2025 AHA/ACC Hypertension Guideline
The 2025 American College of Cardiology/American Heart Association (ACC/AHA) guideline supersedes the 2017 guideline and incorporates evidence through June 2024 [1][2][3]. The guideline defines hypertension as clinic systolic ≥130 mm Hg or diastolic ≥80 mm Hg and recommends initiation of pharmacologic therapy for adults with stage 2 hypertension (≥140/90 mm Hg) or stage 1 hypertension (130‑139/80‑89 mm Hg) with atherosclerotic cardiovascular disease (ASCVD) risk ≥10 % [1][2]. First‑line agents include a thiazide‑type diuretic, calcium‑channel blocker, ACE inhibitor, or ARB, with selection guided by comorbidities and patient characteristics [1][2]. Combination therapy is advised when blood pressure is ≥20/10 mm Hg above target, using two agents of different classes, preferably fixed‑dose combinations [1][2]. Target blood pressure is <130/80 mm Hg for most adults, with individualized higher targets for older adults or those with limited tolerance [1][2].
European ESC/ESH Recommendations
The European Society of Cardiology (ESC) 2024 guideline and the European Society of Hypertension (ESH) 2023 guideline provide parallel recommendations to the ACC/AHA document. Both endorse the <130/80 mm Hg target for most patients and prioritize lifestyle modification before drug therapy. First‑line pharmacologic choices are similar, emphasizing thiazide‑type diuretics, calcium‑channel blockers, ACE inhibitors, or ARBs, with selection tailored to age, renal function, and metabolic profile [4]. ESC/EHS guidelines also stress the use of ambulatory blood pressure monitoring to confirm diagnosis and guide treatment intensity [4].
Renal Denervation Position
Renal denervation (RDN) is addressed in the 2025 ACC/AHA guideline and the ESC 2024 and ESH 2023 guidelines. All three recognize RDN as an adjunctive option for patients with resistant hypertension (≥140/90 mm Hg despite ≥3 antihypertensive agents including a diuretic) who are unsuitable for further medication escalation [4]. The ACC/AHA guideline gives a Class IIb recommendation for RDN in selected patients, whereas ESC/EHS provide a conditional recommendation with emphasis on enrollment in registries or trials [4]. Patient selection criteria include documented adherence, exclusion of secondary hypertension, and adequate renal artery anatomy [4].
Implementation Framework
- Screening: Office or automated office blood pressure measurement; confirm with home or ambulatory monitoring when values are borderline [4][1].
- Risk Stratification: Calculate 10‑year ASCVD risk to guide initiation in stage 1 hypertension [1].
- Lifestyle: Sodium restriction <2 g/day, weight loss, aerobic exercise ≥150 min/week, moderation of alcohol [1][4].
- Pharmacologic Initiation: Start with monotherapy in low‑risk stage 1; use combination therapy for stage 2 or when BP ≥20/10 mm Hg above goal [1][2].
- Titration: Adjust dose or add agents every 1‑2 months until target achieved; monitor electrolytes and renal function with diuretics and renin‑angiotensin system blockers [1].
- Device Therapy: Consider RDN after failure of optimized medical therapy; ensure patient meets adherence and anatomical criteria [4].
Key Differences and Updates
- The 2025 ACC/AHA guideline expands the definition of hypertension to ≥130/80 mm Hg, aligning with ESC/EHS thresholds [4][1].
- ESC/EHS place greater emphasis on out‑of‑office measurements for diagnosis [4].
- RDN receives a conditional endorsement across all three major guidelines, reflecting emerging evidence but acknowledging limited long‑term outcome data [4].