Board-level quick read · Cardiology
Hypertension
ACC/AHA 2025 · reviewed 2026-08-18
Personal study digest for IM board prep. Recommendations are from the cited guideline; the "What's changed" section is reviewer synthesis of newer evidence, each claim cited. Not a substitute for the full guideline.
In one line
Treat to <130/80 for all adults with hypertension; start meds at ≥140/90 universally, or ≥130/80 if clinical CVD, diabetes, CKD, or PREVENT 10-year CVD risk ≥7.5%. Use the PREVENT calculator (not Pooled Cohort Equations) to guide treatment decisions.
How is hypertension defined and staged?
| Category | SBP | DBP |
|---|---|---|
| Normal | <120 | <80 |
| Elevated | 120–129 | <80 |
| Stage 1 | 130–139 | 80–89 |
| Stage 2 | ≥140 | ≥90 |
Categories unchanged from 2017. Overarching goal: <130/80 for all adults; the guideline encourages targeting <120/80 when tolerated.
When do I start medications?
| Scenario | Threshold | Strength |
|---|---|---|
| Stage 2 HTN (≥140/90) | Start meds immediately, all adults | COR 1 |
| Stage 1 + clinical CVD, DM, CKD, or PREVENT ≥7.5% | Start meds at ≥130/80 | COR 1 |
| Stage 1 + PREVENT <7.5% | Lifestyle trial 3–6 months; start meds if still ≥130/80 | COR 2a |
PREVENT replaces Pooled Cohort Equations (PCE). The PREVENT calculator was validated on >6.5 million U.S. adults and predicts 10-year total CVD risk (not ASCVD alone). A PREVENT threshold of ≥7.5% roughly maps to the old PCE ≥10% cutoff (closer to Framingham ≥15%).
What are the first-line drugs?
Four classes, all COR 1: thiazide-type diuretics (HCTZ, chlorthalidone, or indapamide — now grouped under one "thiazide-type" term), long-acting DHP CCBs, ACE inhibitors, ARBs.
Stage 2 HTN: start two drugs
For Stage 2 (≥140/90 or ≥20/10 mmHg above goal), initial therapy with a two-drug single-pill combination (SPC) is recommended (COR 1). Evidence shows faster BP control and better adherence vs. sequential monotherapy.
Key decisions an internist owns
Primary aldosteronism screening
Screen all patients with resistant HTN regardless of serum K+ (COR 1). Most antihypertensives (including ACEi, ARB, DHP CCB, BB) can be continued during screening; only hold MRAs (COR 1). This lowers the barrier to screening dramatically.
Resistant hypertension
Defined as BP above goal despite ≥3 drugs including a diuretic at maximally tolerated doses. After confirming adherence and excluding secondary causes:
- Add spironolactone (COR 1)
- Aprocitentan (Tryvio) — dual endothelin receptor antagonist, FDA-approved 2024 for resistant HTN. Added to the guideline drug table. (COR 2a)
- Renal denervation — FDA-approved (Symplicity Spyral, Paradise; 2023). Guideline requires multidisciplinary team evaluation (COR 1) and shared decision-making (COR 1) before proceeding.
Special populations
| Population | Key recommendation | Strength |
|---|---|---|
| Diabetes | Goal <130/80. ACEi/ARB COR 1 when CKD (eGFR <60 or albuminuria ≥30 mg/g). GLP-1 RAs as adjunct for BP in obesity (COR 2b). | COR 1 |
| CKD | RAASi COR 1 for eGFR <60 + albuminuria ≥30. Goal SBP <130. K+ binders can enable continued RAASi. | COR 1 |
| Stroke — acute ischemic | Post-EVT: SBP <140 within 24–72 h is COR 3: Harm. For thrombolysis: keep SBP <185/DBP <110 pre-treatment, <180/105 post. | — |
| ICH | Target SBP 130–<140 for ≥7 days (INTERACT-2/3). Stop if SBP <130. SBP <130 if presenting >220 is COR 3: Harm. | COR 1 |
| Pregnancy | Treat chronic HTN to <140/90 (COR 1; CHAP trial). Preferred agents: labetalol, ER nifedipine. Low-dose aspirin for preeclampsia risk (COR 1). Contraindicated: atenolol, ACEi, ARB, DRI, nitroprusside, MRA. | COR 1 |
| Cognitive decline | SBP <130 to prevent MCI/dementia (COR 1, upgraded from COR 2a in 2017). SPRINT-MIND legacy: benefit persists ≥7 years after only 3.5 years of intensive treatment. | COR 1 |
| Secondary stroke prevention | Goal SBP/DBP <130/80 (COR 1). Thiazide-type, ACEi, or ARB preferred. | COR 1 |
Severe hypertension (renamed from "hypertensive urgency")
For hospitalized patients with severe HTN (SBP >180 or DBP >120) without target organ damage: IV antihypertensives are COR 3: Harm. Use oral agents; reduce BP gradually over hours to days.
Other notable recommendations
- Potassium salt substitutes (replacing NaCl with KCl-enriched salt): COR 2a to lower BP and reduce CV events. Driven by the SSaSS trial (N = 20,995; NEJM 2021).
- Cuffless BP devices: COR 3: No Benefit — insufficient validation for clinical decisions.
- Team-based care with pharmacist/nurse titration: COR 1. Systematic reviews show SBP reductions of 6–7 mmHg over usual care.
What's changed since 2017
Reviewer synthesis (August 2026) — not the guideline. Each claim cited.
- PREVENT replaces PCE — 10-year total CVD risk from the PREVENT equations (validated on 6.5M adults) replaces the Pooled Cohort Equations for treatment initiation decisions. Khan SS et al. Circulation 2024; 10.1161/CIR.0000000000001191
- Stage 2 → initial SPC — initial two-drug single-pill combination now COR 1 for Stage 2 HTN, replacing sequential monotherapy. New since 2017.
- BPROAD validates intensive BP in T2D — SBP <120 vs <140 reduced major CV events by 21% (HR 0.79) in 12,821 patients with diabetes (median follow-up 4.2 yr). Closes the diabetes gap SPRINT could not address. BPROAD. NEJM 2024; PMID 39555827
- Cognitive decline prevention upgraded to COR 1 — SBP <130 to prevent MCI/dementia, up from COR 2a. SPRINT-MIND legacy follow-up showed benefit persisting ≥7 years after 3.5 years of intensive treatment.
- Post-EVT stroke: aggressive lowering harms — ENCHANTED-2 MT stopped early (OR 1.53 for worse disability with SBP <120); OPTIMAL BP stopped early (mRS 0–2: 39% with <140 vs 54% with 140–180). SBP <140 within 24–72 h post-reperfusion is now COR 3: Harm.
- Primary aldosteronism screening simplified — screen resistant HTN regardless of K+; keep most meds except MRA during screening (both COR 1). Removes a longstanding barrier to case detection.
- Aprocitentan (Tryvio) FDA-approved (Mar 2024) — first endothelin receptor antagonist for resistant HTN. REMS lifted April 2025; label broadened to systemic HTN with background therapy. FDA approval March 2024; REMS update April 2025.
- Renal denervation in the guideline — Symplicity Spyral (RF) and Paradise (ultrasound) FDA-approved Nov 2023. COR 1 for multidisciplinary evaluation + shared decision-making. 3-year SPYRAL HTN-ON MED data: −6.8 mmHg treatment difference sustained.
- Baxdrostat (Baxfendy) FDA-approved May 2026 — first-in-class aldosterone synthase inhibitor for uncontrolled HTN. BaxHTN (NEJM 2025): SBP reduction ~9–10 mmHg vs placebo at 12 weeks. Post-dates the guideline. Freeman MW et al. NEJM 2025; PMID 40888730
- Lorundrostat (Launch-HTN) — second aldosterone synthase inhibitor. Phase 3 (N = 1,083): SBP −16.9 vs −7.9 mmHg (placebo) at 6 weeks in resistant/uncontrolled HTN. FDA filing anticipated. Post-dates the guideline. Launch-HTN. JAMA 2025; PMID 40587141
- Still current — BP categories (normal/elevated/Stage 1/Stage 2 unchanged from 2017), first-line drug classes (thiazide-type, DHP CCB, ACEi, ARB), and the <130/80 goal are confirmed by the 2025 guideline with stronger evidence.
- Open — ATTAIN-HYPERTENSION (oral GLP-1 RA orforglipron for HTN in obesity; Phase 3, N = 1,084) is enrolling; results pending. The guideline gives GLP-1 RAs only COR 2b for BP lowering in obesity. Outcome data may upgrade this.
Anki cards minted this run
4 cards staged as TSV (Anki desktop unavailable). Tags: Guideline::ACC_AHA::Hypertension + Subject::Cardiology.
- PREVENT replaces PCE — the 10-year CVD risk threshold for starting meds; high-yield for boards.
- Stage 2 → initial SPC — new COR 1 recommendation; boards will test the change from sequential monotherapy.
- Primary aldosteronism screening: keep meds, check regardless of K+ — a common boards trap (old teaching was to wash out meds and require low K+).
- Cognitive decline prevention: SBP <130 now COR 1 — upgraded from COR 2a; SPRINT-MIND legacy data.
Sources
- 1. 2025 AHA/ACC Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults. Circulation 2025. 10.1161/CIR.0000000000001356
- 2. Khan SS et al. Novel Prediction Equations for Absolute Risk Assessment of Total Cardiovascular Disease Incorporating Cardiovascular-Kidney-Metabolic Health: A Scientific Statement From the AHA (PREVENT). Circulation 2024. 10.1161/CIR.0000000000001191
- 3. BPROAD Investigators. Intensive Blood-Pressure Control in Patients with Type 2 Diabetes. NEJM 2024. PMID 39555827
- 4. Freeman MW et al. Efficacy and Safety of Baxdrostat in Uncontrolled and Resistant Hypertension (BaxHTN). NEJM 2025. PMID 40888730
- 5. Launch-HTN Investigators. Lorundrostat in Participants With Uncontrolled Hypertension and Treatment-Resistant Hypertension. JAMA 2025. PMID 40587141
- 6. SPRINT-MIND legacy follow-up (cited in the 2025 guideline § 5.3.9.4).
- 7. ENCHANTED-2 MT (cited in the 2025 guideline § 5.3.9.2); OPTIMAL BP; BEST-II.