Major Update | 2025 AHA/ACC Hypertension Guideline Released: 11 New Recommendations for Every Patient With High Blood Pressure
For patients with hypertension and the clinicians who treat them, there is an important piece of breaking news worth special attention—the 2025 AHA/ACC hypertension guideline has just been released.
Before we dive in, one small but useful concept: in the guideline, "COR" refers to the Class of Recommendation. COR 1 means strong recommendation (robust evidence; should generally be followed in practice), COR 2a means moderate recommendation (evidence is fairly strong and can be adopted based on individual context), and COR 3 (harm) means not recommended and may even pose risks.
(1) Secondary Hypertension: Broader Screening to Avoid Missed or Misdiagnosed Cases
Many people with hypertension are not aware that some high blood pressure is not "primary" but caused by other diseases—such as primary aldosteronism. For this type of secondary hypertension, identifying and treating the underlying cause often leads to much better outcomes.
1. COR 1 (Strong Recommendation): In adults with resistant hypertension (in simple terms: blood pressure remains poorly controlled despite multiple antihypertensive drugs), screening for primary aldosteronism is recommended regardless of whether hypokalemia is present. This improves detection and diagnosis rates and allows patients to receive more precise targeted therapy instead of blind escalation of antihypertensive medications.
(2) Primary Aldosteronism: Don't Stop Antihypertensive Drugs Blindly Before Testing
2. COR 1 (Strong Recommendation): In adults who meet the indications for screening primary aldosteronism, most antihypertensive medications should be continued before the initial screening test. Only mineralocorticoid receptor antagonists (MRAs) need to be stopped. This strategy helps reduce interference during testing, avoids delays caused by unnecessary drug withdrawal, and improves the accuracy of screening results.
(3) Lifestyle Intervention: Choosing the Right Salt Also Helps Blood Pressure Control
Lifestyle modification has always been the foundation of hypertension management, and this guideline provides more specific, everyday recommendations—especially regarding diet.
3. COR 2a (Moderate Recommendation): For adults—with or without hypertension—using potassium-enriched salt substitutes (commonly marketed as low-sodium salt) can help prevent or improve elevated blood pressure and hypertension, especially in people whose salt intake mainly comes from home cooking and seasoning. However, for those with chronic kidney disease (CKD) or those taking medications that reduce potassium excretion, additional monitoring is essential to avoid hyperkalemia-related risks.
(4) Acute Intracerebral Hemorrhage: Blood Pressure Targets Matter—Lower Is Not Always Better
Blood pressure management in acute intracerebral hemorrhage has long been a clinical focus and challenge. The new guideline gives clear target ranges to prevent inappropriate blood pressure lowering from worsening outcomes.
4. COR 2a (Moderate Recommendation): In adults with acute spontaneous intracerebral hemorrhage whose presenting systolic blood pressure (SBP) is between 150 and 220 mmHg, it is recommended to promptly reduce SBP to 130–<140 mmHg and maintain this level for at least 7 days, which can help improve functional recovery. However, if SBP is already below 130 mmHg, additional antihypertensive therapy is not recommended to avoid compromising cerebral perfusion.
(5) Hypertensive Disorders in Pregnancy: Three Recommendations to Protect Mother and Baby
Hypertensive disorders in pregnancy affect not only maternal health but also fetal safety. The new guideline adds three dedicated recommendations to address key challenges in blood pressure management during pregnancy.
5. COR 1 (Strong Recommendation): If a pregnant woman has SBP ≥160 mmHg or DBP ≥110 mmHg and this is confirmed by repeat measurement within 15 minutes, antihypertensive therapy should be initiated within 30–60 minutes to reduce blood pressure to <160/<110 mmHg, thereby preventing adverse events such as eclampsia and placental abruption.
6. COR 1 (Strong Recommendation): In women with chronic hypertension (in simple terms: pre-existing hypertension before pregnancy, or SBP 140–159 mmHg and/or DBP 90–109 mmHg before 20 weeks of gestation), antihypertensive treatment is recommended to control blood pressure below 140/90 mmHg, which can reduce morbidity and mortality for both mother and fetus.
7. COR 1 (Strong Recommendation): For patients with hypertension who are planning pregnancy or already pregnant, clinicians should inform them that low-dose aspirin can reduce the risk of preeclampsia and its complications, adding an extra layer of protection to blood pressure management during pregnancy.
(6) Resistant Hypertension and Renal Denervation: Not Everyone Is a Surgical Candidate
For patients with resistant hypertension (blood pressure remains difficult to control), renal sympathetic denervation (RDN) has emerged as a potential interventional option. The new guideline clarifies pre-procedural assessment requirements to prevent indiscriminate use of this procedure.
8. COR 1 (Strong Recommendation): In adults with resistant hypertension, a comprehensive evaluation should be performed first to rule out secondary causes of hypertension. At the same time, all current medications should be carefully reviewed, and drugs that may interfere with blood pressure control should be discontinued. This approach can help lower blood pressure more effectively, simplify treatment regimens, and avoid overtreatment.
9. COR 1 (Strong Recommendation): All patients being considered for renal sympathetic denervation (RDN) must be evaluated by a multidisciplinary team with specific expertise in resistant hypertension and RDN. Not everyone with high blood pressure is an appropriate candidate for this procedure.
In essence, the 2025 AHA/ACC hypertension guideline aims to make blood pressure management more precise and personalized—moving away from one-size-fits-all recommendations toward more tailored strategies based on different populations and clinical scenarios.
We hope this plain-language overview helps you grasp the core messages of the new guideline. May every person living with hypertension use scientific, structured management to keep their blood pressure stable and safeguard long-term health. ❤️