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Hypertension Management in Adults (AHA/ACC 2025)

Hypertension Management in Adults (AHA/ACC 2025): Adult with raised BP: measure correctly → Acute organ damage or other emergency signs? → Emergency: se...

Pathway Overview

24 steps

Algorithm Steps

24 total

  1. 01Start

    Adult with raised BP: measure correctly

    Adults 18 years or older. Pregnant: use a pregnancy hypertension pathway. Seated, validated upper-arm cuff of the right size. Use the average of 2 or more readings on 2 or more occasions.

  2. 02Decision

    Acute organ damage or other emergency signs?

    Yes if: BP >180/120 mm Hg with acute organ damage (chest pain or ACS, acute heart failure or pulmonary oedema, stroke, encephalopathy, retinal haemorrhage or papilloedema, AKI, aortic dissection); or acute stroke, ACS, acute heart failure or aortic dissection at any BP; or pregnant or postpartum with systolic 160 or more or diastolic 110 or more mm Hg.

    • BP >180/120 mm Hg with acute target organ damage = hypertensive emergency
    • BP >180/120 mm Hg without acute organ damage = severe hypertension: not an emergency; treat in clinic (see next steps)
  3. If Yes
    1. 03End

      Emergency: send to the emergency department now

      Hypertensive emergency: ICU-level monitoring and IV therapy; use the hypertensive emergency pathway. Pregnant or postpartum with systolic 160 or more or diastolic 110 or more mm Hg: urgent obstetric review; lower BP to below 160/110 mm Hg within 30-60 minutes.

    If No
    1. 04Action

      No emergency: confirm diagnosis and do baseline tests

      BP >180/120 mm Hg without acute organ damage: check for organ damage now (ECG, creatinine, urinalysis, fundi). Start or intensify oral treatment in clinic (no ED referral needed). Review within 7 days; within 24-72 hours if symptoms such as severe headache. No IV drugs or rapid BP lowering.

      • Confirm hypertension with home BP or 24-hour ambulatory BP before diagnosis
      • Tests: FBC; sodium, potassium, calcium; creatinine and eGFR; lipids; fasting glucose or HbA1c; TSH; urinalysis; urine albumin-creatinine ratio; ECG
      • Estimate CVD risk: PREVENT 10-year risk (US) or Aus CVD Risk Calculator 5-year risk (Australia)
      • Screen for primary aldosteronism (aldosterone, renin, ratio) if resistant BP, low potassium, sleep apnoea, adrenal mass, or family history of early hypertension or stroke before 40 years; consider in stage 2
      • Review drugs that raise BP, for example NSAIDs and decongestants
    2. 05Decision

      Classify the average BP

      Out-of-office readings have their own cut-offs. Stage 1: home 130/80 or 24-hour ambulatory 125/75 or more. Stage 2: home 135/85 or 24-hour ambulatory 130/80 or more. If systolic and diastolic fall in different categories, use the higher one.

      • Normal: <120 and <80 mm Hg
      • Elevated: 120-129 and <80 mm Hg
      • Stage 1: 130-139 or 80-89 mm Hg
      • Stage 2: 140 or more, or 90 or more mm Hg
    3. Normal
    4. 06Outcome

      Normal BP (<120/<80): healthy lifestyle, reassess in 1 year

      Promote a healthy lifestyle. Reassess BP in 1 year.

    5. Elevated
    6. 07Outcome

      Elevated BP (120-129/<80): lifestyle therapy, reassess in 3-6 months

      No BP drugs. Lifestyle therapy, then reassess BP in 3-6 months. If now stage 1 or 2, restart at classification.

      • Weight loss of at least 5% if overweight
      • Heart-healthy diet such as DASH
      • Sodium below 2300 mg/day, ideally below 1500 mg/day
      • More dietary potassium, unless CKD or drugs that raise potassium (then check levels)
      • Structured aerobic and/or resistance exercise
      • Aim for no alcohol; otherwise reduce intake
    7. Stage 1
    8. 08Decision

      Stage 1 (130-139/80-89): CVD, diabetes, CKD or high risk?

      Yes if clinical CVD (including prior stroke), diabetes, CKD, or 10-year PREVENT risk 7.5% or more. Australia: Aus CVD Risk Calculator 5-year risk 10% or more is high risk (5% to <10%: consider drugs).

    9. If Yes
      1. 09Action

        Stage 1 and high risk: lifestyle plus one first-line drug

        Clinical CVD, diabetes, CKD or high risk. Start one first-line drug with lifestyle therapy. Titrate the dose and add drugs as needed. Review in 1 month.

      2. 10Warning

        Before ACEi, ARB or MRA: pregnancy, angioedema, kidney function

        Check these before starting or adding drugs.

        • Pregnant or planning pregnancy: do not use ACEi, ARB, MRA (spironolactone) or atenolol (fetal harm). Counsel anyone who could become pregnant; stop at once if pregnant.
        • Angioedema with an ACEi: never use an ACEi again. An ARB can start 6 weeks after the ACEi is stopped. Angioedema with an ARB: do not use an ARB.
        • Check electrolytes and creatinine at baseline and 2-4 weeks after starting or increasing a diuretic, ACEi, ARB or MRA (hyperkalaemia risk, mainly in CKD).
      3. 11Action

        Choose first-line drugs

        First-line classes: thiazide-type or thiazide-like diuretic, long-acting dihydropyridine CCB, ACEi or ARB. Severe bilateral renal artery stenosis: ACEi or ARB can cause acute kidney failure.

        • Never combine an ACEi with an ARB or a renin inhibitor
        • Stage 2: 2 different classes, for example ACEi or ARB plus CCB or thiazide
        • Thiazides: monitor sodium, potassium, glucose, urate and calcium; care in gout
        • Beta-blockers are not first-line unless a comorbidity needs one
      4. 12Action

        Comorbidity: preferred drug classes

        HFrEF: never use diltiazem or verapamil. Use the heart failure pathway.

        • CKD (eGFR <60 or urine ACR 30 mg/g or more, 3 mg/mmol or more): ACEi or ARB; SBP goal <130
        • Diabetes: any first-line class; ACEi or ARB if eGFR <60 or albuminuria
        • HFrEF: ARNI or ACEi or ARB, beta-blocker, MRA and SGLT2 inhibitor
        • Chronic coronary disease: ACEi, ARB or beta-blocker; add CCB, thiazide or MRA if needed
        • Prior stroke or TIA: thiazide, ACEi or ARB; goal <130/80
      5. 13Action

        Review monthly and titrate until at goal

        Goal <130/80 mm Hg for most adults; encourage SBP <120 if tolerated. Frail, in residential care or limited life expectancy: set the goal with the patient.

        • Use home BP to guide titration
        • Check adherence and measurement technique before each increase
        • Increase the dose or add a drug of another class each month until at goal
        • Recheck electrolytes and creatinine 2-4 weeks after each start or dose increase of a diuretic, ACEi, ARB or MRA
        • Avoid NSAIDs with an ACEi or ARB plus a diuretic (AKI risk). Vomiting, diarrhoea or dehydration: consider pausing ACEi, ARB, diuretic and MRA
        • eGFR fall of up to 30% after starting an ACEi or ARB is expected; review if a fall above 30% persists
        • Australia (Heart Foundation 2016): target <140/90 mm Hg, or lower if tolerated; SBP <120 in selected high-risk patients
      6. 14Decision

        BP at goal?

        Use home or clinic readings.

      7. If Yes
        1. 15Outcome

          At goal: continue treatment, review every 3-6 months

          Continue lifestyle therapy and home BP monitoring. Repeat electrolytes, creatinine, eGFR and urine albumin-creatinine ratio at least once a year.

        If No
        1. 16Decision

          Not at goal: already on 3 drugs at optimal doses?

          3 drugs = ACEi or ARB, plus CCB, plus thiazide-type or thiazide-like diuretic, at maximum tolerated doses.

        2. If Yes
          1. 17Warning

            Resistant hypertension: above goal on 3 drugs including a diuretic

            Exclude pseudoresistance first: measurement technique, adherence, white-coat effect (home or ambulatory BP) and interfering drugs. Screen for primary aldosteronism and sleep apnoea.

            • Maximise the diuretic: switch to a thiazide-like diuretic (indapamide or chlorthalidone) at full dose
            • Adult: add spironolactone 25-50 mg once daily only if eGFR 45 or more and potassium 4.5 mmol/L or less; recheck potassium and creatinine within 2-4 weeks and after each dose change
            • MRA not tolerated or contraindicated: beta-blocker, alpha-blocker, central sympatholytic or vasodilator; amiloride only if potassium and eGFR allow. No beta-blocker in severe asthma, bradycardia or heart block; do not stop clonidine suddenly (rebound)
          2. 18End

            Refer to a hypertension specialist if still uncontrolled

            Refer if a secondary cause is known or suspected, or BP is uncontrolled after 6 months of treatment. Renal denervation only after review by a specialist team.

          If No
          1. 19Outcome

            Fewer than 3 drugs or doses not optimal: intensify, review in 1 month

            Increase the dose or add a first-line drug of another class. Check adherence. Review in 1 month and repeat the review steps until at goal.

      If No
      1. 20Action

        Stage 1, lower risk: lifestyle therapy for 3-6 months

        No clinical CVD, diabetes or CKD and 10-year PREVENT risk below 7.5%. Lifestyle therapy as for elevated BP, then reassess in 3-6 months (home BP preferred).

      2. 21Decision

        Lower-risk stage 1: still 130/80 or more after 3-6 months?

        Use the average of repeat clinic or home readings.

      3. If Yes
        1. 22Action

          Stage 1 still 130/80 or more after lifestyle: start one drug

          Start one first-line drug with lifestyle therapy. Titrate the dose and add drugs as needed. Review in 1 month.

        2. Path rejoins step 10Shared downstream outcome
        If No
        1. 23Outcome

          Below 130/80 after lifestyle: continue, reassess in 3-6 months

          Continue lifestyle therapy. Reassess every 3-6 months; start a drug if BP rises to 130/80 mm Hg or more.

    10. Stage 2
    11. 24Action

      Stage 2 (140/90 or more): lifestyle plus two first-line drugs

      Start 2 first-line drugs of different classes, ideally as a single-pill combination. Frail, older with orthostatic hypotension, or limited life expectancy: start one drug at a low dose and titrate slowly; agree goals with the patient.

      • BP >180/120 mm Hg without acute organ damage: start or intensify oral drugs now; review within 7 days (24-72 hours if symptomatic)
      • Australia (Heart Foundation 2016, Aus CVD risk 2023): 5-year risk 10% or more: start drugs. Below 10%: start drugs if BP stays 160/100 mm Hg or more; 5% to <10%: consider drugs
    12. Path rejoins step 10Shared downstream outcome

Guideline Source

2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults

DOI: 10.1161/HYP.0000000000000249View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Adults only, not pregnant. Pregnancy and postpartum: use a pregnancy hypertension pathway.
  • Thresholds follow the US AHA/ACC 2025 guideline. Australia: Heart Foundation 2016 and the 2023 Aus CVD risk guideline use 5-year risk and a <140/90 mm Hg target.
  • Hypertensive emergency and acute stroke BP care are not covered; use the dedicated pathways.
  • Most drug doses are not given; use product information or the local formulary.
  • Secondary hypertension work-up beyond aldosterone-renin screening needs specialist input.

Contraindicated Populations

pediatricpregnancy

Applicable Regions

USEUAU

AU: Heart Foundation Guideline for the diagnosis and management of hypertension in adults (2016) and the Australian Guideline for assessing and managing CVD risk (2023, Aus CVD Risk Calculator): 5-year risk 10% or more: start BP drugs; below 10%: start if BP stays 160/100 mm Hg or more; target <140/90 mm Hg, or lower if tolerated.

EU: ESC 2024 uses the same first-line classes and single-pill combinations; it defines elevated BP as 120-139/70-89 mm Hg and targets systolic 120-129 mm Hg if tolerated.

US: Based on the 2025 AHA/ACC high blood pressure guideline: treat at 130/80 mm Hg with clinical CVD, diabetes, CKD or 10-year PREVENT risk 7.5% or more; goal <130/80 mm Hg.

Version 2Next review: 2027-09-30

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Frequently Asked Questions

What is the Hypertension Management in Adults (AHA/ACC 2025)?

The Hypertension Management in Adults (AHA/ACC 2025) is a management clinical algorithm for Internal Medicine. It provides a structured decision tree to guide clinical decision-making, based on 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults.

What guideline is the Hypertension Management in Adults (AHA/ACC 2025) based on?

This algorithm is based on 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults (DOI: 10.1161/HYP.0000000000000249).

What are the limitations of the Hypertension Management in Adults (AHA/ACC 2025)?

Known limitations include: Adults only, not pregnant. Pregnancy and postpartum: use a pregnancy hypertension pathway.; Thresholds follow the US AHA/ACC 2025 guideline. Australia: Heart Foundation 2016 and the 2023 Aus CVD risk guideline use 5-year risk and a <140/90 mm Hg target.; Hypertensive emergency and acute stroke BP care are not covered; use the dedicated pathways.; Most drug doses are not given; use product information or the local formulary.; Secondary hypertension work-up beyond aldosterone-renin screening needs specialist input.. Individual patient factors may require deviation from these recommendations.

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