Clinical Quick Reference — Prevention, Detection, Evaluation, and Management of Hypertension in Adults
This guideline replaces the 2017 ACC/AHA guideline and incorporates extensive evidence review through June 2024, including 120+ new studies on BP measurement, risk assessment, and management strategies.
Based on average BP measurements obtained in office setting. Classification framework guides prevention and treatment strategies.
| BP Category | Systolic (SBP) | Diastolic (DBP) | CVD Risk |
|---|---|---|---|
| Normal | <120 mm Hg | and <80 mm Hg | Lowest |
| Elevated | 120-129 mm Hg | and <80 mm Hg | Low |
| Stage 1 Hypertension | 130-139 mm Hg | or 80-89 mm Hg | Moderate |
| Stage 2 Hypertension | ≥140 mm Hg | or ≥90 mm Hg | High |
Recommendation: Standardized office BP measurement is recommended for accurate diagnosis and documentation. Use validated oscillometric device with proper technique.
Proper Technique:
Recommendation: In-office automated device acceptable as alternative to auscultatory method. AOBP involves multiple readings taken while patient rests alone (reduces white-coat effect).
Recommendation: AOBP or HBPM recommended to confirm diagnosis of hypertension and rule out white-coat HTN.
Recommendation: HBPM recommended for diagnosis confirmation, medication titration, and management support.
HBPM Protocol:
| Measurement Location | SBP Threshold | DBP Threshold |
|---|---|---|
| Office (avg ≥2 readings) | ≥140 mm Hg | ≥90 mm Hg |
| AOBP | ≥130 mm Hg | ≥80 mm Hg |
| HBPM (avg) | ≥130 mm Hg | ≥80 mm Hg |
| Daytime ABPM (avg) | ≥135 mm Hg | ≥85 mm Hg |
| Nighttime ABPM (avg) | ≥120 mm Hg | ≥70 mm Hg |
The 2025 guideline integrates 10-year ASCVD risk estimation (via PREVENT calculator) into BP treatment decisions.
Population: Adults aged 40-75 years without prior CVD.
Inputs: Age, sex, race/ethnicity, smoking, diabetes, SBP, cholesterol, eGFR, albuminuria.
Output: 10-year risk of ASCVD events.
| 10-Year ASCVD Risk | Risk Category | Treatment Approach |
|---|---|---|
| <7.5% | Optimal/Low | Lifestyle modification; pharmacotherapy if SBP ≥140 or DBP ≥90 |
| 7.5-19% | Intermediate | Lifestyle modification; pharmacotherapy if SBP ≥130 or DBP ≥80 with PREVENT ≥7.5% |
| ≥20% | High | Pharmacotherapy strongly recommended if SBP ≥130 or DBP ≥80 |
Recommendation: In adults with HTN without clinical CVD, initiate antihypertensive medication if estimated 10-year ASCVD risk ≥7.5%.
Recommendation: In all adults with hypertension and clinical CVD, antihypertensive medication is recommended.
Recommendation: In most adults with hypertension, target BP ≤130/80 mm Hg is recommended.
Recommendation: In older adults (≥65 years), individualize BP targets based on tolerance and comorbidities. Target 130-140 mm Hg systolic reasonable.
Recommendation: In adults with diabetes and HTN, ACEi or ARB recommended in presence of albuminuria; target ≤130/80 mm Hg.
Acute Intracerebral Hemorrhage (ICH): Target SBP <130 mm Hg within 7 days (COR 2a).
Acute Ischemic Stroke: Avoid aggressive BP reduction >15% in acute phase (COR 2b).
Post-MI: Target ≤120 mm Hg systolic if tolerated (COR 2a).
Lifestyle modifications are first-line interventions for all with elevated BP or hypertension.
DASH Diet: Recommended for BP reduction and HTN prevention (fruits, vegetables, whole grains, lean proteins, low-fat dairy).
Sodium Reduction: Sodium intake <1500 mg/day recommended to lower BP and reduce CVD risk.
Potassium Intake: Increased dietary potassium beneficial for BP reduction (bananas, sweet potatoes, spinach, beans, yogurt).
Recommendation: Regular aerobic exercise (150 minutes/week moderate intensity or 75 minutes/week vigorous) recommended to lower BP and reduce CVD risk.
Recommendation: In overweight/obese adults with hypertension, weight loss of 5-10% body weight recommended to lower BP.
Recommendation: Limit alcohol to ≤2 drinks/day for men and ≤1 drink/day for women to reduce BP and CVD risk.
Sleep Apnea Screening: In resistant HTN, screen for obstructive sleep apnea (OSA), as treatment improves BP control.
Monotherapy vs Combination: In stage 1 HTN with low CVD risk, monotherapy reasonable. In stage 2 HTN or higher CVD risk, 2 first-line agents in single-pill combination preferred for improved adherence.
Four drug classes recommended as first-line agents:
Recommendation: Add second agent if BP remains ≥130/80 mm Hg after 3-6 months on monotherapy with adequate adherence.
Preferred Combinations: ACEi/ARB + Thiazide, ACEi/ARB + CCB, Thiazide + CCB.
Recommendation: For patients remaining ≥130/80 mm Hg on 2-drug combination, add third agent such as beta-blocker, alpha-blocker, or spironolactone.
| Clinical Condition | First-Line Agent(s) | Avoid |
|---|---|---|
| CAD / Post-MI | Beta-blocker, ACEi/ARB | Vasodilators alone |
| Heart Failure (HFrEF) | ACEi/ARB, BB, MRA | CCB, direct vasodilators |
| Chronic Kidney Disease | ACEi/ARB | NSAIDs |
| Diabetes | ACEi/ARB, Thiazide, CCB | High-dose thiazides |
| Atrial Fibrillation | Beta-blocker, CCB (rate control) | Direct vasodilators alone |
| Pregnancy | Methyldopa, labetalol, nifedipine | ACEi, ARB, atenolol |
| Drug Class | Examples | Dosing | Key Considerations |
|---|---|---|---|
| ACE Inhibitors | Lisinopril, Enalapril, Ramipril | 5-40 mg/day | First-line for CAD, HF, CKD, diabetes. Monitor K+, creatinine. Dry cough possible (15-20%). |
| ARBs | Losartan, Valsartan, Irbesartan | 16-160 mg/day | Alternative to ACEi (no cough). Similar renal protection. Monitor K+, creatinine. Avoid dual RAS blockade. |
| Thiazide Diuretics | HCTZ | 12.5-25 mg daily | Effective, low-cost. Monitor K+, glucose, uric acid. Avoid in gout. |
| Thiazide-Like Diuretics | Chlorthalidone, Indapamide | 12.5-25 mg daily | More potent than HCTZ. Longer half-life. Monitor electrolytes closely. |
| Dihydropyridine CCBs | Amlodipine, Nifedipine ER, Felodipine | 5-10 mg daily | Well-tolerated. Peripheral edema, headache, flushing. CYP3A4 interactions. |
| Non-DHP CCBs | Diltiazem, Verapamil | Diltiazem 180-480 mg ER | Constipation, bradycardia, AV block. Avoid in HFrEF, acute HF. |
| Beta-Blockers | Metoprolol, Atenolol, Bisoprolol, Carvedilol | 25-200 mg/day | First-line in CAD, post-MI, HF. Fatigue, sexual dysfunction, bradycardia, AV block. |
| Alpha-Blockers | Doxazosin, Terazosin | 1-16 mg/day | Orthostatic hypotension, syncope risk. Avoid as monotherapy (higher CVD events). |
| MRAs | Spironolactone, Eplerenone | 12.5-50 mg/day | Powerful third/fourth agents. MAJOR: hyperkalemia risk. Monitor K+ closely. Monitor creatinine. |
| Direct Vasodilators | Hydralazine, Minoxidil | Hydralazine 25-100 mg/day | Reflex tachycardia (hydralazine), fluid retention (minoxidil). Combine with BB/diuretic. |
BP ≥130/80 mm Hg despite 3+ antihypertensive agents of different classes at optimal doses, including a diuretic. Or BP controlled to <130/80 mm Hg but requires ≥4 agents.
Pseudo-Resistant (More Common):
True Resistant HTN (5-10% of HTN population):
Recommendation: In adults with resistant HTN, evaluate for secondary causes including primary aldosteronism screening.
| Secondary Cause | Screening Test | Further Workup |
|---|---|---|
| Primary Aldosteronism | Serum aldosterone/plasma renin ratio ≥20 | Suppression test, adrenal CT/MRI |
| Renal Artery Stenosis | Doppler ultrasound, CTA, or MRA | Consider revascularization vs medical therapy |
| Pheochromocytoma | 24-hour urine metanephrines, plasma free metanephrines | CT/MRI abdomen if positive |
| Cushing Syndrome | 24-hour urine cortisol, dexamethasone suppression | ACTH, pituitary MRI if positive |
| OSA | STOP-BANG, Epworth Sleepiness Scale, polysomnography | CPAP/BiPAP therapy |
Recommendation: Add spironolactone (12.5-50 mg/day) as third/fourth agent if K+ normal. Monitor K+ and creatinine closely.
Recommendation: Multidisciplinary team evaluation recommended (nephrologist or hypertension specialist).
Recommendation: If BP remains ≥130/80 mm Hg on ≥4 agents, renal denervation may be considered after careful patient selection and counseling.
Secondary HTN accounts for 5-10% of all hypertension. Screen in patients with early-onset HTN, resistant HTN, sudden BP elevations, or clinical clues.
Prevalence: 5-10% of hypertension; 15-20% in resistant HTN.
Screening: Serum aldosterone/plasma renin activity ratio. Ratio ≥20 suggestive.
Confirmation: Saline suppression or captopril challenge; adrenal venous sampling if considering surgery.
Treatment: Spironolactone/eplerenone; salt restriction; surgical adrenalectomy if unilateral adenoma.
Etiology: Atherosclerotic (90%, elderly) or fibromuscular (10%, younger).
Clinical Clues: Renal bruit, recurrent flash pulmonary edema, resistant HTN, acute creatinine elevation with ACEi/ARB.
Imaging: Doppler ultrasound, CTA, or MRA; invasive angiography if intervention planned.
Treatment: Percutaneous transluminal renal angioplasty ± stenting (PTRA) vs optimal medical therapy (ACEi/ARB).
Presentation: Episodic severe HTN, sweating, palpitations, anxiety, tremor, headache.
Screening: 24-hour urine metanephrines/catecholamines or plasma free metanephrines (gold standard).
Imaging: CT/MRI abdomen if positive; MIBG scintigraphy or PET for localization.
Treatment: Alpha-blockade (phenoxybenzamine/doxazosin) prior to beta-blockade; surgical removal (adrenalectomy) definitive.
Presentation: HTN, central obesity, purple striae, proximal weakness, hirsutism, easy bruising.
Screening: 24-hour urine cortisol (gold standard); 1 mg dexamethasone suppression test; late-night salivary cortisol.
Treatment: Surgical resection (pituitary adenoma, adrenalectomy) or medical management (mitotane, ketoconazole).
Prevalence: 50-90% of resistant HTN patients.
Screening: STOP-BANG questionnaire, Epworth Scale; polysomnography gold standard.
Treatment: CPAP or BiPAP improves BP control and reduces CV events.
Hypertensive Urgency: BP ≥180/120 mm Hg without acute target organ damage.
Hypertensive Emergency: BP ≥180/120 mm Hg WITH acute target organ damage (encephalopathy, MI, acute stroke, pulmonary edema, acute kidney injury, ICH, eclampsia).
| Agent | Dose | Onset | Uses |
|---|---|---|---|
| Nicardipine (CCB) | 5-15 mg/hour IV infusion | 5-10 min | Most situations; predictable dose-response |
| Labetalol (alpha/beta-blocker) | 10-20 mg IV bolus q10min, or 0.5-2 mg/min infusion | 5-10 min | Most situations; pregnancy; CAD |
| Hydralazine (vasodilator) | 5-10 mg IV bolus q20min | 10-20 min | Pregnancy-related emergencies; eclampsia |
| Sodium Nitroprusside (nitric oxide donor) | 0.25-10 mcg/kg/min IV infusion | Seconds | Rapidly progressive emergency; careful titration needed |
| Esmolol (short-acting BB) | Loading: 0.5-1 mg/kg IV; infusion 50-300 mcg/kg/min | 1-2 min | Tachycardia-driven HTN, perioperative |
| Enalaprilat (IV ACEi) | 1.25-5 mg IV q6h | 15-30 min | CAD, HF, CKD |
Acute Intracerebral Hemorrhage (ICH): Reduce SBP to <130 mm Hg within first 7 days to reduce hematoma expansion. Use nicardipine or labetalol infusion.
Acute Ischemic Stroke: Avoid aggressive BP reduction >15% in first 24 hours unless candidate for thrombolysis or mechanical thrombectomy.
Acute Coronary Syndrome/MI: Reduce SBP gradually to ≤120 mm Hg if tolerated. Use beta-blockers + vasodilators.
Acute Pulmonary Edema/HF: Reduce SBP to ≤140 mm Hg with IV vasodilators + diuretics + oxygen.
BP Targets: Individualize based on functional status, tolerance, and fall risk. Target 130-140 mm Hg systolic reasonable in most.
Considerations: Orthostatic hypotension risk, polypharmacy, reduced renal function, cognitive impairment common. Start low, go slow.
Recommendation: ACEi or ARB recommended in presence of albuminuria or kidney disease. Target ≤130/80 mm Hg.
Avoid: High-dose thiazides (hyperglycemia effect).
Recommendation: ACEi or ARB recommended to slow CKD progression and reduce albuminuria. BP target ≤130/80 mm Hg.
Monitoring: Serum creatinine, eGFR, potassium (hyperkalemia risk); expect 20-30% creatinine rise after ACEi/ARB initiation (expected physiologic response).
Post-MI HTN: First-line = Beta-blockers + ACEi/ARB for cardioprotection. Target ≤120 mm Hg if tolerated.
HFrEF: GDMT per HF guidelines: ACEi/ARB/ARNI, beta-blockers, MRA. Avoid direct vasodilators and non-DHP CCB.
HFpEF: BP control is cornerstone. Target ≤130/80 mm Hg. SGLT2 inhibitors beneficial.
Prior Ischemic Stroke/TIA: Antihypertensive therapy recommended. ACEi/ARB or thiazide preferred. Target ≤130/80 mm Hg.
Prior ICH: Intensive BP control (target ≤130/80 mm Hg) recommended to reduce recurrent ICH.
Recommendation: Pregnant individuals with chronic HTN should receive antihypertensive medication to lower BP to <140/90 mm Hg to reduce preeclampsia risk.
Safe Antihypertensives: Labetalol (first-line), nifedipine (immediate-release), methyldopa, hydralazine (resistant cases).
Avoid in Pregnancy: ACEi, ARB (teratogenic in 2nd/3rd trimester), atenolol, thiazide diuretics, NSAIDs (3rd trimester).
Acute Severe HTN in Pregnancy: SBP ≥160 mm Hg or DBP ≥110 mm Hg requires acute treatment. Immediate-release labetalol 10-20 mg IV or immediate-release nifedipine 10-20 mg PO repeated q20-30min.
Epidemiology: Higher prevalence of HTN, earlier onset, greater severity, higher CVD mortality in Black Americans.
Recommendation: In Black adults with HTN and no other compelling indication, thiazide diuretic or CCB may be reasonable as monotherapy.
Considerations: Higher risk of hypertensive complications. Early BP control critical. Combination therapy often needed. Address social determinants of health.
Definition: HTN in children = BP ≥95th percentile for age, sex, height on ≥3 separate occasions.
Screening: Annual BP screening in all children ≥3 years old. Confirm diagnosis with HBPM or 24-hour ABPM to rule out white-coat HTN.
Secondary Causes Common in Children: Renal parenchymal disease, renal artery stenosis, coarctation of aorta, endocrine disorders.
Management: Lifestyle modifications first. Pharmacotherapy reserved for stage 2 HTN or comorbidities (CKD, diabetes, LVH). ACEi/ARB preferred; avoid high-dose diuretics as first-line.
Management: Strict rate control (target resting HR <110 bpm) essential. Beta-blockers and non-DHP CCB preferred. ACEi/ARB beneficial for AF prevention.
BP Targets: ≤130/80 mm Hg reasonable to reduce AF burden and stroke risk.
The following calculators help guide BP management decisions and risk assessment. Open in new window for full functionality.
10-year atherosclerotic CVD risk using Framingham equations. Useful for baseline risk stratification.
Updated 2025 CVD risk calculator incorporating diverse populations, kidney function, and albuminuria. Central to 2025 AHA/ACC HTN guideline recommendations.
European 10-year CVD risk model. Useful for international populations and cross-reference risk estimates.
Original Framingham equations for HTN development and CVD risk prediction.
Estimates glomerular filtration rate from serum creatinine. Essential for drug dosing and ACEi/ARB monitoring in renal disease.
Alternative eGFR estimation; sometimes used for drug dosing in older adults.
Stroke risk in atrial fibrillation. Hypertension is major component; guides anticoagulation in HTN + AF.
Risk stratification in acute coronary syndrome. Hypertensive emergency with chest pain warrants ACS workup.
Lifetime (to age 80) CVD risk estimation. Useful for counseling younger patients on long-term HTN control benefits.
Primary Source: Jones DW, et al. 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. J Am Coll Cardiol. 2025;86(18):1567-1678. doi:10.1016/j.jacc.2025.05.007
Related Guidelines:
Patient Resources:
Last Updated: March 2025
Quick Reference Version: Satti MD Clinical Summary
Full Guideline DOI: 10.1016/j.jacc.2025.05.007