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Hypertension: diagnosis & target

4 recommendations ACC/AHA 2025 · USPSTF 2021 · AAFP 2022 Updated Sept. 25, 2026

Recommendations

ACC/AHA2025

Replaces 2017; categories unchanged: Normal <120/80; Elevated 120-129/<80; Stage 1 130-139 or 80-89; Stage 2 ≥140 or ≥90. Goal <130/80, and with increased CVD risk, encouragement to reach systolic <120. Start medication at ≥140/90, or ≥130/80 with clinical CVD, diabetes, CKD, or PREVENT 10-yr risk ≥7.5% (Class 1, LOE A). New: stage 1 at lower risk, start medication if still ≥130/80 after 3 to 6 months of lifestyle change (Class 1, B-R).

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USPSTF2021Grade A

Screen adults ≥18 with office BP; confirm with out-of-office (ambulatory or home) measurement before diagnosis and treatment. Suggested intervals: yearly at 40 or older or with increased risk (eg, Black adults, high-normal BP, overweight or obesity); every 3 to 5 years at 18 to 39 without increased risk and a prior normal reading.

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ACC/AHA2025Grade Class 1

Use home BP monitoring to confirm the diagnosis and to titrate medications (LOE A). First-line drugs: thiazide-type diuretic, long-acting dihydropyridine CCB, ACEi, or ARB (LOE A). For stage 2, and some higher-risk stage 1, start two drugs from different classes, ideally as a single-pill combination (B-R). Screen for primary aldosteronism with resistant hypertension, hypokalemia, obstructive sleep apnea, adrenal incidentaloma, or family history of early hypertension or stroke before 40 (C-EO).

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AAFP2022Grade Strong (140/90); weak (135/85)

Family medicine target: treat adults with hypertension to below 140/90 to reduce all-cause and cardiovascular mortality (strong recommendation, high-quality evidence). A lower target below 135/85 adds no mortality benefit but may be considered to reduce myocardial infarction risk, based on patient preferences (weak recommendation, moderate-quality evidence). Still the AAFP's current hypertension guideline; it differs from the ACC/AHA goal of <130/80.

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Who this applies to

  • Screen every adult 18 and older (USPSTF 2021, Grade A): yearly from 40 or with risk factors; every 3 to 5 years at 18 to 39 with a normal reading and no risk factors.
  • Categories (ACC and AHA 2017, kept in 2025): normal under 120/80; elevated 120 to 129 and under 80; stage 1, 130 to 139 or 80 to 89; stage 2, 140 or more or 90 or more.
  • Start medication at stage 2 for everyone; at stage 1 with cardiovascular disease, diabetes, CKD or a PREVENT 10-year risk of 7.5 percent or more; otherwise after 3 to 6 months of lifestyle change if still stage 1.

How it is done in practice

  • Confirm before diagnosing: home monitoring with a validated upper-arm cuff (two readings morning and evening for 7 days, discard day 1, average the rest) or 24-hour ambulatory monitoring. This catches white-coat hypertension, present in 10 to 30 percent, and masked hypertension.
  • Office technique adds or removes 5 to 15 mmHg: seated 5 minutes, back supported, feet flat, arm at heart level, the right cuff size, no talking, and the average of at least two readings.
  • First-line drugs: a thiazide-type diuretic (chlorthalidone or indapamide preferred), an ACE inhibitor or ARB, or a dihydropyridine calcium channel blocker. Start two drugs from different classes, ideally in one pill, for stage 2 and for some higher-risk stage 1 (ACC and AHA 2025). The 2025 guideline no longer chooses the first drug by race. Diabetes or CKD with albuminuria: ACE inhibitor or ARB. Never combine an ACE inhibitor with an ARB.
  • Baseline labs (ACC and AHA 2025): CBC, basic metabolic panel, lipids, fasting glucose or A1c, urinalysis with albumin-to-creatinine ratio, TSH, and an ECG (this is one of the indications for it). Recheck monthly until controlled.
  • Lifestyle that moves the number: the DASH diet, sodium under 1,500 mg a day or at least a 1,000 mg reduction, potassium-rich foods, 150 minutes a week of aerobic exercise plus resistance training, alcohol limits, and weight loss at roughly 1 mmHg per kilogram.

What changed recently

The 2025 ACC and AHA guideline kept the 2017 thresholds, adopted PREVENT for risk estimation, set under 130/80 as the target for most adults, with encouragement to reach a systolic under 120 for those at increased cardiovascular risk, started medication for lower-risk stage 1 that persists after 3 to 6 months of lifestyle change, and renewed the emphasis on out-of-office measurement and single-pill combinations.

Points that matter in clinic

  • Resistant hypertension (uncontrolled on three drugs including a diuretic): confirm adherence and technique first, then add spironolactone, and screen for primary aldosteronism with an aldosterone-to-renin ratio.
  • Older adults: the same target when tolerated (the SPRINT trial included people over 75), but watch for orthostatic drop, falls and a rising creatinine, and individualize in frailty or limited life expectancy.
  • Pregnancy: labetalol, extended-release nifedipine or methyldopa, treating at 140/90 (the CHAP trial, 2022). ACE inhibitors and ARBs are contraindicated.

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