Updated October 2025

Guideline Brief

Hypertension Management 2024–2025: Guideline Updates and Therapeutic Sequencing

Recent European and North American updates converge on earlier initiation of combination therapy, strong use of out-of-office BP, and structured sequencing: ACEi/ARB + CCB or thiazide-like diuretic as the default, with clear roles for β‑blockers, mineralocorticoid receptor antagonists, and device therapy in resistant cases. Targets generally <130/80 mm Hg for most, with some societies retaining <140/90 mm Hg standard targets. Nuanced initiation thresholds for very old adults appear in ESH 2023, whereas ESC 2024 promotes uniform thresholds.

Clinical question

What are the current (2023–2025) evidence-based recommendations for diagnosing, treating, and sequencing pharmacotherapy in adult hypertension, and how do recent guidelines differ?

HypertensionGuidelinesTherapeuticsPrimary CareCardiology

Key points

Earlier, combination-first pharmacotherapy

ESC 2024 endorses prompt lifestyle + pharmacologic therapy at ≥140/90 mm Hg for all ages, reflecting data that age is not a major effect modifier up to ~85 years. Single-pill combinations are preferred to accelerate control ^[1].

ESH nuance for very old adults

ESH 2023 permits initiating pharmacotherapy at SBP ≥160 mm Hg (Class I) in adults ≥80 years, with consideration at 140–160 mm Hg (Class II), and allows a lifestyle-only trial in low-risk grade 1 hypertension before drugs ^[4], ^[1].

Out-of-office BP emphasized

ESH 2023 strongly emphasizes ambulatory and home BP monitoring to confirm diagnosis and guide therapy, reducing white-coat and masked hypertension misclassification ^[6].

Therapeutic sequencing clarified

Default initial therapy is ACEi/ARB + CCB or thiazide-like diuretic; add the third class if needed, then spironolactone for resistant hypertension, with β‑blockers positioned earlier when compelling indications exist ^[4], ^[9].

Targets and pragmatism

Most modern societies aim for <130/80 mm Hg in many adults, while some (e.g., AAFP) recommend a standard <140/90 mm Hg target, underscoring shared decision-making and tolerability ^[8].

Evidence highlights

≥140/90 mm Hg for lifestyle + drugs ^[1]

Universal start threshold (ESC 2024)

Often at SBP ≥160 mm Hg; consider 140–160 mm Hg ^[4]

Very old (≥80 y) ESH 2023 start

ACEi/ARB, CCB, thiazide-like diuretic; β‑blockers restored role ^[4], ^[9]

First-line classes

Diagnosis and Risk Stratification

Confirming Hypertension and Establishing Targets

Use standardized techniques, confirm with out-of-office readings, and individualize targets based on age, comorbidity, and treatment tolerance.

Standardize measurement and confirm with out-of-office BP

Use repeat seated office measurements, then confirm with HBPM or 24-hour ABPM to exclude white-coat and detect masked hypertension, as emphasized in ESH 2023 ^[6], ^[4].

Set initial targets

Aim for <130/80 mm Hg when tolerated for most non-frail adults per contemporary practice trends; recognize that some groups (e.g., AAFP) endorse <140/90 mm Hg as a standard target, particularly in primary care contexts ^[8].

Decide when to start medications

ESC 2024: Start drugs at ≥140/90 mm Hg regardless of age/CVD risk and pair with lifestyle (Class I) ^[1]. ESH 2023: start at ≥140/90 mm Hg for most, but in ≥80 years, Class I at SBP ≥160 mm Hg, with consideration at 140–160 mm Hg; low-risk grade 1 may try lifestyle first for several months ^[4], ^[1].

Therapeutic Sequencing

Stepwise Pharmacotherapy: From First-Line to Resistant Hypertension

Prioritize combination therapy early, expand to triple therapy, and use mineralocorticoid receptor antagonism before device therapy.

Start with 2-drug single-pill therapy

Preferred: ACEi/ARB + DHP-CCB or ACEi/ARB + thiazide-like diuretic (chlorthalidone or indapamide). Single-pill combinations improve adherence and speed BP control ^[4], ^[1].

Escalate to triple therapy

If uncontrolled, add the third class to form ACEi/ARB + CCB + thiazide-like diuretic before switching classes ^[4].

Resistant hypertension (≥3 drugs including a diuretic, uncontrolled)

Add spironolactone 12.5–50 mg as the preferred fourth agent (monitor K+ and renal function). Consider chlorthalidone/indapamide optimization and evaluate for secondary causes. For persistent true resistance, consider renal denervation in select patients, acknowledging evolving evidence and guideline positioning ^[4], ^[5].

Role of β‑blockers

β‑blockers are restored as therapeutic options in ESH 2023, particularly for coronary disease, heart failure with reduced EF, arrhythmias, pregnancy, or sympathetic overactivity; they may be earlier-line in those indications ^[9], ^[4].

Nonpharmacologic Therapy

Lifestyle and Adherence Optimization

Initiate lifestyle measures for all patients at diagnosis and throughout care; they potentiate medications and reduce pill burden.

Lifestyle interventions

Weight reduction and physical activity; even modest loss lowers BP ^[11].

DASH-style diet, sodium restriction, and moderation of alcohol ^[11].

Sleep hygiene and OSA screening when suggestive; treat OSA to aid control.

Smoking cessation and stress reduction to lower overall CVD risk.

Adherence and simplification

Use single-pill combinations when possible to improve persistence ^[4], ^[1].

Align dosing with routines; address cost and side effects proactively.

Employ home BP logs and digital reminders; verify technique ^[6].

Special Populations and Considerations

Tailoring Therapy

Adjust agents, thresholds, and targets based on comorbidity, age, and physiologic context.

Very old adults (≥80 years)

ESC 2024: treat at ≥140/90 mm Hg similar to younger adults ^[1].

ESH 2023: initiate at SBP ≥160 mm Hg (Class I); consider 140–160 mm Hg based on frailty, orthostasis, and preferences ^[4].

Prioritize tolerance, orthostatic BP checks, and renal/electrolyte monitoring.

Compelling indications

CAD, HFrEF, arrhythmias, pregnancy: β‑blockers often indicated ^[9], ^[4].

CKD/proteinuria: ACEi/ARB foundational; diuretic intensity often needed ^[4].

Diabetes: standard first-line classes; monitor for orthostasis and albuminuria.

Emerging/advanced therapies

RNA-based therapeutics targeting the renin–angiotensin system (e.g., AGT knockdown) show promise for infrequent dosing; phase II data awaited ^[2].

Interventional approaches (e.g., renal denervation) are expanding for true resistant cases in specialized centers ^[5].

Targets and Monitoring

Follow-Up and Treatment Targets

Frequency and intensity of follow-up should match risk and BP level.

Follow-up cadence

Reassess every 4–6 weeks until control; sooner for stage 2 or high risk.

Use home BP averages to guide titration; confirm control with ABPM when uncertain ^[6].

Targets and de-intensification

Aim <130/80 mm Hg if tolerated; ensure diastolic not pushed too low in CAD.

AAFP supports a standard <140/90 mm Hg target; individualize per frailty and adverse effects ^[8].

Consider cautious de-intensification if orthostatic symptoms or adverse events emerge.

References