New 2025 BP guideline introduces major updates
What’s new in the latest guideline for hypertension care? Lots, according to leaders of the writing committee, including an important new tool, revised approaches to clinical practice and an emphasis on professional teamwork and patient encouragement.
A multi-organization effort, led by the American Heart Association and the American College of Cardiology, produced the guideline, which was the subject of yesterday’s session “The 2025 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults.”
The update encompasses many positive steps forward, said Guideline Vice Chair Keith C. Ferdinand, MD, FACC, FAHA, FASPC, FNLA. Ferdinand is a professor of medicine and director of preventative cardiology at Tulane University School of Medicine in New Orleans.
“These updates reflect years of work and collaboration,” Ferdinand said. “They’re not just tweaks. They’re transformative changes that will shape how we care for patients with hypertension.”
One of the most notable changes, he said, is the introduction of the PREVENT (Predicting Risk of cardiovascular disease EVENTs) Equations, to more accurately assess cardiovascular risk using data from over six million Americans. This replaces the older Pooled Cohort model and allows clinicians to better determine whether patients should begin medication immediately or first attempt lifestyle modifications.
In addition, the American Heart Association PREVENT™ Online Calculator allows for the inclusion of hemoglobin A1C and urine albumin-to-creatinine ratio. It also incorporates social deprivation index data, offering a more nuanced view of patient risk based on socioeconomic factors.
“For patients with a 10-year cardiovascular disease risk score below 7.5% and no history of cardiovascular disease, chronic kidney disease or diabetes, the guideline recommends three to six months of lifestyle changes,” Ferdinand said. These changes include a low-sodium DASH diet, increased potassium intake, physical activity and — for the first time — a recommendation to address stress through transcendental meditation or yoga, he said.
Patients with a risk score of 7.5% or above, stage 2 hypertension (greater or equal to 140/90 mmHg) or pre-existing cardiovascular disease conditions are advised to begin medication immediately, Ferdinand said. In these patients, the guideline supports starting with combination therapy containing two or more medications to improve adherence and outcomes.
Sandra Taler, MD, FACP, FAHA, a guideline vice chair and a professor of medicine and nephrologist at the Mayo Clinic in Rochester, Minnesota, emphasized that while the fundamental definition of hypertension remains unchanged — blood pressure of 130/80 mmHg or higher — the new guideline encourages clinicians to aim for and patients to reach a systolic pressure below 120 mmHg through diet, lifestyle changes and medication.
This shift is supported by recent trials showing benefits of the lower target in reducing risks of heart disease, stroke and notably, dementia. Specifically, the guideline reports that intensive blood pressure control can reduce the risk of dementia by 12% to 19%, citing data from the SPRINT trial and a large Chinese study involving over 33,000 participants, Taler said.
“Dementia is a concern for all of us as we age,” she said. “The data supporting lower blood pressure goals to prevent cognitive decline is compelling.”
Another major guideline update that Ferdinand cited is the emphasis on identifying secondary causes of resistant hypertension, such as primary hyperaldosteronism. The guideline recommends testing for aldosterone-to-renin ratio testing without discontinuing most medications, except mineralocorticoid receptor antagonists such as spironolactone.
The guideline also stresses the importance of accurate blood pressure measurement, advising against the use of cuffless devices, which have not been validated, Ferdinand said. For initial medication, the guideline recommends four classes: thiazide-type diuretics, long-acting dihydropyridine calcium channel blockers, ACE inhibitors and angiotensin II receptor blockers.
The guideline for the first time includes a Class 2b recommendation for renal nerve denervation in patients with resistant hypertension, Ferdinand said, and a Class 1 recommendation for evaluation by a multidisciplinary team if the procedure is being considered.
Routine testing for urine albumin-to-creatinine ratio to detect subclinical kidney disease is another significant new recommendation in the guideline, he said.
Not surprisingly, several lifestyle recommendations have evolved. The new document recommends potassium-based salt substitutes or a high-potassium diet. It also advises abstinence from alcohol, compared with previous guidance that allowed for two or fewer standard drinks per day for men and one or fewer for women, Ferdinand said.
Clinicians will notice the guideline’s renewed emphasis on team-based care and using available tools, said Daniel Jones, MD, MACP, FAHA, and chair of the writing committee. Jones is a professor emeritus at the University of Mississippi School of Medicine in Jackson.
“The big issue with blood pressure management is control rates,” Jones said. “We’re just not doing a very good job of using the good tools we have to get blood pressure down to the levels that prevent dementia, heart disease, stroke and kidney disease.”
Jones highlighted the importance of involving nurses, nurse practitioners and pharmacists in routine patient interactions to accelerate medication adjustments and improve outcomes. This approach aims to overcome clinical inertia and improve national blood pressure control rates, he said.
He also noted a shift in tone within the guideline, encouraging clinicians to support rather than shame patients.
“We want to encourage them, not discourage them,” he said, reinforcing the importance of empathy in patient care.
As the guideline begins to influence clinical practice, Jones said he is optimistic about its potential impact.
“So far, I’ve been in front of a lot of different kinds of audiences. We’ve not had any pushback,” he said. “But the proof will be in what happens to our national blood pressure control rates.”
The new guideline marks a pivotal moment in cardiovascular care, with the potential to reshape how clinicians approach hypertension — and how patients experience it. To that end, Taler stressed that the guideline is designed to be user-friendly, with concise sections, clearly graded recommendations and a navigable format.
“Providers should use it as a reference — jump to the sections most relevant to their practice,” she said. “It’s much easier to use than previous versions.”
