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CLINICAL STATEMENTS AND GUIDELINES Circulation. 2025;152:e114–e218. DOI: 10.1161/CIR.0000000000001356 September 16, 2025 e133 hypertension, white-coat effect is not associated with an increased risk of CVD events.1,4,13 These studies primarily did not focus on individuals with apparent resistant hypertension, indicating that it is reasonable to conduct out-of-office BP moni toring for the larger group of individuals who are taking antihypertensive medication and who have high office BP (ie, office SBP/DBP ≥130/80 mm Hg). Individuals with office SBP/DBP ≥160/100 mm Hg should have antihypertensive medication intensification as necessary to control BP (Section 5.2, “Medical Management”). 5. Systematic reviews and meta-analyses of obser vational studies have demonstrated that compared with sustained normotension, masked hypertension is associated with an increased risk of CVD events with a risk range similar to that of sustained hyper tension.5,13–15 Studies have examined whether using specific office BP ranges (ie, those approaching the high office BP threshold) or prediction models incorporating demographic and clinical factors for targeting individuals with out-of-office BP moni toring would be a better approach than screening all individuals who do not have high office BP.28–32 Clinicians may consider using these targeted screening approaches, particularly among those patients with unexplained BP-related target organ damage. However, it remains unclear which diag nostic approach is the best for excluding masked hypertension among individuals without high office BP and what false-positive and -negative rates are acceptable for population screening. Further, these targeted screening approaches should also be examined among populations with a high prevalence of masked hypertension, such as Black populations.33 Therefore, in the absence of knowing the best approach for targeted screen ing, the use of out-of-office BP monitoring may be reasonable to exclude masked hypertension among adults with office SBP/DBP <130/80 mm Hg. Recent evidence suggests that compared with placebo, antihypertensive medication may improve target organ damage among adults with masked hypertension.34 However, the effect on cardiovas cular outcomes remains unknown. 6. Systematic reviews and meta-analyses have demon strated that compared with controlled hypertension, masked uncontrolled hypertension is associated with an increased risk of CVD events and mortality.13–15 There are some data to suggest that antihyperten sive medication targeting out-of-office BP among individuals with masked uncontrolled hypertension reduces hypertension-related target organ damage measures, including urinary albumin-to-creatinine ratio, pulse wave velocity, and left ventricular mass index.35 Although the effect of antihypertensive medication intensification on the risk of CVD events among individuals with masked uncontrolled hyper tension remains unknown, it may be reasonable to exclude masked uncontrolled hypertension using outof-office BP monitoring for CVD risk stratification. 3.2.3 Secondary Forms of Hypertension Recommendations for Secondary Forms of Hypertension References that support recommendations are summarized in the Evidence Table. COR LOE Recommendations 1 C-EO 1 In adults with hypertension, screening for specific forms of secondary hypertension is recommended when clinical suspicion is present (Table 10, Figure 5) to increase rates of detection, diagnosis, and specific targeted therapy. 1 B-NR 2 In adults with resistant hypertension, screening for primary aldosteronism is recommended regard less of whether hypokalemia is present to increase rates of detection, diagnosis, and specific targeted therapy.1,2 2a C-EO 3 In adults who have a positive screening test for a form of secondary hypertension, referral to a clini cian who has expertise in that form of hypertension is reasonable for diagnostic confirmation and treatment. Synopsis Secondary causes of hypertension can be identified in approximately 5% to 25% of adult patients with hyper tension.1–3 If a cause can be correctly diagnosed and treated, patients with secondary hypertension may ex perience a marked improvement in BP control with a reduction in CVD risk. Patients with a new diagnosis of hypertension and concomitant conditions should be screened (Figure 4) with a history and physical exami nation and laboratory tests, as recommended in Section 3.1.2 (“Patient Evaluation, Including Laboratory Tests and Other Diagnostic Procedures”). Recommendation-Specific Supportive Text 1. Secondary hypertension is more common with stage 2 hypertension, treatment-resistant hypertension, sud den onset of hypertension, increased BP in patients with hypertension previously controlled on drug ther apy, early-onset hypertension (age <30 years), dia stolic hypertension in older adults, and target organ damage disproportionate to the duration or severity of the hypertension. Common forms of secondary hyper tension include primary aldosteronism and obstructive sleep apnea (OSA).4–9 Atherosclerotic renovascular disease may be present in 14% to 40% of adults with hypertension; however, only a small fraction (0.1% to 5%) is considered to be hemodynamically significant to result in renovascular hypertension.10 Numerous substances, including prescription medications, overthe-counter medications, herbals, and food sub stances, may affect BP (Table 11).11,12 Changes in BP Downloaded from http://ahajournals.org by on October 7, 2026