Hypertension
2025 AHA/ACC High Blood Pressure Guideline
Blood pressure categories (adults)
| Category | Systolic | Diastolic | |
|---|---|---|---|
| Normal | <120 | and | <80 |
| Elevated | 120–129 | and | <80 |
| Stage 1 hypertension | 130–139 | or | 80–89 |
| Stage 2 hypertension | ≥140 | or | ≥90 |
| Severe hypertension | >180 | and/or | >120 |
If the two numbers fall in different categories, use the higher category. Diagnose from the average of ≥2 readings on ≥2 occasions (home or ambulatory readings confirm).
Measure it right
- No caffeine, smoking or exercise for 30 min; empty bladder.
- Sit 5 min, back supported, feet flat, legs uncrossed.
- Arm supported at heart level; bare arm.
- Correct cuff size: bladder encircles ~80% of the arm. Too small → falsely high; too large → falsely low.
- No talking during the reading.
When to start medication
- Everyone with elevated BP or hypertension: lifestyle changes.
- Stage 2: start medication; often 2 drugs, preferably in a single combined pill.
- Stage 1: start medication if the person has heart disease, diabetes, CKD or a PREVENT 10-year cardiovascular risk ≥7.5%; otherwise lifestyle for 3–6 months, then medication if BP stays ≥130/80.
- Target: <130/80 for most adults (lower systolic, toward 120, if tolerated).
First-line drug classes
Thiazide-type diuretic (chlorthalidone, HCTZ) · ACE inhibitor or ARB (never both together) · long-acting dihydropyridine CCB (amlodipine).
Pregnancy: avoid ACE inhibitors and ARBs; use labetalol, extended-release nifedipine, or methyldopa.
Lifestyle (each lowers systolic BP)
| Weight loss | ~1 mmHg per kg lost |
| DASH eating pattern | Fruit, vegetables, whole grains, low-fat dairy |
| Sodium | Ideally <1,500 mg/day, or cut by ≥1,000 mg/day |
| Potassium | Potassium-rich foods (unless CKD or K⁺-raising drugs) |
| Activity | ≥150 min/week moderate (or 75 min vigorous) aerobic + resistance training ≥2 days/week |
| Alcohol | Ideally none; at most 1/day (women), 2/day (men) |
| Smoking | Stop |
Severe hypertension: urgency vs. emergency
Without new organ damage: resume or adjust oral meds and arrange close follow-up. Lower gradually.
Hypertensive emergency = severe BP plus acute target-organ damage: brain (headache, confusion, seizure, stroke), eyes (vision change), heart (chest pain, pulmonary edema), aorta (dissection), kidneys (↓ urine output, ↑ creatinine).
- ICU; arterial line; IV titratable drug (nicardipine, clevidipine, labetalol, esmolol).
- Lower BP by no more than 25% in the first hour, then to ~160/100–110 over the next 2–6 h, then toward normal over 24–48 h.
- Exceptions: aortic dissection (rapidly to systolic <120), severe preeclampsia, acute stroke (special targets).
Orthostatic hypotension
Drop of ≥20 mmHg systolic or ≥10 mmHg diastolic within 3 min of standing. Teach: rise slowly, dangle legs before standing, hydrate, report dizziness. Common with diuretics, alpha blockers, and in older adults.