Big Changes in Blood Pressure: A Simple Guide to the 2025 Hypertension Guidelines

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The way doctors and pharmacists manage high blood pressure is about to change. The new 2025 AHA/ACC Hypertension Guidelines have been released, introducing significant, evidence-based updates designed to improve patient safety and provide more effective care.

Whether you are a patient or a healthcare provider, it’s important to understand these key shifts. Here’s a simple breakdown of what you need to know.

1. “Hypertensive Urgency” Gets a New Name and a Safer Approach

One of the biggest changes is the terminology. The term “hypertensive urgency” is now being replaced with

“severe hypertension”. This refers to a blood pressure reading higher than 180/120 mm Hg in a patient

without symptoms of acute target organ damage.

Why the change? The old term often led to unnecessary emergency department visits and the use of potent IV medications that could lower blood pressure too quickly, causing harm. The new approach for patients with asymptomatic severe hypertension is to:

• Avoid IV medications in the hospital or ED.
• Start well-tolerated oral medications.
• Arrange for a follow-up appointment with a primary care provider or cardiologist within a few days.

2. A Smarter Way to Decide Who Needs Medication: The PREVENT Calculator

The new guidelines integrate the

PREVENT risk calculator, a more accurate and inclusive tool for predicting a person’s 10-year risk of heart attack or stroke. This calculator includes factors like kidney disease and social determinants of health to better guide treatment decisions.

The new rules are:

• High-Risk Patients: If you have established cardiovascular disease, diabetes, chronic kidney disease, or a PREVENT risk score of 7.5% or higher, medication is now recommended if your blood pressure is 130/80 mm Hg or higher.
• Lower-Risk Patients: If your blood pressure is between 130-139/80-89 mm Hg and your risk score is less than 7.5%, the first step is a 3-6 month trial of lifestyle changes. Medication is only recommended if blood pressure remains high after that period.

3. New Rules for Stroke and Brain Bleeds

The guidelines provide critical updates for managing blood pressure during neurological emergencies:

• After an Ischemic Stroke (Post-Reperfusion): The guidelines now state that lowering systolic blood pressure below 140 mm Hg in the first 24-72 hours can be harmful and should be avoided. The goal is to maintain pressure between 140-180 mm Hg to ensure the brain gets enough blood flow to recover.
• For a Brain Bleed (ICH): If the systolic pressure is between 150-220 mm Hg, the new target is to lower it to 130-140 mm Hg within the first 7 days. For extremely high pressures (>220 mm Hg), a continuous IV infusion is recommended over single “bolus” injections to prevent dangerous blood pressure swings.

4. Critical Updates for Managing Hypertension in Pregnancy

The 2025 guidelines emphasize safer and more proactive care for pregnant patients:

• Treat Urgently: Severe hypertension (BP ≥160/110 mm Hg) during pregnancy is a medical emergency. Treatment must be started within 30-60 minutes to prevent a maternal stroke.
• Treat Earlier: For chronic hypertension in pregnancy, treatment should now begin when blood pressure is 140-159/90-109 mm Hg to a target of <140/90 mm Hg.
• Preeclampsia Prevention: Low-dose aspirin (81 mg daily) is strongly recommended for pregnant patients with chronic hypertension, starting at 12 weeks of gestation, to reduce the risk of preeclampsia.
• Medication Safety: The list of contraindicated medications has been expanded. Common drugs like ACE inhibitors (e.g., lisinopril), ARBs (e.g., losartan), and the beta-blocker atenolol should be avoided during pregnancy due to risks to the fetus.

Guideline Resources

These updates represent a major step forward in hypertension management. For healthcare professionals seeking more information, the following resources are available:

• Download the Pharmacist’s Guide: Comprehensive Clinical Reference: 2025 AHA/ACC Hypertension Guidelines for Pharmacists
• Read the Full Guideline: 2025 Guideline for the Management of High Blood Pressure in Adults (AHA/ACC)