new hypertension guidelines

 

Two sets of new hypertension guidelines were developed recently, one by the European Society of Cardiology (ESC) in 2024; the other by the American College of Cardiology/American Heart Association in 2025 (the ESC guidelines predated the 2025 ACC/AHA guidelines). In the following, I will compare the 2024 ESC guidelines mostly to the 2017 ACC/AHA guidelines (see https://gmodestmedblogs.blogspot.com/2017/11/new-aha-hypertension-guidelines.html), since the updated 2025 ACC/AHA guidelines added very few new recommendations.

 

ACC/AHA guidelines: see: htn 2025 AHA guidelines JACC2025 in dropbox, or doi.org/10.1016/j.jacc2025.05.007

ESC guidelines: htn 2024 european guidelines HTN2025 in dropbox, or doi/suppl/10.1161/HYPERTENSIONAHA.124.24173.

 

-- here is the list of all of their summary points of "what is new" in the 2025 AHA/ACC guidelines' new and revised recommendations beyond the 2017 AHA/ACC guidelines (these new guidelines are quite long, 112 pages, and have a lot of detail but largely reflect the 8-year-old AHA/ACC 2017 guidelines):

    -- “in adults with resistant hypertension, screening for primary aldosteronism is recommended regardless of whether hypokalemia is present”. [This is in contradistinction to the 2024 ESC recommendations to screen everyone, see below]. new recommendation

    -- “in adults with an indication for screening for primary aldosteronism, it is recommended to continue most antihypertensive medications (other than mineralocorticoid receptor antagonist, MRA) prior to initial screening to minimize barriers to or delays in screening”. new recommendation

    -- “in adults with or without hypertension, potassium-based substances can be useful to prevent or treat elevated BP and hypertension, particularly for patients in whom salt intake is related mostly to food preparation or flavoring at home, except in the presence of CKD or use of drugs that reduce potassium excretion, where additional monitoring is probably indicated”. new recommendation

    -- “in adults with hypertension without clinical CVD but with diabetes or CKD or increased 10-year risk (ie, at least 7.5% based on the PREVENT risk calculator), initiation of medications to lower BP is recommended when average SBP >= 130 mmHg and average DBP >= 80 mmHg to reduce the risk of CVD events and total mortality”. revised recommendation

    -- “in adults with hypertension without clinical CVD and with increased 10-year risk (ie, at least 7.5% based on PREVENT risk calculator), initiation of medications to lower BP is recommended if average SBP remains >=130 mmHg or average DBP >= 80 mmHg after 3- to 6-month trial of lifestyle intervention to prevent target organ damage and mitigate further increases in BP”. revised recommendation

    -- “for adults with hypertension and CKD as identified by eGFR <60 with albuminuria of > 30 mg/g, RAASi (either with ACEi or ARB but not both) is recommended to decrease CVD and delay progression of kidney disease”. revised recommendation

    -- “in adults with hypertension, a goal of <130 mmHg SBP is recommended to prevent mild cognitive impairment and dementia”. revised recommendation

   -- the rest of the new recommendations do not apply to outpatient internal medicine primary care:

        -- two recommendations were for patients with acute intracerebral hemorrhage. one new and one revised recommendation

        -- one recommendation was for patients with acute ischemic stroke. revised recommendation

        -- 3 recommendations for those with renal denervation. all new recommendations

        -- one recommendation for those with hypertensive emergencies. new recommendation

        -- 4 recommendations were for pregnant women or women planning pregnancy:

            -- those with SBP at least 160 mmHg or DBP at least 110 mmHg require rapid intervention within 15 minutes to lower BP to < 160/110 within 30-60 minutes. new recommendation

            -- those with chronic hypertension (pre-pregnancy SBP 140-169 mmHg and/or DBP 90-109 mmHg prior to 20 weeks gestation) should get meds to achieve BP <140/90. new recommendation

            -- women who are pregnant or planning pregnancy should be on low-dose aspirin. new recommendation

            -- women who are pregnant or planning pregnancy should not take atenolol, ACEi, ARB, direct renin inhibitors, nitroprusside, or MRA. revised recommendation

 

Recommendations:

-- definition of hypertension and classifications of blood pressure:

    -- 2024 ESC guidelines (the authors acknowledge that this guideline delineates specific blood pressure levels arbitrarily, since there is a continuously increasing risk of CVD with increments in blood pressure):

        -- BP <120/70 mmHg: non-elevated; drug treatment is not recommended

        -- BP 120-139/70-89 mmHg: elevated; drug treatment is recommended in select individuals depending on CVD risk and follow-up BP

        -- BP >= 140/90 mmHg: hypertension; prompt confirmation and treatment are recommended in most individuals

            -- they chose this relatively high definition of >=140/90 as advanced blood pressure, since in that category, treatment to lower BP results in net benefits for almost all adults and that randomized clinical trials have demonstrated a relative benefit of BP reduction for the prevention of cardiovascular events

    -- 2025 AHA/ACC guidelines (no change from the 2017 guidelines): 

        -- SBP <120 and DBP <80 mmHg: normal

        -- SBP 120-129 and DBP <80 mmHg: elevated BP

        -- SBP 130-139 mmHg or DBP 80-89 mmHg: stage 1 hypertension, with SBP 120-130 mmHg being elevated and from 130-140 mmHg being Stage 1; DBP from  80-89 mmHg

        -- SBP >= 140 or diastolic >= 90 mmHg: stage 2 hypertension

 

-- role of risk assessment as guide to treatment:

    -- 2024 ESC guidelines: risk assessment is important, especially for individuals with BP >= 130/80 mmHg despite 3 months of lifestyle intervention

        -- strong emphasis on a CVD risk assessment to identify those needing hypertension treatment based on accumulating clinical trials, with a 4-step approach to identifying those individuals for treatment initiation:

            -- individuals with elevated BP and established CVD, moderate or severe CKD, hypertension-mediated organ damage (HMOD), diabetes, or familial hypercholesterolemia

            -- in the absence of these high-risk conditions, they recommend using the SCORE-2 (Systematic Coronary Risk Evaluation 2) or SCORE-2-OP (SCORE-2 for older persons) to predict 10-year CVD event risk likelihood and treat if at least 10% (see SCORE-2 criteria below)

            -- for individuals with scores between 5%-10%, use specific nontraditional risk modifiers to see if people up-classify to high risk. [they do not define these "nontraditional" risk modifiers. but there are lots of known cardiovascular risk factors besides the traditional ones (see https://gmodestmedblogs.blogspot.com/2023/10/update-ascvd-risk-factor-critique.html )

                -- in the absence of such risk modifiers, specific risk assessment tests can be considered in the decision to use medications (e.g. coronary artery calcium score, cardiac biomarkers, carotid or femoral plaque, or pulse wave velocity)

    -- 2017 ACC/AHA guidelines: also recommend use of risk-guided BP lowering treatment with both lifestyle and pharmacologic therapy, specifically for those with blood pressure 130-139/80-89 mmHg. similarly for individuals with established atherosclerotic cardiovascular disease (ASCVD), heart failure, diabetes, COPD, or with 10-year ASCVD risk at least 10%

 

-- measurement of BP

    -- 2024 ESC guidelines: increased emphasis in recommendation for out-of-office BP measurement in both the diagnosis and subsequent management of elevated BP, with repeat office measurements only recommended if out-of-office measurements are not feasible. And a very strong specific recommendation for home-based blood pressure monitoring rather than ambulatory blood pressure measurement for this purpose

    -- 2017 guidelines had less emphasis on out-of-office BP measurement, though they did recommend it for the diagnosis of hypertension. of note, the US Preventive Services Task Force did recommend ambulatory blood pressure monitoring as the gold standard in 2015:  https://gmodestmedblogs.blogspot.com/2015/10/uspstf-guidelines-on-blood-pressure.html

 

-- evaluation for HMOD (hypertension-mediated organ damage)

    -- 2024 ESC guidelines: measure serum creatinine, estimated eGFR (creatinine-based), and urine albumin/creatinine ratio in all patients with hypertension at least annually if moderate-to-severe CKD is diagnosed [not defined specifically], a 12-lead EKG in all patients, echocardiogram in patients with hypertension and EKG abnormalities or signs/symptoms of cardiac disease, and fundoscopy for those with hypertensive emergency, malignant hypertension, or hypertension and diabetes. Renal ultrasound should be considered in hypertensive patients with CKD. Echocardiogram, coronary artery calcium scoring, measurement of pulse wave velocity, fundoscopy, and carotid or femoral ultrasound may be considered when it is likely to change patient management. and screen for HMOD, since the SCORE-2 is not validated in adults less than 40 years old

    --2017 ACC/AHA guidelines: advises EKG in all patients with hypertension (no formal recommendation), with optional additional tests including echocardiogram and urine albumin/creatinine ratio

        -- neither recommendation comments on the apparently superior role of cystatin-c as a predictor of bad clinical outcomes over creatinine for many individuals (see https://gmodestmedblogs.blogspot.com/2023/12/cystatin-c-better-predictor-of-bad.html )

 

-- evaluation for secondary hypertension:

    -- 2024 ESC guidelines: patients with hypertension presenting with suggestive signs, symptoms, or medical history of secondary hypertension should be screened

        -- and in a major change they also recommend “screening for primary aldosteronism by renin and aldosterone measurements should be considered in all adults with confirmed hypertension”, noting that 5%-20% of individuals with hypertension have primary aldosteronism, most individuals do not have hypokalemia or diuretic-induced hypokalemia, and adrenalectomy or targeted drug treatment are effective for reducing CVD in those with aldosterone-producing adenomas 

        -- for adults <40 years old, comprehensive screening for the main causes of secondary hypertension is recommended, except in young adults with obesity where it is recommended to simply start with obstructive sleep apnea evaluation

    -- 2017 ACC/AHA guidelines: screening when there are suggestive clinical findings, which include drug-resistant hypertension, abrupt-onset hypertension, hypertension among individuals <30yo, exacerbation of previously controlled hypertension, disproportionate target organ damage, malignant hypertension, late-onset diastolic hypertension, and unprovoked or excessive hypokalemia. They recommend screening for primary aldosteronism only for those with resistant hypertension, hypokalemia, incidental adrenal mass, family history of early-onset hypertension, or stroke at a young age

        -- my comment: it should be noted that many of the studies on primary aldosteronism and subthreshold aldosteronism (also referred to as "dysregulated aldosteronism") were completed and in the literature well before these 2017 guidelines were released (see https://gmodestmedblogs.blogspot.com/2025/09/resistant-hypertension-are-diuretics.html) and https://gmodestmedblogs.blogspot.com/2025/09/hyperaldosteronism-2025-guidelines.html ). For example, a summary study printed in 2020 documented the huge importance of evaluating patients for renin-independent aldosteronism (which includes patients with even "normal" aldosterone levels); this article stressed that the evolution of knowledge about this condition over the prior decades urgently needs to be spread to the general population of primary care clinicians and others treating hypertension, and that current hypertension guidelines are insufficient in promoting the importance of testing and treating aldosteronism appropriately: see aldosteronism syndrome evolution JClinEndoMetab2020 in dropbox, or doi:10.1210/clinem/dgaa606). It is true that the 2025 ACC/AHA guidelines do have a section about the importance of primary aldosteronism, but there is really no mention of the sub-threshold aldosteronism, its pretty high prevalence in the population (though we do not have adequate prevalence data on this; there needs to be more studies given the data we do have suggesting that it is quite common), and its important clinical outcomes (effects on heart, kidneys, poorer control of blood pressure with standard meds, though studies have found that thiazides and loop diuretics can increase aldosterone levels, and, as mentioned above, this information has been known for decades. the ESC guidelines are more focused on this, though neither guideline has suggested a different therapeutic approach to hypertension based on this. it is clear in the studies that suppressed renin levels even in the absence of significantly high aldosterone levels not only are associated with bad clinical outcomes (see https://gmodestmedblogs.blogspot.com/2025/09/resistant-hypertension-are-diuretics.html ), but that thiazide diuretics and furosemide can make matters worse (torsemide, on the other hand, tends to decrease sympathetic tone and likely improves matters).

 

-- Management of nonresistant hypertension:

    -- 2024 ESC and 2017 ACC/AHA guidelines had similar recommendations for nonpharmacologic interventions, including minimizing alcohol intake, and maintenance or weight loss to achieve a normal BMI

    -- 2024 ESC guidelines also specifically recommend smoking cessation for CVD health; all guidelines recommend exercise, sodium restriction, and potassium supplementation in those without advanced CKD, though the ESC does provide a target of daily sodium intake of 2g, with no target in the formal 2017 ACC/AHA guidelines. All guidelines recommend 150 minutes of moderate-intensity or 75 minutes of vigorous intensity-aerobic exercise per week

-- when to initiate pharmacological therapy

    -- 2024 ESC guidelines: prompt initiation of both lifestyle and BP lowering meds for those with confirmed hypertension of > 140/90 mmHg, irrespective of age and CVD risk

    -- 2024 ESC and 2017 ACC/AHA guidelines both suggest: lifestyle therapy for all individuals with systolic BP at least 120 mmHg or diastolic BP 70-89 mmHg, and initiation of meds for those with SBP 130-139 mmHg or DBP 80-89 mmHg in those with high-risk CVD conditions (established CVD, HMOD, diabetes, moderate or severe CKD, and familial hypercholesterolemia), individuals with 10-year CVD risk at least 10% or those with risk of 5%-10% with risk modifiers for clinical ASCVD, heart failure, CKD, diabetes, or 10-year risk at least 10%

 

Blood pressure lowering treatment selection:

    -- 2024 ESC and 2017 ACC/AHA guidelines recommend ACE-i, ARB’s, dihydropyridine calcium channel blockers, and thiazide or thiazide-like diuretics as first-line treatments

    -- 2024 ESC guidelines recommend beta-blockers be combined with one of these other meds when there is a compelling indication for b-blocker use, such as heart failure with reduced ejection fraction. The 2017 ACC/AHA guidelines state that beta-blockers are secondary agents, but they do not have a formal recommendation

-- the 2024 ESC guidelines recommend prompt initiation of both lifestyle and meds for people with confirmed hypertension (>=140/90 mmHg, irrespective of age or CVD risk); the 2017 AHA/ACC guidelines also recommend meds if BP >140/90 mmHg. ESC guidelines focus on lifestyle changes in those with BP 120-130/70-89, though meds will be necessary for most with SBP 130-139/80-89, especially if high CVD risk

-- both the 2017 ACC/AHA and 2024 ESC guidelines recommend initiation of 2-drug fixed dose combination therapy for individuals with BP at least 140/90 mmHg, though the 2017 ACC/AHA guidelines have a prerequisite that the average BP is >20/10 mmHg above target)

 

blood pressure targets:

    -- 2024 ESC guidelines recommend an initial default SBP of 120-129 mmHg in most adults if tolerated, though the SBP target of 120 mmHg is the optimal point in the target range; for individuals who cannot achieve this target range due to tolerability, the guidelines do recommend an “as low as reasonably achievable” target. In addition, there should be a more lenient target, such as <140/90, in those with pretreatment symptomatic orthostatic hypotension or age >85yo, limited life expectancy or moderate-to-severe frailty

        -- the specifics noted above were based on several contemporary clinical trials finding that age is not a modifier in the recommendations up to age 85 (insufficient data on older ages to have clear recommendations)

    -- 2017 ACC/AHA guidelines: similar targets but less exact BP levels, suggesting a target of 130/80 mmHg for adults with known CVD or a 10-year risk of at least 10%, but encouragement to achieve SBP >=120 mmHg; however in the absence of these high-risk conditions, they propose the same target of <130/80, with encouragement to achieve SBP <120 mmHg as reasonable, and for both recommendations a DBP target of <80 mmHg may be reasonable

         -- [it should be noted that the 2025 ACC/AHA guidelines were not updated to include these contemporary clinical trials, including SPRINT and ESPRIT, though they were included in the ESC document, despite the fact that ESC was released a year before the ACC/AHA document]

 

Management of resistant hypertension:

-- 2024 ESC guidelines: favor the use of spironolactone as a first-line agent for resistant hypertension, also noted in the 2017 ACC/AHA guidelines but there was no formal recommendation

    -- [I would add that the two recent blogs (https://gmodestmedblogs.blogspot.com/2025/09/resistant-hypertension-are-diuretics.html) and https://gmodestmedblogs.blogspot.com/2025/09/hyperaldosteronism-2025-guidelines.html) do suggest a more mechanistically-driven approach, including checking renin and aldosterone levels in all patients, and initiating mineralocorticoid receptor antagonist therapy as a primary intervention in those with low renin and suprathreshold aldosterone levels as well as with primary aldosteronism (though low renin levels are a more significant predictor of later cardiovascular events)]

 

-- both the 2024 ESC guidelines and the 2017 ACC/AHA guidelines recommend a multi-dimensional team-based care approach to hypertension, with a focus on patient-centered care

-- overall, the 2024 ESC guidelines are more likely to put individuals on blood pressure lowering medications than the 2017 ACC/AHA guidelines

 

Commentary:

-- the ESCc authors bring up some important points regarding guidelines, especially in light of the plethora of guidelines that seem to be coming out from all around the world:

    -- there may well be regional differences within a country or large geographic differences around the world that justifies a very different approaches to hypertension management in different areas

    -- there may also be specific incentives for individual medical societies to push their own guidelines, perhaps to bring people to their rather expensive annual meetings, perhaps for other self-serving reasons (for example, for promoting one drug over another because a lot of the senior members on the committee were involved in research about one of the drugs)

    -- and, different medical societies have very different numbers of members and very different amounts of money to spend on guideline development

        -- the ESC, in aligning with the Institute of Medicine for trustworthy guideline development, standardized policies for all of its guidelines, including temporal  rotation of guideline chairs, diversity of the Task Force members, limits on the number of times an individual can co-author a guideline, management of financial disclosures and conflicts of interest, anonymous voting procedures, and external review processes

            -- for example, neither Task Force members nor their spouses can receive > €10,000 per annum in personal payments from industry, direct or indirect, in the aggregate (indirect payments being payment to a department, institution or other body that affects a member’s or spouse’s remuneration)

    -- there are, of course, some benefits to having different guidelines around, including the ability to choose guidelines that more reflect the local population that a clinician sees

    -- also, the variability of these guidelines does reinforce the basic issue with guidelines: they are a set of recommendations that the end-user may or may not choose to follow. They are not set in stone, nor immutable

    -- I would add a few comments to the above (including a few I snuck in):

        -- as referred above, I would add a specific example: the observation in Boston in the debate between the benefits of GLP-1 receptor agonists and SGLT-2 inhibitors for people with diabetes; at several hospitals i know the cardiologists were favoring SGLT2’s and the endocrinologists were favoring GLP-1’s. This reflects both of their societies' assessments of the pluses and minuses based on their review, likely from articles within their societies’ medical literature and reflecting perhaps different funding for research for these meds in different specialists

        -- there was also one pretty egregious (to me) guideline development: the 2019 guidelines from GINA (Global Initiative for Asthma) included two new studies in the medical literature that found that budesonide/formoterol inhalers in adults with asthma were much better for asthma treatment and prevention than beta agonists based on the SYGMA1 and SYGMA2 studies and later reinforced from other studies in asthmatics with more severe disease (see https://gmodestmedblogs.blogspot.com/2019/10/new-and-improved-asthma-guidelines.html). The newest asthma guidelines in the US where in 2020 (1 year later), and updated their prior (and quite old) 2007 recommendations. Even though GINA has always included the US along with its backing and support, these latest US guidelines did not include these two SYGMA studies because the task force was empowered to deal specifically with six predetermined Key Questions that needed to be addressed, and the role of beta agonists versus budesonide/formoterol was not in one of those Key Questions. Although there were clear disappointments expressed by the committee members, they were told they needed to stick with the Key Questions, despite the fact that the two pivotal and reasonable therapy-changing studies had been released over a year before (see https://gmodestmedblogs.blogspot.com/2020/12/new-us-asthma-guidelines.html)

        -- literally, but not to the extreme issue with the asthma guidelines, the ACC/AHA 2025 hypertension guidelines have very little new information on outpatient treatment of hypertension, including exceptionally little information about aldosteronism or the role of  early spironolactone therapy, despite the fact that hypertension is remarkably common, atherosclerotic cardiovascular disease is still the major cause of death (let alone significant morbidity) in the United States, and there is no update on pretty much any outpatient issue other than hypertension in pregnancy in the eight years since the 2017 guidelines. And, as we all know only too well, there have been significant changes in the treatment of hypertension in the outpatient setting, which are extensively included in the ESC guidelines printed the prior year.

        -- as above, the issue of the role of aldosteronism, including the well-known (for decades) role of sub-threshold aldosteronism, is (to me) a real game-changer in our approach to hypertension assessment and treatment (eg see: https://gmodestmedblogs.blogspot.com/2025/09/resistant-hypertension-are-diuretics.html)

 

-- one other issue is that the organizations use different ASCVD risk calculators:

    -- ESC uses SCORE-2 risk assessment that has been used for European patients aged 40-69 without prior CVD or diabetes, which clearly limits its utility in younger or older patients as well as the rather frequent patient with either diabetes or known CVD

        -- this calculator includes sex, age, smoking ("current" or "other"), SBP, total and HDL cholesterol, and risk region (the world is divided into low to very high risk regions with UK being low, Scandinavia being mostly moderate, northern Africa and Russia being very high risk), again limiting its generalizability (eg, the US is not on their map)

    -- ACC/AHA is using the PREVENT risk calculator, which is known to overestimate ASCVD risk:

        -- this calculator includes age, sex total and HDL cholesterol, SBP, diabetes, current smoker, eGFR, use of antihypertensive meds, using statins, and BMI; the full PREVENT calculator includes urinary albumin-creatinine ration, A1c, and zip code as a surrogate for "social deprivation index" . As with the SCORE-2 calculator, many of the questions are binary (current smoker without intensity of smoking, etc). The full PREVENT risk calculator often requires more information than is available, so may not access its full risk calculation. for more info see: https://gmodestmedblogs.blogspot.com/2024/07/prevent-new-cardiac-risk-factor.html and https://gmodestmedblogs.blogspot.com/2025/04/prevent-cardiovasc-risk-calculator.html

-- and, i would add, there are significant clinical issues in using these calculators:

    -- the 10-year horizon is not very helpful in a younger person without shockingly high risk factors, since their likelihood of an adverse cardiovascular event over that time frame is low. BUT the cumulative effect of even mild-to-moderate risk factor elevation beginning at an early age is very likely to lead to more adverse events well after that 10-year time frame. and, one of our most important roles in medicine is prevention....

    -- these calculators (as well as the recommendations in guidelines) are based on clinical studies, yet these studies typically do not apply directly to many of the individuals we see, who perhaps have renal failure and were excluded from the studies, perhaps come from cultures with very different eating habits than in the studies, perhaps have very different social circumstances that would affect their subsequent medical problems, etc.  Our role as clinicians is to try to guess whether the conclusions of the studies (and their inclusion into guidelines, and standard clinical care) are reasonable and appropriate for the patient sitting in front of us

    -- and i am concerned about the limitations of creatinine-based estimates of GFR. the most accurate estimate of GFR in terms of reflecting the actually measured GFR is the combination of creatinine and cystatin-c measurements: eg see http://gmodestmedblogs.blogspot.com/2023/12/cystatin-c-better-predictor-of-bad.html

 

so, some useful and important changes in the categorization of hypertension, the appropriate workup, and treatment, with a few caveats:

-- the European guidelines are quite extensive and appropriately (to me) emphasize the importance of the priority of home-based blood pressure evaluation, assessing for aldosteronism, and highlighting the role of spironolactone earlier in therapy

-- the American guidelines are quite long but do not address well some of the important changes in hypertension in the past 8 years

-- both of these guidelines have the same (old) recommendations of meds to use, and both support the use of meds that may make cardiovascular disease worse (eg thiazide-type diuretics, furosemide) as noted in the blog above. and, of note, many of the studies in this new emphasis on aldosteronism are decades old and perhaps should have raised some notable concern a long time ago. This reinforces the important social issue that guideline makers should see that one of their major roles is to inform clinicians in general, and not just those members of their medical societies, of the important observations and potential upcoming related clinical changes; these changes should, of course, be noted with relevant references and caveats that more studies need to be done before a more formal recommendation could be made. But even then, as with the aldosteronism studies, there might be such a profound change in understanding hypertension and its treatment, that we clinicians might consider earlier changes in our approach to hypertension...

 

geoff

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