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CLINICAL STATEMENTS AND GUIDELINES

Circulation. 2025;152:e114–e218. DOI: 10.1161/CIR.0000000000001356 September 16, 2025 e117

Table 1.  What Is New New or Revised Section Title 2017 Recommendation 2025 Recommendation New terminology N/A Hypertensive urgency Severe hypertension New recommendation 3.2.3. Secondary Forms of Hy­ pertension N/A COR 1: In adults with resistant hypertension, screening for primary aldosteronism is recom­ mended regardless of whether hypokalemia is present to increase rates of detection, diagno­ sis, and specific targeted therapy. New recommendation 3.2.3.1. Primary Aldosteronism N/A COR 1: In adults with an indication for screen­ ing for primary aldosteronism, it is recommend­ ed to continue most antihypertensive medica­ tions (other than MRA) prior to initial screening to minimize barriers to or delays in screening. New recommendation 5.1. Lifestyle and Psychosocial Approaches N/A COR 2a: In adults with or without hypertension, potassium-based salt substitutes can be useful to prevent or treat elevated BP and hyperten­ sion, particularly for patients in whom salt intake is related mostly to food preparation or flavoring at home, except in the presence of CKD or use of drugs that reduce potassium excretion where additional monitoring is probably indicated. Revised recommen­ dation 5.2.2. BP Treatment Threshold and the Use of CVD Risk Estimation to Guide Drug Treatment of Hypertension COR 1: Use of BP-lowering medications is rec­ ommended for secondary prevention of recurrent CVD events in patients with clinical CVD and an average of SBP ≥130 mm Hg or an average DBP ≥80 mm Hg and for primary prevention in adults with an estimated 10-year ASCVD risk of ≥10% and an average SBP ≥130 mm Hg or an average DBP ≥80 mm Hg COR 1: In adults with hypertension without clinical CVD but with diabetes or CKD or at increased 10-year CVD risk (ie, ≥7.5% based on PREVENT), initiation of medications to lower BP is recommended when average SBP is ≥130 mm Hg and average DBP is ≥80 mm Hg to reduce the risk of CVD events and total mortality. Revised recommen­ dation 5.2.2. BP Treatment Threshold and the Use of CVD Risk Estimation to Guide Drug Treatment of Hypertension COR 1: Use of BP-lowering medication is recommended for primary prevention of CVD in adults with no history of CVD and with an esti­ mated 10-year ASCVD risk <10% and an SBP ≥140 mm Hg or a DBP ≥90 mm Hg COR 1: In adults with hypertension without clin­ ical CVD and with estimated 10-year CVD risk <7.5% based on PREVENT, initiation of medica­ tions to lower BP is recommended if average SBP remains ≥130 mm Hg or average DBP remains ≥80 mm Hg after a 3- to 6-month trial of lifestyle intervention to prevent target organ damage and mitigate further increases in BP. Revised recommen­ dation 5.3.1. Diabetes COR 2b: In adults with diabetes and hyperten­ sion, ACEi or ARB may be considered in the presence of albuminuria. COR 1: In adults with diabetes and hyperten­ sion, ACEi or ARB are recommended in the presence of CKD as identified by eGFR <60 mL/min/1.73 m2 or albuminuria ≥30 mg/g and should be considered when mild albuminuria (<30 mg/g) is present to delay progression of diabetic kidney disease. Revised recommen­ dation 5.3.8. Hypertension Treatment in Patients With Chronic Kidney Disease COR 2a: In adults with hypertension and CKD (stage 3 or higher or stage 1 and 2 with albumin­ uria ≥300 mg/d, or ≥300 mg/g albumin-tocreatinine ratio or the equivalent in the first morn­ ing void), treatment with an ACEi is reasonable to slow kidney disease progression.

AND COR 2b: In adults with hypertension and CKD (stage 3 or higher or stage 1 and 2 with albumin­ uria ≥300 mg/d, or ≥300 mg/g albumin-tocreatinine ratio or the equivalent in the first morning void), treatment with an ARB may be reasonable if an ACEi is not tolerated. COR 1: For adults with hypertension and CKD as identified by eGFR <60 mL/min/1.73 m2 with albuminuria of ≥30 mg/g, RAASi (either with ACEi or ARB but not both) is recommended to decrease CVD and delay progression of kidney disease.

New recommendation 5.3.9.1. Acute Intracerebral Hemorrhage N/A COR 2a: For adult patients with acute sponta­ neous ICH who present with SBP between 150 and 220 mm Hg, it can be beneficial to immedi­ ately lower SBP to 130 to <140 mm Hg for at least 7 days after ICH to improve functional out­ comes, but stop antihypertensive medications if SBP <130 mm Hg.

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