Summary

Multisociety update replacing the 2017 hypertension guideline, redefining BP categories, treatment thresholds, and goals using the PREVENT 10-year CVD risk equation rather than pooled cohort equations. Universal BP target is <130/80 mm Hg, with risk-based initiation of pharmacotherapy at ≥130/80 mm Hg for high-risk patients and ≥140/90 mm Hg for all others. New recommendations address primary aldosteronism screening in resistant hypertension, potassium-based salt substitutes, pregnancy management (including aspirin prophylaxis), renal denervation, and management of acute ICH and stroke.

Key Recommendations

Target BP <130/80 mm Hg for all adults with hypertension, including those with CVD, diabetes, CKD, or elevated CVD risk.
Initiate antihypertensive therapy at ≥130/80 mm Hg in adults with clinical CVD, diabetes, CKD, or PREVENT 10-year CVD risk ≥7.5%; at ≥140/90 mm Hg otherwise.
In low-risk adults (PREVENT <7.5%) with BP ≥130/80 mm Hg, trial 3–6 months of lifestyle intervention before starting medication.
First-line agents are thiazide-type diuretics, long-acting dihydropyridine CCBs, ACEi, or ARBs; beta-blockers are not first-line unless compelling indication (CHD, HF).
Initiate combination therapy with two first-line agents as a single-pill combination for stage 2 hypertension (≥140/90 mm Hg) to improve adherence.
Screen all adults with resistant hypertension for primary aldosteronism using aldosterone-to-renin ratio regardless of potassium level, continuing most antihypertensives except MRAs.
Use ACEi or ARB (not both) in adults with hypertension plus CKD (eGFR <60 or albuminuria ≥30 mg/g) and in diabetes with albuminuria.
In pregnancy, treat chronic hypertension to <140/90 mm Hg with labetalol or extended-release nifedipine; avoid ACEi, ARB, atenolol, MRA, nitroprusside, direct renin inhibitors.
Prescribe low-dose aspirin from 12 weeks gestation in pregnant individuals with hypertension to reduce preeclampsia risk.
For acute spontaneous ICH with SBP 150–220 mm Hg, lower SBP to 130–<140 mm Hg for ≥7 days; avoid SBP <130 mm Hg.
After successful endovascular thrombectomy, do not lower SBP <140 mm Hg in first 24–72 hours (harm).
For severe hypertension (>180/120 mm Hg) without acute target organ damage in hospitalized patients, do not use intermittent IV/PO antihypertensives; manage as outpatient.
Add spironolactone 25–50 mg/day as fourth-line therapy in resistant hypertension when eGFR ≥45 mL/min/1.73 m²; consider renal denervation only after multidisciplinary evaluation.
Recommend potassium-based salt substitutes to lower BP, except in CKD or with potassium-sparing drugs.
Do not rely on cuffless or smartwatch BP devices; use validated oscillometric upper-arm devices with averaged readings.

Thresholds & Doses

Normal BP: <120/<80 mm Hg; Elevated: 120–129/<80; Stage 1: 130–139/80–89; Stage 2: ≥140/≥90 mm Hg.
Universal BP treatment goal: <130/80 mm Hg.
Pharmacotherapy threshold for high-risk adults (CVD, diabetes, CKD, PREVENT ≥7.5%): ≥130/80 mm Hg.
Pharmacotherapy threshold for low-risk adults: ≥140/90 mm Hg, or ≥130/80 mm Hg after 3–6 month lifestyle trial.
PREVENT 10-year CVD risk threshold for intensification: ≥7.5% (applicable ages 30–79).
Sodium intake target: <2300 mg/day (ideal <1500 mg/day); potassium intake: 3500–5000 mg/day.
Alcohol limit: ≤1 drink/day women, ≤2 drinks/day men; abstinence optimal.
Physical activity: 90–150 min/week aerobic at 65–75% heart rate reserve.
Weight loss goal: ≥5% body weight or ≥3 kg/m² BMI reduction (≈1 mm Hg per 1 kg).
Severe hypertension defined as BP >180/120 mm Hg.
Pregnancy hypertension: ≥140/90 mm Hg; severe-range: ≥160/110 mm Hg requiring treatment within 30–60 min to <160/<110.
Acute ICH with SBP 150–220 mm Hg: target SBP 130–<140 mm Hg for ≥7 days; stop antihypertensives if SBP <130.
Post-thrombolysis ischemic stroke: maintain BP <180/105 mm Hg for 24 hours.
Resistant hypertension: BP above goal on ≥3 agents including diuretic at max tolerated doses, or controlled on ≥4 agents.
ACEi/ARB acceptable eGFR decline: up to 30%; reassess if persistently >30%.
Aspirin for preeclampsia prevention: low-dose starting at 12 weeks gestation.
Spironolactone for resistant HTN: 25–50 mg/day (requires eGFR ≥45 mL/min/1.73 m²).
HBPM threshold corresponding to office 130/80: 130/80 mm Hg; daytime ABPM 130/80; 24-hour ABPM 125/75.

Citations

Table 1 (What Is New) — summary of new/revised recommendations vs 2017 guideline
Top Take-Home Messages #4 and #6 — BP classification and treatment initiation thresholds
Section 5.2.2 — BP treatment threshold and use of PREVENT for CVD risk estimation
Section 5.2.7 — BP goal <130/80 mm Hg for treated hypertension
Section 5.2.3 and Table 13 — first-line antihypertensive medication classes and dosing
Section 3.2.3.1 — primary aldosteronism screening in resistant hypertension
Section 5.5 and Tables 20–23 — hypertension in pregnancy diagnosis, drugs, and dosing
Section 5.3.9.1–5.3.9.3 — BP management in acute ICH, ischemic stroke, and secondary stroke prevention
Section 5.6 and Table 25 — resistant hypertension management and renal denervation patient selection
Section 6.2 and Tables 26–27 — hypertensive emergencies and IV antihypertensive selection