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CLINICAL STATEMENTS AND GUIDELINES Circulation. 2025;152:e114–e218. DOI: 10.1161/CIR.0000000000001356 September 16, 2025 e145 Combination training with aerobic and resistance exercise appears similarly efficacious as either alone.33,36,38 BP-lowering effects are observed for lower- and higher-intensity exercise and with con tinuous and interval training.33,38,106,117,118 8 A number of stress-reduction strategies have been assessed for their effect on BP lowering.119 There is consistent moderate- to high-level evidence from short-term clinical trials that transcenden tal meditation can lower BP in patients without and with hypertension, with mean reductions of approximately 5/2 mm Hg in SBP/DBP.14,40 Meditation appears to be somewhat less effec tive than BP-lowering lifestyle interventions, such as the DASH eating plan, structured exercise pro grams, or low-sodium/higher-potassium intake.14 The study designs and means of teaching and practicing meditation interventions are heteroge neous across trials, and trials have been of smaller size and short duration, so further data would be beneficial. 9. Among other stress-reducing and mindfulness-based interventions, data are less robust, and evidence is of lower quality because of smaller, short-term trials with heterogenous interventions and results. There is moderate-grade evidence that breathing control inter ventions lower SBP/DBP by approximately 5/3 mm Hg in people with and without hypertension.14 There is also low- to moderate-grade evidence that yoga of diverse types lowers BP.14,41,42 5.2 Medical Management Synopsis Throughout this guideline, we use the term thi azide-type diuretic to collectively refer to HCTZ, chlorthalidone, and indapamide. Although the literature traditionally differentiates these medications based on their chemical structures, categorizing HCTZ as a thiazide-type diuretic because it possesses a benzo thiadiazine ring and categorizing chlorthalidone and indapamide as thiazide-like diuretics because they lack this ring (yet remain closely related sulfonamide derivatives), the interchangeability of thiazide-type and -like agents remains a debated topic. For simplicity and to minimize confusion, in this guideline we have chosen to group them under a single term. In most settings, it is acceptable for clinicians to choose among these agents for treatment. We recognize there are differ ences in potency and half-life between these agents that may be relevant in some situations, particularly in the management of resistant hypertension (Section 5.6, “Resistant Hypertension”). In that setting, thiazidelike diuretics are preferred due to their greater efficacy; therefore, treatment recommendations in this setting continue to advocate thiazide-like diuretics. 5.2.1 Initiation of Pharmacologic BP Treatment in the Context of Overall CVD Risk Synopsis Evidence from meta-analyses of clinical trial data, large observational studies, and simulation models has con sistently shown the benefits of antihypertensive therapy initiation can be maximized by prioritizing those at high est cardiovascular risk with the use of absolute risk estimation.1–7 Although the public health burden is sig nificant at stage 1 hypertension and many will progress to stage 2 hypertension with associated risk,8 the BP Low ering Treatment Trialists’ Collaboration demonstrated that treatment with BP-lowering drugs provides similar rela tive risk reduction across all levels of predicted total CVD risk and thus greater absolute risk reduction for patients at higher predicted risk.1 Across a wide range of BP thresholds and predicted CVD risk, a risk-based strategy for target ing antihypertensive therapy in primary prevention patients is more effective than a BP-alone based strategy in terms of events avoided and numbers-needed-to-treat to prevent 1 CVD event.4 The benefit and efficiency of antihyperten sive therapy initiation (ie, number of CVD events prevented for the same cost, or cost savings for the same number of events prevented) is greater using a risk-based strategy rather than a BP level-only strategy in simulation models.2,9 In support, one of the inclusion criteria for SPRINT (Systolic Blood Pressure Intervention Trial) was having an estimated 10-year predicted CVD risk based on Framingham Heart Study criteria of 15% or greater.7 Thus, employing quan titative CVD risk estimation in conjunction with BP levels can improve the benefit and efficiency of antihypertensive therapy initiation for individual patients and society. 5.2.2 BP Treatment Threshold and the Use of CVD Risk Estimation to Guide Drug Treatment of Hypertension Recommendations for BP Treatment Threshold and the Use of CVD Risk Estimation to Guide Drug Treatment of Hypertension Referenced studies that support the recommendations are summarized in the Evidence Table. COR LOE Recommendations 1 A 1 In all adults with hypertension, initiation of medications to lower BP is recommended when average SBP is ≥140 mm Hg to reduce the risk of cardiovascular events and total mortality.1–6 1 A 2 In all adults with hypertension, initiation of medications to lower BP is recommended when average DBP is ≥90 mm Hg to reduce the risk of cardiovascular events and total mortality.1–6 1 A 3. In adults with hypertension and clinical CVD, initiation of medications to lower BP is recommended when average SBP is ≥130 mm Hg to reduce the risk of cardiovascular events and total mortality.5–8 1 C-LD 4. In adults with hypertension and clinical CVD, initiation of medications to lower BP is recommended when average DBP is ≥80 mm Hg to reduce the risk of cardiovascular events and total mortality.5–8 Downloaded from http://ahajournals.org by on October 7, 2026