if average SBP≥130 mm Hg or
Thresholds for (CHD, stroke, HF)? Yes
DBP≥80 mm Hg for secondary prevention of CVD
Initiation of BP COR 1
Treatment for
Adults* No
Initiate anti-hypertensive medications to lower BP
Does the patient have diabetes or CKD, or
and reduce CVD risk if average SBP≥130 mm Hg or
is the patient at increased short-term risk Yes
of CVD (10-year PREVENT-CVD risk≥7.5%)† DBP≥80 mm Hg for primary prevention of CVD
COR 1
No

Initiate anti-hypertensive medications to lower BP if average SBP≥130 mm Hg

or DBP≥80 mm Hg after 3-6 months of lifestyle intervention attempts
COR 1

Abbreviations: BP indicates blood pressure; CHD, coronary heart disease; CKD, chronic kidney disease; CVD, cardiovascular disease;
DBP, diastolic blood pressure; HF, heart failure; PREVENT, Predicting Risk of CVD EVENTs; and SBP, systolic blood pressure.
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Initial Medication Selection for Treatment of Primary HTN

COR RECOMMENDATIONS

For adults initiating antihypertensive drug therapy, thiazide-type diuretics, long-acting

1 dihydropyridine CCBs, and ACEi or ARBs are recommended as first-line therapy to prevent CVD.

Thiazide
Long acting
type
DHP-CCB
diuretic

ACEi OR ARB

Abbreviations: ACEi indicates Angiotensin Converting Enzyme inhibitors; ARB, Angiotensin Receptor Blocker;
CVD, cardiovascular disease; and LA DHP-CCB, Dihydropyridine Calcium Channel Blocker.
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Choice of initial monotherapy vs
combination drug therapy

Stage 1 HTN* Stage 2 HTN* Any stage HTN

Class 2a Class 1 Class 3: Harm
SBP 130-139 mmHg SBP ≥140 mmHg
DBP 80-89 mmHg DBP ≥90 mmHg

Some high-risk patients

with stage 1 HTN.

Initiation of a single 1st line agent is Initiation of two 1st line

reasonable. agents Don’t combine ACEi, ARBs
of different classes. and/or renin inhibitors.
Dosing titration and sequential addition
of other agents as needed. Ideally, in a single pill
combination to improve
adherence.

Abbreviations: ACEi indicates Angiotensin Converting Enzyme inhibitors; ARB, Angiotensin Receptor Blocker; and HTN, hypertension.
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Antihypertension medication adherence strategies

Single pill
combination
(Class 1)

Education/
Coaching
Medication
sync

Other To improve Once daily

Reminder
Aids interventions adherence dosing
(Class 2a) (Class 1)
Home BP
Monitoring
with Manage
feedback anxiety/
depression
Abbreviation: BP indicates blood pressure
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Blood pressure goals for patients with HTN

Adults with confirmed HTN

10-year ASCVD risk ≥7.5% using PREVENT

Yes No

SBP <130 mmHg, SBP <130 mmHg,

ideally <120 mmHg ideally <120 mmHg
(Class 1) (Class 2b)

DBP <80 mmHg DBP <80 mmHg

(Class 1) (Class 2b)

Abbreviations: ASCVD indicates atherosclerotic cardiovascular disease; BP, blood pressure; DBP, diastolic blood pressure;
HTN, hypertension; PREVENT, Predicting Risk of CVD EVENTs; and SBP, systolic blood pressure.
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Hypertension Management with DM

Greater than 80 % of adults with T2D have HTN.

Take Home Point: Intensive BP goals are associated with improved CV outcomes.

BP Goal Initial Management Special considerations: CKD

Use antihypertensive All first-line agents are • If eGFR <60 ml/min/1.73m2 or moderate to severe
medication(s) for effective. albuminuria >30 mg/g; ACEi or ARB are
SBP >130 mmHg (ie. Thiazide type recommended.
or diuretics, CCB, ACEi
DBP > 80 mmHg and ARBs, etc) • If mild albuminuria (<30,g/g), ACEi or ARBs
(Class 1) can delay progression of DM-related kidney disease.
(Class 1)
(Class 1)

Abbreviations: ACEi indicates Angiotensin Converting Enzyme inhibitors; ARB, Angiotensin Receptor Blocker; BP, blood pressure; CV, cardiovascular;
CCB, Calcium Channel Blocker; DBP, diastolic blood pressure; DM, diabetes mellitus; T2D, type two diabetes mellitus; and SBP, systolic blood pressure.
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Hypertension Management with
Obesity and Metabolic Syndrome

COR RECOMMENDATIONS

In adults with hypertension who also have overweight or

obesity with a BMI ≥27 kg/m2, incretin mimetics, like GLP-1
2b RAs, 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 for weight loss in combination with
2b behavioral interventions and antihypertensive therapies may
be effective at lowering BP.

Abbreviations: BMI indicates body mass index; BP, blood pressure; and GLP-1 RA, glucagon-like polypeptide-1 receptor agonist.
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Prevention of Heart Failure in Adults with HTN

COR RECOMMENDATIONS

In adults with HTN, treat SBP to <130 mm

1 Hg or DBP to <80 mm HG to prevent the
progression of HF.

Abbreviations: DBP indicates diastolic blood pressure; HF, heart failure; HTN, hypertension; and SBP, systolic blood pressure.
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HTN Treatment with CKD

COR RECOMMENDATIONS

If eGFR <60 ml/min/1.73m2 or moderate

to severe albuminuria ≥30 mg/g; SBP
1 goal of <130 mmHg to decrease all-
cause mortality.

RAASi (either ACEi or ARB but not both)

1 is recommended to decrease CVD and
delay progression of kidney disease.

Abbreviations: ACEi indicates Angiotensin Converting Enzyme inhibitors; ARB, Angiotensin Receptor Blocker; CKD, chronic kidney disease;
CVD, cardiovascular disease; eGFR, estimated glomerular filtration rate; HTN, hypertension; and RAASi, renin-angiotensin-aldosterone system inhibitor.
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Intracerebral Hemorrhage

Acute Spontaneous Intracerebral Hemorrhage

SBP: 150–220 mmHg Titration of SBP SBP: >220 mmHg

Immediately lower SBP to

• Smooth, non-labile SBP should not be lowered
130 to <140 mmHg for at
• Avoid peaks below 130 mmHg to reduce
least 7 days after ICH but
• Avoid peaks and large adverse events
stop medications if
variability Class 3: Harm
SBP<130

Improved functional
outcomes
Class 2a

Abbreviations: ICH indicates intracerebral hemorrhage; and SBP, systolic blood pressure.
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Plan of Care for Adults with Uncontrolled HTN

COR RECOMMENDATIONS

1 Team-based care approach is recommended.

Evidence-based care plan utilizing HBPM and team-based care

1 that is responsive to addressing adverse SDOH is recommended.

An integrated treatment model that includes accurate BP

1 measurement, prompt treatment, patient engagement, and
ongoing review of HBPM is recommended to improve BP control.

Abbreviation: BP indicates blood pressure; HBPM, home blood pressure monitoring; HTN, hypertension; and SDOH, social determinants of health.
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Plan of Care for Adults with Uncontrolled HTN

COR RECOMMENDATIONS

Health information technology is beneficial in improving BP

1 control, access to care, and adherence to standards of care.

Use of electronic health record and patient registries is beneficial

1 for screening and identification of hypertension to focus on
those who need additional care.

Telehealth interventions can be useful to reduce BP and improve

2a office BP control.

Adults with uncontrolled hypertension placed on new or

intensified medical therapy should have follow-up evaluations
1 for medication adherence and response to treatment at
monthly intervals until control is achieved.

Abbreviation: BP indicates blood pressure; and HTN, hypertension.

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Hypertension and Pregnancy

Individuals with hypertension who are planning a

Pregnant individuals
pregnancy or become pregnant

Labetalol and Should be counseled Should not be treated With SBP ≥160 mmHg or With Chronic
extended-release about the benefits of with atenolol, ACEi, DBP ≥ 110 mm Hg hypertension,
nifedipine are preferred low-dose (81mg/day) ARBs, direct renin confirmed on repeat treat to achieve BP
to minimize fetal risk aspirin to reduce the inhibitors, measurement within 15 <140/90 mm Hg to
and treat hypertension risk of preeclampsia nitroprusside, or MRAs minutes, lower BP to prevent maternal and
Class 1 and its sequelae to avoid fetal harm <160/<110 mm Hg within perinatal morbidity and
Class 1 Class 3: Harm 30-60 minutes to mortality
prevent adverse events Class 1
Class 1

Abbreviations: ACEi indicates Angiotensin Converting Enzyme inhibitors; ARB, Angiotensin Receptor Blocker; BP, blood pressure;
DBP, diastolic blood pressure; HTN, hypertension; MRA, mineralocorticoid receptor antagonist; SBP, systolic blood pressure; and TX, treatment.
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Diagnostic Criteria for Preeclampsia

Diagnostic Criteria for Preeclampsia

Blood pressure AND Proteinuria OR Other Criteria

Any of the following:

Either of the following: Any of the following: • Thrombocytopenia (platelet count <100k)
• SBP≥140 mmHg AND/OR • ≥300mg per 24 h urine • Reduced kidney function (serum
DBP≥90 mmHg on 2 collection creatinine>1.1 mg/dL or 2x baseline
occasions 4 hours apart >20 creatinine)
weeks gestation in a woman • Protein/creatinine ratio
with previously normal BP ≥0.3 • Impaired liver function (transaminases
>2x ULN)
• SBP ≥160 mmHg OR DBP ≥110 • Dipstick reading of 2+ (if
mmHg (confirmed over 15 other quantitative • Pulmonary edema
min) methods not available)
• New-onset headache unresponsive to
medication OR visual symptoms

Abbreviations: BP indicates blood pressure; DBP, diastolic blood pressure; SBP, systolic blood pressure; and ULN, upper limit of normal.
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Management of Resistant Hypertension
Resistant Hypertension
• Office BP ≥ 130/80 on ≥ 3 antihypertensives (ACEi/ARB + CCB + thiazide diuretic)
• Office BP < 130/80 but requires ≥ 4 antihypertensives

Workup and Address Potential Causes

• Exclude psuedoresistance (ambulatory BPs, medication adherence)
• Review and remove interfering medications
• Screen for secondary causes (primary aldosteronism, OSA, renal parenchymal disease and
renovascular disease, etc.)
Class 1

Add MRA Adding an alternative second line agent

In adults with uncontrolled resistant is reasonable to control BP
hypertension despite optimal treatment No Contraindications Yes • Amiloride • Central sympatholytic drug
with first-line antihypertensive therapy or Intolerant of MRA? • Beta Blocker • Dual endothelin receptor antagonist
and with an eGFR of ≥45 ml/min/1.73 m2 • Alpha Blocker • Direct vasodilator
Class 1 Class 2a

Abbreviations: ACEi indicates Angiotensin Converting Enzyme inhibitors; ARB, Angiotensin Receptor Blocker; BP, blood pressure; CCB, Calcium
Channel Blocker; eGFR, estimated glomerular filtration rate; MRA, mineralocorticoid receptor antagonist; and OSA, obstructive sleep apnea.
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Renal Denervation (RDN)

COR RECOMMENDATIONS

RDN Therapy may be a reasonable adjunct treatment to

meds and lifestyle modifications to reduce BP in those with
2b Resistant Hypertension Patients
office SBP 140-180 mmHg and DBP ≥ 90 mm Hg AND eGFR ≥40 ml/min/1.73m2
despite optimal medical therapy and/or side effects from medications

All Patients who are being considered for RDN should be

1 evaluated by a Multidisciplinary Team with expertise in
resistant hypertension and RDN.

For patients who are being considered for RDN, the benefits
1 and risks of the procedure should be discussed as part of the
Shared Decision-Making process.

Abbreviations: BP indicates blood pressure; DBP, diastolic blood pressure; eGFR, estimated glomerular filtration rate;
RDN, renal denervation; and SBP, systolic blood pressure.
Jones, D.W., et al. (2025). 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM 27
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Orthostatic Hypotension

COR RECOMMENDATIONS

In adults with hypertension, improved BP control is

1 recommended to reduce the risk for orthostatic
hypotension (OH).

In adults receiving intensive BP lowering therapy with

asymptomatic OH, treatment with a goal of SBP
2a <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,
2a assessment for symptomatic OH is reasonable to
detect other chronic conditions

Abbreviations: BP indicates blood pressure; CVD, cardiovascular disease; OH, orthostatic hypertension; and SBP, systolic blood pressure.
Jones, D.W., et al. (2025). 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM 28
Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults.Circulation.
 Severe Hypertension and Hypertensive Emergencies
Diagnosis and Treatment

SBP > 180 mmHg or DBP > 120 mmHg

Acute target organ damage?

Yes No

Hypertensive emergency Severe hypertension

Admit to ICU (Class 1)

Identified in ED Identified in OPT setting

Aortic dissection Evaluate inpatient vs OPT No need to refer to ED. Reinstitute

Pheochromocytoma crisis? treatment depending on and intensify or modify medical
Yes No indications(s) other than BP alone therapy in the OPT setting (Class 1)
(Class 1)
Reduce SBP <140 Reduce SBP by 25% in the
mmHg in the first hour first hour and to <160/100-110 Avoid parenteral BP lowering
and to <120 mmHg in over the next 6 hours and to Close follow-up in the OPT setting
therapy or intensified oral therapy
aortic dissection normal in the net 24-48 hours in 4 weeks
in the acute setting
(Class 1) (Class 1) (Class 3: HARM)
Abbreviations: DBP indicates diastolic blood pressure; ED, emergency department; ICU, intensive care unit; OPT, outpatient; and SBP, systolic blood pressure.
Jones, D.W., et al. (2025). 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM 29
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 Patients Scheduled for Surgical Procedures

Patient with Hypertension Planned for Major Surgery

SBP > 180 or DBP > 110 Consider delaying elective surgery to
minimize perioperative complications
Yes Class 2b
No

Continue most antihypertensive medications throughout perioperative period Class 2a

Beta Blockers Clonidine ACEi/ARB

BB therapy should not be Abrupt Discontinuation Preoperative

In patients on chronic BB, Abrupt Discontinuation
started on day of of chronic clonidine discontinuation may
continue BB throughout of chronic BB therapy is
surgery in BB naïve therapy is not reduce risk of
perioperative period not recommended
patients recommended perioperative hypotension
Class 1 Class 3: Harm
Class 3: Harm Class 3: Harm Class 2b

Abbreviations: ACEi indicates Angiotensin Converting Enzyme inhibitors; ARB, Angiotensin Receptor Blocker;
BB, beta blocker; DBP, diastolic blood pressure; and SBP, systolic blood pressure.
Jones, D.W., et al. (2025). 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM 30
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Evidence Gaps and Future Directions

Research to improve
BP targets and Studies of patients with
screening and Optimal management
long-term benefits in white coat HTN and
implementation of pregnant patients
younger adults their long-term risk
strategies for BP control

Understand genetic Understand intersection Identify alternative and

and epigenetic risk of BP race/ethnicity accurate methods to
factors for hypertension and social determinants measure BP
of health

Abbreviation: BP indicates blood pressure

Jones, D.W., et al. (2025). 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM 31
Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults.Circulation.
Acknowledgments
Many thanks to our Guideline Ambassadors who were guided by Dr. Elliott
Antman in developing this translational learning product in support of the
2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AMA/ASPC/NMA/PCNA/SGIM Guideline for
the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults.

Dr. Olu Akinrimisi Dr. Chaitanya Rojulpote

Dr. Francisco Aguilar Nunez Dr. Tayyab Shah
Dr. Jessica Oribabor

The American Heart Association requests this electronic slide deck be cited as follows:
Akinrimisi, O., Aguilar Nunez, F., Oribabor, J., Rojulpote, C., Shah, T., Reyna, G.G., Bezanson, J. L., & Antman,
E. M. (2025). AHA Clinical Update; Adapted from: [PowerPoint slides]. Retrieved from the 2025
AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention,
Detection, Evaluation and Management of High Blood Pressure in Adults.
https://professional.heart.org/en/science-news .

Jones, D.W., et al. (2025). 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM 32

Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults.Circulation.
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