ACC/AHA Blood Pressure Guideline: Current Classification System and Treatment Targets

SUMMARY:  

Hypertension is the most prevalent and modifiable risk factor for the development of CVD, including CAD, HF, AFib, Stroke, Dementia, CKD and all-cause mortality.

The USPSTF, based on high certainty regarding net benefit, “recommends screening for hypertension in adults 18 years or older with office blood pressure measurement. The USPSTF recommends obtaining blood pressure measurements outside of the clinical setting for diagnostic confirmation before starting treatment. (grade A recommendation)”.

The ACC/AHA guideline, representing the work of several professional bodies and based upon hundreds of studies, provides the thresholds, definitions and management for high blood pressure in adults in the US. Lower BP targets continue to be a focus and remain the same as the previous guidance. An important change from the previous recommendations is the inclusion of the PREVENT calculator (see ‘Learn More – Primary Sources’ below). Cuffless devices (e.g., smartwatches) are not recommended for BP evaluation. Another important update includes the management of severe hypertension in nonpregnant individuals, defined as blood pressure >180/120 mm Hg. In the absence of acute target organ damage, outpatient treatment is appropriate. For more details regarding the changes, see the JAMA Expert Review: What to Know About the New Blood Pressure Guidelines in the ‘Learn More – Primary Sources’ below.

The document states

The overarching blood pressure treatment goal is <130/80 mm Hg for all adults, with additional considerations for those who require institutional care, have a limited predicted lifespan, or are pregnant

The ACC/AHA Task Force Classification System

Systolic <120 mmHg and Diastolic <80 mmHg: NORMAL BP

• Healthy lifestyle choices  
• Yearly check-ups 

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Systolic 120 to 129 mmHg and Diastolic <80 mmHg: ELEVATED BP

• Healthy lifestyle changes  
• Reassess in 3 to 6 months  

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Systolic 130 to 139 mmHg or 80 to 89 mmHg: STAGE 1  

• Initiate treatment in patients with clinical CVD | previous stroke | diabetes | CKD | 10-year predicted CV risk ≥ 7.5% defined by PREVENT calculator (see ‘Learn More’ below)
  • 10-year heart disease and stroke risk assessment 3-to-6-month trial of lifestyle changes and persistent elevation of average blood pressure 

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≥140 mmHg or ≥90 mmHg: HIGH BP – STAGE 2 

• Lifestyle changes
• Initiation of therapy with 2 different classes of medications in a combination pill to improve adherence and reduce time to BP control
• Monthly follow-up until BP is under control utilizing ambulatory monitoring and frequent interactions with multidisciplinary clinic team members e.g. RNs, pharmacists, medical assistants, etc.
• Do not rely on cuffless devices including smartwatches due lack of precision and reliability
• If BP ≥160/100 mm Hg: Treat promptly, monitor carefully and adjust medication dose upward as necessary to achieve control

Additional Hypertension Classifications  

‘White Coat’ hypertension 

• Elevated BP in the office but not outside the office  
• Checking for ‘White Coat’ hypertension using either daytime Ambulatory Blood Pressure Monitoring (ABPM) or Home Blood Pressure Monitoring (HBPM) is “reasonable” if  
• • Office SBP is >130 but <160 mm Hg or  
• • Office diastolic BP (DBP) >80 but <100 mm Hg and  
  • Patient has failed to improve with 3 months of lifestyle modification  

‘Masked’ hypertension 

• Elevated BP out-of-office but not in-office 
• Checking for ‘masked’ hypertension with daytime ABPM or HBPM is “reasonable if”  
  • Office SBP is 120 to 129 and DBP is <80 while not on antihypertensive medications or
  • If patient is on antihypertensive therapy with office SPB of 120 to 129 and DBP is <80, and they have high risk comorbidities such as CKD, >10% risk of stroke, or signs of hypertension related end organ damage

Severe hypertension

• Severe hypertension: SBP ≥180 mmHg or DBP ≥120 mmHg with end organ damage (e.g., pulmonary edema, cardiac ischemia, neurologic deficits, acute renal failure, aortic dissection, and eclampsia is termed hypertensive emergency. This is a medical emergency that requires hospital care.
• If no evidence of end organ damage can manage in ambulatory setting with close follow up
• Blood pressure should not be decreased abruptly to prevent cerebral hypoperfusion

Resistant hypertension 

• Uncontrolled BP despite treatment with ≥3 antihypertensive agents of different classes (one of which is usually a diuretic) 

The ACC/AHA task force also recommends the following as cut offs for hypertension when using at home BP measurements: >110/>65 mmHg for nighttime mean and >125/>75 mmHg for 24hr mean.  

KEY POINTS:  

Risk Factors   

• Genetic predisposition  
  • Complex polygenic disorder  
  • Rarely single gene disorder (e.g. Liddle’s or Gordon’s syndrome) 
• Environmental Risk Factors  
  • Overweight and Obesity 
  • Sodium Intake 
  • Potassium  
    • Higher levels appear to blunt sodium effect on BP  
    • Lower sodium/potassium ratio may reduce risk of CVD  
  • Physical fitness  
    • Even modest levels of physical activity is associated with a decrease in the risk of incident hypertension  
  • Alcohol 
    • In US, may account for 10% of BP burden  
    • Also associated with higher HDL and at modest intake range, lower risk for CHD when compared to abstinence 

Non-pharmacological Interventions 

• Weight loss 
  • Goal: Optimum goal is ideal body weight but can expect 1mm Hg for every 1kg reduction 
• Diet 
  • DASH diet: Fruits and vegetables, whole grains, low-fat dairy products, reduced saturated and total fat 
  • Other diets with supportive evidence 
    • Low in calories from carbohydrates  
    • High-protein diets  
    • Vegetarian diets  
    • Mediterranean dietary pattern  
  • Sodium: Goal <1500 mg/d, but aim for at least a 1000mg/d reduction 
  • Potassium: Goal 3500 to 5000 mg/d, preferably through diet 
• Exercise – Recommend structured exercise program  
  • Aerobic: 90 to 150 min/wk; 65% to 75% heart rate reserve 
  • Dynamic resistance and Isometric resistance also shown to lower BP  
• Alcohol Reduction (drink = 12 oz regular beer [5% alc] / 5 oz wine [12% alc] / 1.5 oz distilled spirits [40% alc])  
  • Women: ≤ 1 drink per day  
  • Men: ≤ 2 drink per day 

Taking a BP 

• Prep 
  • Avoid caffeine, exercise, smoking at least 30 minutes before  
  • Empty bladder 
  • No talking while measurement is taken 
  • Remove clothing covering cuff placement 
  • Patient should sit on chair, feet on floor and back supported for > 5 min before taking pressure (not lying or sitting on an exam table) 
• Technique 
  • Validated device 
  • Support arm 
  • Middle of cuff on upper arm at level of atrium (midpoint of the sternum) 
  • Cuff size: Bladder should encircle 80% of the arm  
  • Can use either stethoscope diaphragm or bell 
• Taking the measurement 
  • First visit: Record BP in both arms and use arm with higher reading for subsequent measurements  
  • Separate measurement by 1 to 2 minutes 
  • To estimate systolic BP, use radial pulse obliteration and then inflate cuff 20 to 30 mmHg higher  
  • Deflate cuff pressure 2 mmHg per second and listen for Korotkoff sounds  
    • Systolic BP: First Korotkoff sound 
    • Diastolic BP: Disappearance of all Korotkoff sounds  
    • Use nearest even number  
  • Note time of most recent BP medication before taking measurements  
• Average the readings to estimate BP 
  • Use average of ≥ 2 readings obtained on ≥ 2 occasions  

Note: The AHA has released a scientific statement that validated oscillometric devices allow accurate BP measurement in the outpatient setting, while reducing human errors associated with the auscultation.  

Target BP Goal 

• Less than 130/80 for ALL adults
• Special consideration for institutionalized patients | limited predicted lifespan | pregnant
• Recommendation differs from ACP and AAFP goals
  • ACP and AAFP < 150/90 for adults > 60 and <140/90 if high risk for MI | Stroke
  • AAFP <140/90 for all adults <60 and possibly < 135/85 using shared decision making to further reduce risk of MI
  • ACP <140/90 for all adults <60, even with diabetes or CKD

Note: You can find guideline summaries and links in ‘Learn More – Primary Sources’ section below

Oral Contraceptives and NSAIDs

• Oral contraceptives and NSAIDs are listed as commonly used medications that may cause elevated BP
• The ACC/AHA guideline recommends the following

 OCPs

• Use low-dose (e.g., 20 to 30 mcg ethinyl estradiol) agents or a progestin-only form of contraception, or consider alternative forms of birth control where appropriate (e.g., barrier, abstinence, IUD)
• Avoid use in women with uncontrolled hypertension

NSAIDs

• Avoid systemic NSAIDs when possible
• Consider alternative analgesics (e.g., acetaminophen, tramadol, topical NSAIDs), depending on indication and risk

Learn More – Primary Sources:

Screening for Hypertension in Adults: US Preventive Services Task Force Reaffirmation Recommendation Statement

2025 AHA/ACC Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults

American Heart Association PREVENT Online Calculator

AHA AMA: BP Treatment Algorithm 

Measurement of Blood Pressure in Humans: A Scientific Statement From the American Heart Association

AAFP Hypertension. Management Guidelines

JAMA Expert Review: What to Know About the New Blood Pressure Guidelines

ACC/AHA Blood Pressure Treatment Guideline: Lifestyle Modification and Drug Therapy

SUMMARY:

Treatment of hypertension should involve non-pharmacologic therapy (also called lifestyle modification) alone or in concert with antihypertensive drug therapy.  The ACC/AHA Blood Pressure Guidelines updated in 2025 address both areas. In addition, the AHA scientific statement (2019) on BP measurement concluded that validated oscillometric devices allow for accurate BP measurement in the outpatient setting and “may provide a more accurate measurement of BP than auscultation”

Table of Contents  

• Current ACC/AHA Definitions
• Lab Work-Up
• BP Treatment Summary
• Lifestyle Modification
• First Line Pharmacological Treatment
• Second Line Pharmacological Treatment
• Target BP and Treatment Strategy
• Special Populations

Current ACC/AHA Definitions

• Normal
  • Systolic <120 mmHg and diastolic <80 mmHg
• Elevated
  • Systolic 120 to 129 mmHg and diastolic <80 mmHg
• Hypertension
  • Stage 1: Systolic 130 to 139 mmHg or diastolic 80 to 89 mmHg
  • Stage 2: Systolic ≥140 mmHg or diastolic ≥90 mmHg
• ‘White Coat’ hypertension
  • Elevated BP in the office but not outside the office
  • Checking for ‘White Coat’ hypertension using either daytime Ambulatory Blood Pressure Monitoring (ABPM) or Home Blood Pressure Monitoring (HBPM) is “reasonable” if
    • Office SBP is >130 but <160 mm Hg or
    • Office diastolic BP (DBP) >80 but <100 mm Hg
• ‘Masked’ hypertension
  • Elevated BP out-of-office but not in-office
  • Checking for ‘masked’ hypertension with daytime ABPM or HBPM may be “reasonable if”
• Hypertensive emergency (formerly called ‘malignant hypertension’)
  • Severe hypertension: SBP ≥180 mmHg or DBP ≥120 mmHg with evidence of end organ damage e.g., acute pulmonary edema, neurological disorders, AKI, acute decompensated HF
    • Consider this a medical emergency which may need ICU care
  • If no end organ damage, treat in the outpatient setting and is no longer termed hypertensive urgency
• Resistant hypertension
  • Uncontrolled BP despite treatment ≥3 antihypertensive agents (one of which is usually a diuretic)

Lab Work-Up

• Basic
  • Fasting blood glucose | Sodium | Potassium | Calcium
    • Can be part of comprehensive metabolic panel
  • Serum creatinine with eGFR
  • CBC
  • Lipid profile
  • TSH
  • Urinalysis
  • Electrocardiogram
• Optional testing
  • Echocardiogram
  • Uric acid
  • Urinary albumin/creatinine ratio

BP Treatment Summary

• <120 mmHg and <80 mmHg → NORMAL BP
  • Healthy lifestyle choices  
  • Yearly check-ups 
• 120 to 129 mmHg and <80 mmHg → ELEVATED BP
  • Lifestyle changes  
  • Reassess in 3 to 6 months  
• 130 to 139 mmHg or 80 to 89 mmHg → HIGH BP – STAGE 1
  • 10-year heart disease and stroke risk assessment <10% risk
    • Lifestyle changes  
    • Re-assess in 3 to 6 months 
  • 10-year heart disease and stroke risk assessment ≥10% risk
    • Lifestyle changes  
    • Medication  
    • Monthly follow-up until BP is under control 
• ≥140 mmHg or ≥90 mmHg → HIGH BP – STAGE 2
  • Lifestyle changes  
  • Consider initiation of therapy with 2 different classes of medications 
  • Monthly follow-up until BP is under control
  • If BP ≥160/100 mm Hg: Treat promptly, monitor carefully and adjust medication dose upward as necessary to achieve control  

NOTE: Calculate 10-year risk of heart disease or stroke using the PREVENT calculator published by the ACC/AHA in 2023 Guideline on the Assessment of Cardiovascular Risk (see ‘Learn More – Primary Sources’ below)

Lifestyle Modification (Non-pharmacological Interventions) 

• Weight loss
  • Goal: Optimum goal is ideal body weight but can expect 1mm Hg for every 1kg reduction 
• Diet
  • DASH diet: Fruits and vegetables, whole grains, low-fat dairy products, reduced saturated and total fat 
  • Other diets with supportive evidence
    • Low in calories from carbohydrates  
    • High-protein diets  
    • Vegetarian diets  
    • Mediterranean dietary pattern  
  • Sodium: Goal <1500 mg/d, but aim for at least a 1000mg/d reduction 
  • Potassium: Goal 3500 to 5000 mg/d, preferably through diet 
• Exercise – Recommend structured exercise program
  • Aerobic: 90 to 150 min/wk; 65% to 75% heart rate reserve 
  • Dynamic resistance and Isometric resistance also shown to lower BP  
• Alcohol Reduction (drink = 12 oz regular beer [5% alc] / 5 oz wine [12% alc] / 1.5 oz distilled spirits [40% alc])
  • Women: ≤ 1 drink per day  
  • Men: ≤ 2 drink per day 

First Line Pharmacological Treatment

• Consider any existing comorbidities e.g., CAD, HF, stroke, diabetes, or CKD to select agents that address both blood pressure and these conditions.
• Strong evidence from RCT supports thiazide-type diuretics | long-acting dihydropyridine calcium channel blockers (CCBs) | ACE inhibitors (ACEi) | angiotensin II receptor blockers (ARBs) as preferred first-line therapy due to their proven benefits for blood pressure reduction, CVD prevention, and overall tolerability

Thiazide or thiazide-type diuretics e.g, Chlorthalidone, Hydrochlorothiaizide, Indapamide:

• Preferred due to prolonged half-life and evidence of reduced adverse CVD outcomes
• Monitor for: Hyponatremia & hypokalemia | Uric acid & calcium levels
• Caution: Ask about history of acute gout unless patient is on uric acid–lowering therapy

ACE (angiotensin-converting-enzyme) inhibitors e.g., benazepril, enalapril, lisinopril

Caution: Do not combine with ARBs or direct renin inhibitor | Increased risk of hyperkalemia (watch for patients with CKD, on K⁺ supplements or sparing meds) | Risk for acute renal failure in patients with severe bilateral renal artery stenosis | Do not use in pregnancy | Do not use if patient has history of angioedema with ACE inhibitors

ARBs (Angiotensin II Receptor Blockers) e.g., olmesartan, valsartan, azilsartan, irbesartan

Caution: Do not combine with ACE or direct renin inhibitor | Increased risk of hyperkalemia (watch for patients with CKD, on K⁺ supplements or sparing meds) | Risk for acute renal failure in patients with severe bilateral renal artery stenosis | Do not use in pregnancy | Do not use if patient has history of angioedema with ARBs | Note: Patient with history of angioedema due to ACE inhibitor can start ARBs six weeks after ACE inhibitor has been stopped

CCB (Calcium Channel Blocker): Dihydropyridines e,g., amlodipine, nifedipine, nicardipine

Caution: Avoid use in patients with heart failure/reduced ejection fraction (HFrEF) – amlodipine or felodipine may be used if required | Dose-related pedal edema is more common in women

CCB: Nondihydropyridines e.g., diltiazem, verapamil

Caution: Avoid routine use with beta blockers due to increased risk of bradycardia and heart block| Avoid in patients with HFrEF | Note drug interactions with diltiazem and verapamil (CYP3A4 major substrate and moderate inhibitor)

Second Line Pharmacological Treatment

Complete list with dosing available in the guideline link (see ‘Learn More – Primary Sources’ below)

• Second line treatment includes the following classes of medications
  • Diuretics: Loop | Potassium sparing | Aldosterone antagonists
  • Beta-blockers: Cardioselective | Cardioselective and vasodilatory | Noncardioselective | Intrinsic sympathomimetic activity | combined alpha- and beta-receptor
  • Direct renin inhibitor
  • Alpha-1 blockers
  • Central alpha2 agonist and other centrally acting drugs
  • Direct vasodilators
• While some are generally less effective than first-line class drugs, some may be preferred in certain clinical settings such as symptomatic heart failure  

KEY POINTS:

Target BP and Treatment Strategy

 BP Target Goals

• <130/80 mm Hg recommended for ALL patients
• May consider higher goals for institutionalized patients or patients with limited predicted lifespan

Monotherapy vs Combination Therapy

• Stage 1 hypertension
  • Start with a single agent Initiation of antihypertensive drug therapy and titrate dose or add another medication to achieve target  
• Stage 2 hypertension and an average BP more than 20/10 mm Hg above BP target
  • Start with a combination of 2 first-line agents of different classes
  • Can be either separate or fixed-dose combination

Treatment of white coat and masked hypertension (ACC/AHA)

• Sparse data on the risks and benefits of treating white coat and masked hypertension
• Recent evidence suggests that compared with placebo, antihypertensive medication may improve target organ damage among adults with masked hypertension
• Consistent evidence that masked hypertension and masked uncontrolled hypertension are associated with adverse outcomes related to elevated BP compared to normotensive individuals
• More recent evidence that there may associated risk with white coat hypertension and guidelines suggest lifestyle modification and monitoring to what for possible transition to sustained hypertension

Special Populations

During Pregnancy

• Transition to
  • Methyldopa | Nifedipine | Labetalol (see ‘Related ObG Entry’ below)
• Caution: Do not treat with
  • ACE inhibitors | ARBs | Direct renin inhibitors

Race / Ethnicity

• Black adults with hypertension but no heart failure or chronic kidney disease
  • Begin initial treatment with a thiazide-type diuretic or CCB
  • Target of <130/80 using two or more antihypertensives if needed is recommended for most adults, but “especially in black adults with hypertension”

Diabetic Patients with Hypertension

• Initiate treatment at ≥130/80 mm Hg with a treatment goal of <130/80 mm Hg
• All first-line classes of antihypertensive are useful and effective
• “ACE inhibitors or ARBs may be considered in the presence of albuminuria”

Learn More – Primary Sources  

2025 ACC/AHA Hypertension Guidelines

Measurement of Blood Pressure in Humans: A Scientific Statement From the American Heart Association

AHA/ACC PREVENT Calculator