Targets for treatment and optimal strategies for managing hypertension in 2025: indications for clinical practice from recent hypertension guidelines

Recent hypertension guidelines differ in their recommendations on managing hypertension and associated cardiovascular risk. In this review, we highlight the key similarities and discrepancies among the recently published American College of Cardiology/American Heart Association (ACC/AHA), European Society of Cardiology (ESC), and European and International Society of Hypertension (ESH and ISH) hypertension guidelines. Despite differences in the definition of hypertension, all guidelines reflect a general trend towards earlier intervention and more stringent blood pressure (BP) targets, particularly for individuals at high cardiovascular risk. They align on lifestyle recommendations, such as dietary modification and physical activity, and advocate for combination therapy with a target BP of <130/80 mmHg if the risk is sufficiently high and treatment well tolerated. However, notable differences exist in treatment thresholds and BP targets for elderly individuals, as well as in the classification of hypertension phenotypes in younger patients. There are few discrepancies in recommended treatment classes, with all guidelines endorsing angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium channel blockers, and thiazide-type diuretics as first-line therapy. Knowledge gaps remain regarding optimal BP thresholds and targets across sex, age, and ethnic groups. Additional uncertainties include the clinical utility of intermediate outcomes in cardiovascular risk assessment, the long-term impact of life-course approaches to prevention, and the role of novel therapeutic agents. Emerging concerns such as climate change and air pollution also warrant further investigation for their potential effects on hypertension and cardiovascular risk.

Guidelines are important tools to help clinicians make treatment decisions. For the management of hypertension, different guidelines have been released in recent years. Being the most important risk factor worldwide and with its burden still increasing, management of hypertension remains a challenge. This is especially true for low- and middle-income countries where hypertension awareness, treatment, and control rates are still low. To help clinicians make informed decisions, we have compared the most important hypertension guidelines that have appeared in the past 10 years and summarized their most important recommendations.

Key findings are that:

All recent hypertension guidelines advocate earlier intervention and more stringent blood pressure targets and promote a healthy lifestyle

Important knowledge gaps remain regarding optimal blood pressure thresholds and targets across sex, age, and ethnic groups.