Recommendations-2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults (Circulation, 2018) [MEDLINE]
Performance Measures
Use of Performance Measures in Combination with Other Quality Improvement Strategies at Patient, Provider, and System-Based Levels is Reasonable to Facilitate Optimal Hypertension Control (Class of Recommendation: IIa, Level of Evidence: B-NR)
Quality Improvement Strategies
Use of Quality Improvement Strategies at the Health System, Provider, and Patient Levels to Improve Identification and Control of Hypertension Can Be Effective (Class of Recommendation: IIa, Level of Evidence: B-R)
Financial Incentives Paid to Providers Can Be Useful in Achieving Improvements in Treatment and Management of Patient Populations with Hypertension (Class of Recommendation: IIa, Level of Evidence: B-NR)
Health System Financing Strategies (i.e. Insurance Coverage and Copayment Benefit Design) Can Be Useful in Facilitating Improved Medication Adherence and Blood Pressure Control in Patients with Hypertension (Class of Recommendation: IIa, Level of Evidence: B-NR)
Nonpharmacologic Management
Recommendations-2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults (Circulation, 2018) [MEDLINE]
Strategies to Promote Lifestyle Modification
Effective Behavioral and Motivational Strategies to Achieve a Healthy Lifestyle (i.e. Tobacco Cessation, Weight Loss, Moderation in Alcohol Intake, Increased Physical Activity, Reduced Sodium Intake, and Consumption of a Healthy Diet) are Recommended for Adults with Hypertension (Class of Recommendation: I; Level of Evidence: C-EO)
Recommendations-2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults (Circulation, 2025) MEDLINE]
Weight
In Adults Who are Overweight/Obesity, Weight Loss is Recommended with a Goal of ≥5% of Body Weight Reduction to Prevent/Treat Elevated Blood Pressure or Hypertension (Class of Recommendation: I, Level of Evidence: A)
Approximate Mean Change in Systolic Blood Pressure (SBP) with Weight Loss in the Absence of Hypertension: -3 to -5 mm Hg
Approximate Mean Change in Systolic Blood Pressure (SBP) with Weight Loss in the Presence of Hypertension: -6 to -8 mm Hg
Diet/Nutrition
In Adults with/without Hypertension, a Heart-Healthy Eating Pattern (Such as the DASH Eating Plan) is Recommended to Prevent/Treat Elevated Blood Pressure or Hypertension (Class of Recommendation: I, Level of Evidence: A)
Approximate Mean Change in Systolic Blood Pressure (SBP) with DASH Eating Pattern in the Absence of Hypertension: -3 to -7 mm Hg
Approximate Mean Change in Systolic Blood Pressure (SBP) with DASH Eating Pattern in the Presence of Hypertension: -5 to -8 mm Hg
In Adults with/without Hypertension, Reduction of Dietary Sodium Intake is Recommended to <2300 mg/day, Moving Toward an Ideal Limit of <1500 mg/day to Prevent/Treat Elevated Blood Pressure or Hypertension (Class of Recommendation: I, Level of Evidence: A)
Approximate Mean Change in Systolic Blood Pressure (SBP) with Decreased Sodium Intake in the Absence of Hypertension: -1 to -4 mm Hg
Approximate Mean Change in Systolic Blood Pressure (SBP) with Decreased Sodium Intake in the Presence of Hypertension: -6 to -8 mm Hg
In Adults with/without Hypertension, Potassium-Based Salt Substitutes Can Be Useful to Prevent/Treat Hypertension, Particularly for Patients in Whom Salt Intake is Related Mostly to Food Preparation or Flavoring at Home, Except in the Presence of Chronic Kidney Disease (CKD) or Use of Medications Which Decrease Potassium Excretion Where Monitoring of Serum Potassium Levels is Indicated (Class of Recommendation: 2a, Level of Evidence: A)
Approximate Mean Change in Systolic Blood Pressure (SBP) with Use of Salt Substitutes in the Absence of Hypertension: -5 mm Hg
Approximate Mean Change in Systolic Blood Pressure (SBP) with Use of Salt Substitutes in the Presence of Hypertension: -5 to -7 mm Hg
In Adults with Hypertension, Moderate Potassium Supplementation (Ideally from Dietary Sources) is Recommended to Prevent/Treat Elevated Blood Pressure or Hypertension, Except in the presence of Chronic Kidney Disease (CKD) or Use of Medications Which Decrease Potassium Excretion Where Monitoring of Serum Potassium Levels is Indicated (Class of Recommendation: I, Level of Evidence: A)
Approximate Mean Change in Systolic Blood Pressure (SBP) with Potassium Supplementation in the Absence of Hypertension: -3 to -6 mm Hg
Approximate Mean Change in Systolic Blood Pressure (SBP) with Potassium Supplementation in the Presence of Hypertension: -6 mm Hg
Alcohol
Adults with/without Hypertension Who Currently Consume Alcohol Should Be Advised a Goal of Abstinence from Alcohol, or at Least to Reduce Alcohol Intake to ≤1 Drinks Per Day for Females and ≤2 Drinks Per Day for Males to Prevent/Treat Hypertension (Class of Recommendation: I, Level of Evidence: A)
Approximate Mean Change in Systolic Blood Pressure (SBP) with Decreased Alcohol Intake in the Absence of Hypertension: -3 mm Hg
Approximate Mean Change in Systolic Blood Pressure (SBP) with Decreased Alcohol Intake in the Presence of Hypertension: -4 to -6 mm Hg
Physical Activity
In Adults with/without Hypertension, Increasing Physical Activity (Through a Structured Exercise Program Which Includes Aerobic Exercise and/or Resistance Training) is Recommended to Prevent/Treat Hypertension (Class of Recommendation: I, Level of Evidence: A)
Approximate Mean Change in Systolic Blood Pressure (SBP) with Aerobic Exercise in the Absence of Hypertension: -2 to -7 mm Hg
Approximate Mean Change in Systolic Blood Pressure (SBP) with Aerobic Exercise in the Presence of Hypertension: -4 to -8 mm Hg
Approximate Mean Change in Systolic Blood Pressure (SBP) with Dynamic Resistance Exercise in the Absence of Hypertension: -2 to -5 mm Hg
Approximate Mean Change in Systolic Blood Pressure (SBP) with Dynamic Resistance Exercise in the Presence of Hypertension: -2 to -7 mm Hg
Approximate Mean Change in Systolic Blood Pressure (SBP) with Isometric Resistance Exercise in the Absence of Hypertension: -4 to -6 mm Hg
Approximate Mean Change in Systolic Blood Pressure (SBP) with Isometric Resistance Exercise in the Presence of Hypertension: -5 to -10 mm Hg
Stress Reduction
In Adults with/without Hypertension, Stress Reduction Through Transcendental Meditation May Be Reasonable to Prevent/Treat Elevated Blood Pressure or Hypertension, as an Adjunct to Lifestyle/Medication Interventions (Class of Recommendation: 2b, Level of Evidence: B-R)
Approximate Mean Change in Systolic Blood Pressure (SBP) with Transcendental Meditation in the Absence of Hypertension: -5 mm Hg
Approximate Mean Change in Systolic Blood Pressure (SBP) with Transcendental Meditation in the Presence of Hypertension: -5 to -7 mm Hg
In Adults with/without Hypertension, Other Type of Stress Management (Such as Breathing Control Techniques or Yoga) May Be Reasonable to Prevent/Treat Elevated Blood Pressure or Hypertension, as an Adjunct to Lifestyle/Medication Interventions (Class of Recommendation: 2b, Level of Evidence: B-R)
Approximate Mean Change in Systolic Blood Pressure (SBP) with Breathing Control Techniques in the Absence of Hypertension: -5 mm Hg
Approximate Mean Change in Systolic Blood Pressure (SBP) with Breathing Control Techniques in the Presence of Hypertension: -5 mm Hg
Plan for Care for Hypertension
Clinical Efficacy
Randomized Emergency Department Trial Using the Vanderbilt Emergency Room Bundle (VERB) Intervention to Achieve Improved Blood Pressure Control (J Am Heart Assoc, 2022) [MEDLINE]: n = 206 adults
VERB Bundle Included Educational Materials, Brief Motivational Interview, Pillbox, Primary Care Engagement Letter, Pharmacy Resources, and 45 Days of Informational and Reminder Text Messages
VERB Arm with Text Messaging Resulted in a Decreased 30-Day Blood Systolic Pressure (8.57 mm Hg) (95% CI: 0.98‒16.2; p = 0.027)
Recommendations-2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults (Circulation, 2018) [MEDLINE]
Follow-Up After Initial Blood Pressure Evaluation
Adults with an Elevated Blood Pressure or Stage 1 Hypertension Who Have an Estimated 10-Year Atherosclerotic Cardiovascular Disease (ASCVD) Risk <10% Should Be Managed with Nonpharmacological Therapy and Have a Repeat Blood Pressure Evaluation within 3-6 mos (Class of Recommendation: I, Level of Evidence: B-R)
Adults with Stage 1 Hypertension Who Have an Estimated 10-Year Atherosclerotic Cardiovascular Disease (ASCVD) Risk of ≥10% Should Be Managed Initially with a Combination of Nonpharmacological and Antihypertensive Therapy and Have a Repeat Blood Pressure Evaluation in 1 mo (Class of Recommendation: I, Level of Evidence: B-R)
Adults with Stage 2 Hypertension Should Be Evaluated by or Referred to a Primary Care Provider within 1 mo of the Initial Diagnosis, Have a Combination of Nonpharmacological and Antihypertensive Therapy (with 2 Agents of Different Classes) Initiated, and Have a Repeat Blood Pressure Evaluation in 1 mo (Class of Recommendation: I, Level of Evidence: B-R)
For Adults with a Very High Average Blood Pressure (i.e. Systolic Blood Pressure ≥180 mm Hg or DBP ≥110 mm Hg), Evaluation Followed by Prompt Antihypertensive Therapy is Recommended (Class of Recommendation: I, Level of Evidence: B-R)
For Adults with a Normal Blood Pressure, Repeat Evaluation Every Year is Reasonable (Class of Recommendation: IIa, Level of Evidence: C-EO)
Follow-Up After Initiating Antihypertensive Therapy
Adults Initiating a New or Adjusted Antihypertensive Regimen Should Have a Follow-Up Evaluation of Adherence and Response to Treatment at Monthly Intervals Until Control is Achieved (Class of Recommendation: I, Level of Evidence: B-R)
Monitoring Strategies to Improve Control in Patients on Drug Therapy for Hypertension
Follow-Up and Monitoring After Initiation of Drug Therapy for Hypertension Control Should Include Systematic Strategies to Help Improve Blood Pressure, Including Use of Home Blood Pressure Monitoring (HBPM), Team-Based Care, and Telehealth Strategies (Class of Recommendation: I, Level of Evidence: A)
Plan of Care for Hypertension
Every Adult with Hypertension Should Have a Clear, Detailed, and Current Evidence-Based Plan of Care Which Ensures the Achievement of Treatment and Self-Management Goals, Encourages Effective Management of Comorbid Conditions, Prompts Timely Follow-up with the Healthcare Team, and Adheres to Cardiovascular Disease Guideline-Directed Medical Therapy (Class of Recommendation: I, Level of Evidence: C-EO)
Recommendations-2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults (Circulation, 2025) MEDLINE]
For Adults with Uncontrolled Hypertension, a Team-Based Care Approach is Recommended to Achieve and Maintain Blood Pressure Control (Class of Recommendation: 1; Level of Evidence: A)
For Adults with Uncontrolled Hypertension, an Evidence-Based Care Plan Utilizing Home Blood Pressure Monitoring (HBPM), and Team-based Care Which is Responsive to Addressing Adverse Social Determinants of Health, is Recommended to Achieve and Maintain Blood Pressure Control (Class of Recommendation: 1; Level of Evidence: C-LD)
For Adults with Uncontrolled Hypertension, an Integrated Treatment Model Which Includes Accurate Blood Pressure Measurement, Prompt Treatment, Patient Engagement, and Ongoing Review of Home Blood Pressure Monitoring (HBPM) is Recommended to Improve Blood Pressure Control (Class of Recommendation: 1; Level of Evidence: B-NR)
Adults with Uncontrolled Hypertension Placed on New or Intensified Antihypertensives Should Have Follow-Up Evaluations for Medication Adherence and Response to Treatment at Monthly Intervals Until Control is Achieved (Class of Recommendation: 1; Level of Evidence: B-R)
For Adults with Uncontrolled Hypertension, Health Information Technology by Synchronous (Phone, Video Call, etc) or Asynchronous (Text, E-Mail) Communication is Beneficial in Improving Blood Pressure Control, Access to Care, and Adherence to Standards of Care and Should Be Incorporated in the Management of Hypertension, Including the Titration of Antihypertensives (Class of Recommendation: 1; Level of Evidence: B-R)
In Adults with Undiagnosed/Uncontrolled Hypertension, Use of the Electronic Medical Record (EMR) and Patient Registries is Beneficial for Screening and Identification of Hypertension to Focus on Those Who Require Additional Care (Class of Recommendation: 1; Level of Evidence: B-NR)
In Adults with Uncontrolled Hypertension, Telehealth Interventions Can Be Useful to Decrease Blood Pressure and Improve Office Blood Pressure Control (Class of Recommendation: 2a; Level of Evidence: B-R)
Blood Pressure Treatment Threshold
Clinical Efficacy
Study of Optimal Timing of Systolic Hypertension Treatment (Using STEP Trial Data) (Hypertension, 2024) [MEDLINE]: n = 8,442
Each 1 yr Increase in Hypertension Duration Continuously Increased the Adjusted Risk of Major Cardiovascular Events by 4% (95% CI: 1.01-1.08) Up to 20 yrs, Plateauing at an Adjusted Hazard Ratio of 2.27 (95% CI: 1.28-4.04)
After Intensive Systolic Blood Pressure Treatment, the Incidences of Major Cardiovascular Events were Similar Across Different Hypertension Duration Groups, Which were 2.22%, 1.69%, 3.02%, and 2.52%, Respectively (P > 0.05)
Initiating Intensive Systolic Blood Pressure Treatment at Any Stage of Hypertension Duration Could Decrease Cardiovascular Disease Risk to a Comparable Level
Recommendations-2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults (Circulation, 2025) MEDLINE]
Blood Pressure Treatment Thresholds and Use of Cardiovascular Disease Risk Estimation to Guide Medication Treatment of Hypertension
All Adults with Hypertension
In All Adults with Hypertension, Initiation of Medications to Lower Blood Pressure is Recommended When Average Systolic Blood Pressure (SBP) is ≥140 mm Hg to Decrease the Risk of Cardiovascular Events and Total Mortality (Class of Recommendation: I; Level of Evidence: A)
In All Adults with Hypertension, Initiation of Medications to Lower Blood Pressure is Recommended When Average Diastolic Blood Pressure (DBP) is ≥90 mm Hg to Decrease the Risk of Cardiovascular Events and Total Mortality (Class of Recommendation: I; Level of Evidence: A)
Adults with Hypertension without Clinical Cardiovascular Disease
In Adults with Hypertension without Clinical Cardiovascular Disease, But with Diabetes or Chronic Kidney Disease (CKD) or at Increased Short-Term Cardiovascular Disease Risk (i.e. Estimated 10-Year Cardiovascular Disease Risk Risk ≥7.5%, Based on PREVENT), Initiation of Medications to Lower Blood Pressure is Recommended When Average Systolic Blood Pressure (SBP) is ≥130 mm Hg to Decrease the Risk of Cardiovascular Disease Events and Total Mortality (Class of Recommendation: I; Level of Evidence: A)
In Adults with Hypertension without Clinical Cardiovascular Disease, But with Diabetes or Chronic Kidney Disease (CKD) or at Increased 10-Year Cardiovascular Disease Risk (i.e. ≥7.5%, Based on PREVENT), Initiation of Medications to Lower Blood Pressure is Recommended When Average Diastolic Blood Pressure (DBP) is ≥80 mm Hg to Decrease the Risk of Cardiovascular Disease Events and Total Mortality (Class of Recommendation: I; Level of Evidence: C-LD)
In Adults with Hypertension without Clinical Cardiovascular Disease and with Estimated 10-Year Cardiovascular Disease Risk <7.5%, Based on PREVENT, Initiation of Medications to Lower Blood Pressure is Recommended if Average Systolic Blood Pressure (SBP) Remains ≥130 mm Hg After a 3-6 Month Trial of Lifestyle Intervention to Prevent Target Organ Damage and Mitigate a Further Rise in Blood Pressure (Class of Recommendation: I; Level of Evidence: B-R)
In Adults with Hypertension without Clinical Cardiovascular Disease and with Estimated 10-Year Cardiovascular Disease Risk <7.5% (Based on PREVENT), Initiation of Medications to Lower Blood Pressure is Recommended if Average Diastolic Blood Pressure (DBP) ≥80 mm Hg After a 3-6 Month Trial of Lifestyle Intervention to Prevent Target Organ Damage and Mitigate a Further Rise in Blood Pressure (Class of Recommendation: I; Level of Evidence: B-R)
Adults with Hypertension and Clinical Cardiovascular Disease
In Adults with Hypertension and Clinical Cardiovascular Disease, Initiation of Medications to Lower Blood Pressure is Recommended when Average Systolic Blood Pressure (SBP) is ≥130 mm Hg to Decrease the Risk of Cardiovascular Events and Total Mortality (Class of Recommendation: I; Level of Evidence: A)
In Adults with Hypertension and Clinical Cardiovascular Disease, Initiation of Medications to Lower Blood Pressure is Recommended When Average Diastolic Blood Pressure (DBP) is ≥80 mm Hg to Decrease the Risk of Cardiovascular Events and Total Mortality (Class of Recommendation: I; Level of Evidence: C-LD)
Secondary Analysis of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) to Study the Impact of Antihypertensives on Morbidity/Mortality (JAMA Netw Open, 2023) [MEDLINE]: randomized to thiazide-type diuretic (n = 15,002), a calcium channel blocker (n = 8,898), or an ACE inhibitor (n = 8,904) for planned in-trial follow-up of approximately 4-8 yrs and post-trial passive follow-up for up to 23 yrs
Cardiovascular Disease Mortality Rate was Similar Across All 3 Groups
Long-Term Risks of Most Secondary Outcomes (All-Cause Mortality, Combined Fatal and Nonfatal Morbidity for Cardiovascular Disease, Morbidity/Mortality for Coronary Artery Disease, Morbidity/Mortality Stroke, Morbidity/Mortality for Heart failure, Morbidity/Mortality for End-Stage Renal Disease, and Morbidity/Mortality for Cancer) were Similar Across All 3 Groups
ACE Inhibitors Increased the Risk of Stroke Outcomes by 11%, as Compared to Diuretics
This Effect Persisted Well Beyond the Trial Period
Verapamil (Calan, Isoptin, Verelan, Verelan PM, Bosoptin, Covera-HS) (see Verapamil)
Clinical Efficacy
Secondary Analysis of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) to Study the Impact of Antihypertensives on Morbidity/Mortality (JAMA Netw Open, 2023) [MEDLINE]: randomized to thiazide-type diuretic (n = 15,002), a calcium channel blocker (n = 8,898), or an ACE inhibitor (n = 8,904) for planned in-trial follow-up of approximately 4-8 yrs and post-trial passive follow-up for up to 23 yrs
Cardiovascular Disease Mortality Rate was Similar Across All 3 Groups
Long-Term Risks of Most Secondary Outcomes (All-Cause Mortality, Combined Fatal and Nonfatal Morbidity for Cardiovascular Disease, Morbidity/Mortality for Coronary Artery Disease, Morbidity/Mortality Stroke, Morbidity/Mortality for Heart failure, Morbidity/Mortality for End-Stage Renal Disease, and Morbidity/Mortality for Cancer) were Similar Across All 3 Groups
ACE Inhibitors Increased the Risk of Stroke Outcomes by 11%, as Compared to Diuretics
This Effect Persisted Well Beyond the Trial Period
Dose-Response Meta-Analysis of Omega-3 Fatty Acids in the Treatment of Hypertension (J Am Heart Assoc, 2022) [MEDLINE]
Optimal Combined Intake of Omega-3 Fatty Acids for Blood Pressure Lowering is Likely Between 2-3 g/Day
Doses of Omega-3 Fatty Acid Intake Above the Recommended 3 g/Day May Be Associated with Additional Benefits in Lowering Blood Pressure Among Groups at High Risk for Cardiovascular Diseases
Metolazone (Zytanix, Metoz, Zaroxolyn, and Mykrox) (see Metolazone)
Clinical Efficacy
Secondary Analysis of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) to Study the Impact of Antihypertensives on Morbidity/Mortality (JAMA Netw Open, 2023) [MEDLINE]: randomized to thiazide-type diuretic (n = 15,002), a calcium channel blocker (n = 8,898), or an ACE inhibitor (n = 8,904) for planned in-trial follow-up of approximately 4-8 yrs and post-trial passive follow-up for up to 23 yrs
Cardiovascular Disease Mortality Rate was Similar Across All 3 Groups
Long-Term Risks of Most Secondary Outcomes (All-Cause Mortality, Combined Fatal and Nonfatal Morbidity for Cardiovascular Disease, Morbidity/Mortality for Coronary Artery Disease, Morbidity/Mortality Stroke, Morbidity/Mortality for Heart failure, Morbidity/Mortality for End-Stage Renal Disease, and Morbidity/Mortality for Cancer) were Similar Across All 3 Groups
ACE Inhibitors Increased the Risk of Stroke Outcomes by 11%, as Compared to Diuretics
This Effect Persisted Well Beyond the Trial Period
Choice of Initial Antihypertensive Medication
Recommendations-2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults (Circulation, 2025) MEDLINE]
For Adults Initiating Antihypertensives, Thiazide-Type Diuretics, Long-Acting Dihydropyridine Calcium Channel Blockers, and Angiotensin Converting Enzyme (ACE) Inhibitors/Angiotensin II Receptor Blockers (ARB’s) are Recommended as First-Line Therapy to Prevent Cardiovascular Disease (Class of Recommendation: I, Level of Evidence: A)
Initial Monotherapy vs Initial Combination Therapy
All Adults with Hypertension
In Adults with Hypertension, Simultaneous Use of an Angiotensin Converting Enzyme (ACE) Inhibitor, Angiotensin II Receptor Blockers (ARB), and /or Renin Inhibitor in Combination is Not Recommended Due to the Potential for Harm (Class of Recommendation: 3 = Harm; Level of Evidence: A)
Stage 1 Hypertension (Systolic Blood Pressure 130-139 mm Hg and Diastolic Blood Pressure 80-89 mm Hg)
In Adults with Stage 1 Hypertension (SBP 130-139 mm Hg and DBP 80-89 mm Hg), Initiation of Antihypertensives with a Single First-Line Antihypertensive is Reasonable, with Dosage Titration and Sequential Addition of Other Agents as Needed to Achieve Blood Pressure Control (Class of Recommendation: 2a; Level of Evidence: C-EO)
Stage 2 Hypertension (Systolic Blood Pressure ≥140 mm Hg and Diastolic Blood Pressure ≥90 mm Hg)
In Adults with Stage 2 Hypertension (Systolic Blood Pressure ≥140 mm Hg and Diastolic Blood Pressure ≥90 mm Hg), Initiation of Antihypertensives with 2 First-Line Agents of Different Classes (Ideally in a Single-Pill Combination) is Recommended to Improve Blood Pressure Control and Adherence (Class of Recommendation: I; Level of Evidence: B-R)
Antihypertensive Medication Adherence Strategies
Evidence-Based Strategies for Improving Antihypertensive Medication Adherence (Circulation, 2025) MEDLINE]
Dose Consolidation
Single Pill Combination (R)ather than Separate Pills)
Education/Coaching by Pharmacists and Other Health Care Professionals
Electronic/Home Blood Pressure Monitoring and Feedback
Integration of Patient Preferences and Values/Shared Decision-Making into Management plan
Medication Synchronization and Reminder Aids
Mindfulness-Based Stress Reduction or Counseling for High Stress, Anxiety, and/or Depression
Self-Management Interventions
Recommendations-2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults (Circulation, 2025) MEDLINE]
In Adults with Hypertension, Antihypertensive Medication Dosing Once Daily (Rather than Multiple Times Per Day) is Beneficial to Improve Medication Adherence (Class of Recommendation: 1; Level of Evidence: B-R)
In Adults with Hypertension, the Use of a Single Pill Combination Antihypertensive to Reduce Pill Burden (Rather than Taking Separate Pills is Effective to Improve Medication Adherence (Class of Recommendation: 1; Level of Evidence: B-R)
In Adults with Hypertension, Use of Medication Reminder Aids and Educational or Self-Management Interventions Can Be Useful to Improve Medication Adherence (Class of Recommendation: 2a; Level of Evidence: B-R)
Blood Pressure Goals
Recommendations-2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults (Circulation, 2025) MEDLINE]
In Adults with Confirmed Hypertension Who are at Increased Risk for Cardiovascular Disease (Defined as a 10-Year Predicted Risk for Cardiovascular Disease Events of ≥7.5%, Using PREVENT), a Systolic Blood Pressure (SBP) of at Least <130 mm Hg, with Encouragement to Achieve Systolic Blood Pressure (SBP) <120 mm Hg, is Recommended to Reduce the Risk of Cardiovascular Events and Total Mortality (Class of Recommendation: I; Level of Evidence: A)
In Adults with Confirmed Hypertension Who are Not at Increased Risk for Cardiovascular Disease (Defined as a 10-Year Predicted Risk for Cardiovascular Disease Events of <7.5%, Using PREVENT), a Systolic Blood Pressure (SBP) Goal of <130 mm Hg, with Encouragement to Achieve SBP <120 mm Hg, May Be Reasonable to Reduce Risk of Further Elevation of Blood Pressure (Class of Recommendation: 2b; Level of Evidence: B-NR)
In Adults with Confirmed Hypertension Who are at Increased Risk for Cardiovascular Disease (Defined as a 10-Year Predicted Risk for Cardiovascular Disease Events of ≥7.5%, Using PREVENT) a Diastolic Blood Pressure (DBP) Target of <80 mm Hg is Recommended to Reduce the Risk of Cardiovascular Events and Total Mortality (Class of Recommendation: I; Level of Evidence: B-R)
In Adults with Confirmed Hypertension Who are Not at Increased Risk for Cardiovascular Disease (Defined as a 10-Year Predicted Risk for Cardiovascular Disease Events of <7.5%, Using PREVENT), a Diastolic Blood Pressure (DBP) Target of <80 mm Hg May Be Reasonable to Reduce the Risk of Cardiovascular Events (Class of Recommendation: 2b; Level of Evidence: B-NR)
Recommendations-American Heart Association (AHA)/American Stroke Association (ASA) Guidelines for the Early Management of Patients with Acute Ischemic Stroke (Stroke, 2013) [MEDLINE]
Blood Pressure Management in the Setting of Thrombolytic Therapy
Antihypertensive Options in a Patient Otherwise Eligible for Acute Reperfusion Therapy, Except that Blood Pressure is >185/110 mm Hg
Labetalol 10–20 mg IV Over 1–2 min (May Repeat x 1) (see Labetalol)
Nicardipine 5 mg/h IV Infusion, Titrate Up by 2.5 mg/hr q5–15 min (Maximum: 15 mg/hr) (see Nicardipine)
When Desired Blood Pressure is Reached, Adjust to Maintain Proper Blood Pressure Limits
If Blood Pressure is Not Maintained at ≤185/110 mm Hg, Do Not Administer Thrombolytic Therapy
Management of Blood Pressure During and After Thrombolytic Therapy or Other Acute Reperfusion Therapy to Maintain Blood Pressure ≤180/105 mm Hg
Monitor Blood Pressure q15 min x 2 hrs from the Start of Thrombolytic Therapy, then q30 min x 6 hrs, and then q1hr x 16 hrs
Antihypertensive Options if Systolic Blood Pressure >180–230 mm Hg or Diastolic Blood Pressure >105–120 mm Hg
Labetalol 10 mg IV, Followed by Continuous IV Infusion 2–8 mg/min (see Labetalol)
Nicardipine 5 mg/h IV Infusion, Titrate Up to Desired Effect by 2.5 mg/hr q5–15 min (Maximum: 15 mg/hr) (see Nicardipine)
If Blood Pressure is Not Controlled or Diastolic Blood Pressure is >140 mm Hg, Consider Nitroprusside IV Infusion (see Nitroprusside)
Recommendations-2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults (Circulation, 2018) [MEDLINE]
During the Acute Management of Ischemic Stroke
Starting or Restarting Antihypertensive Therapy During Hospitalization in Patients with Blood Pressure >140/90 mm Hg Who are Neurologically Stable is Safe and Reasonable to Improve Long-Term Blood Pressure Control, Unless Contraindicated (Class of Recommendation: IIa; Level of Evidence: B-NR)
Intravenous Thrombolytic Treatment
Adults with Acute Ischemic Stroke and Elevated Blood Pressure Who are Eligible for Treatment with Intravenous Thrombolytic Should Have Their Blood Pressure Slowly Decreased to <185/110 mm Hg Before Thrombolytic Therapy is Initiated (Class of Recommendation: I; Level of Evidence: B-NR)
In Adults with an Acute Ischemic Stroke, Blood Pressure Should Be <185/110 mm Hg Before Administration of Intravenous Thrombolytic and Should Be Maintained <180/105 mm Hg for at Least the First 24 hrs After Initiating Thrombolytic Drug Therapy (Class of Recommendation: I; Level of Evidence: B-NR)
No Intravenous Thrombolytic or Endovascular Treatment
In Patients with Blood Pressure ≥220/120 mm Hg Who Did Not Receive Intravenous Thrombolytic or Endovascular Treatment and Have No Comorbid Conditions Requiring Acute Antihypertensive Treatment, the Benefit of Initiating or Reinitiating Treatment of Hypertension within the First 48-72 hrs is Uncertain (Class of Recommendation: IIb; Level of Evidence: C-EO)
It Might Reasonable to Decrease Blood Pressure Blood Pressure by 15% During the First 24 hrs After Onset of Stroke
In Patients with Blood Pressure <220/120 mm Hg Who Did Not Receive Intravenous Thrombolytic or Endovascular Treatment and Do Not Have a Comorbid Condition Requiring Acute Antihypertensive Treatment, Initiating or Reinitiating Treatment of Hypertension within the first 48-72 hrs After an Acute Ischemic Stroke is Not Effective (Class of Recommendation: III = No Benefit; Level of Evidence: A)
Secondary Stroke Prevention
General
For Adults Who Experience a Acute Ischemic Stroke or Transient Ischemic Attack (TIA), Treatment with a Thiazide-Type Diuretic, Angiotensin Converting Enzyme (ACE) Inhibitor, or Angiotensin II Receptor Blocker (ARB), or Combination Treatment Consisting of a Thiazide-Type Diuretic Plus Angiotensin Converting Enzyme (ACE) Inhibitor, is Useful (Class of Recommendation: I: No Benefit; Level of Evidence: A)
For Adults Who Experience a Acute Ischemic Stroke or Transient Ischemic Attack (TIA), Selection of Specific Drugs Should Be Individualized on the Basis of Patient Comorbidities and Agent Pharmacological Class (Class of Recommendation: I: No Benefit; Level of Evidence: B-NR)
For Adults Who Experience a Acute Ischemic Stroke or Transient Ischemic Attack (TIA), a Blood Pressure Goal of <130/80 mm Hg May Be Reasonable (Class of Recommendation: IIb: No Benefit; Level of Evidence: B-R)
For Adults with a Lacunar Stroke, a Target Systolic Blood Pressure (SBP) Goal of <130 mm Hg May Be Reasonable (Class of Recommendation: IIb: No Benefit; Level of Evidence: B-R)
No Prior History of Hypertension
Adults Previously Untreated for Hypertension Who Experience a Stroke or Transient Ischemic Attack (TIA) and Have an Established Blood Pressure of ≥140/90 mm Hg Should Be Prescribed Antihypertensive Treatment a Few Days After the Index Event to Decrease the Risk of Recurrent Stroke and Other Vascular Events (Class of Recommendation: I; Level of Evidence: B-NR)
In Adults Previously Untreated for Hypertension Who Experience a Stroke or Transient Ischemic Attack (TIA) and Have a Systolic Blood Pressure (SBP) <140 mm Hg and a Diastolic Blood Pressure (DBP) <90 mm Hg, the Usefulness of Initiating Antihypertensive Treatment is Not Well Established (Class of Recommendation: IIb; Level of Evidence: C-LD)
Prior History of Hypertension
Adults with Previously Treated Hypertension and the Occurrence of Acute Ischemic Stroke or Transient Ischemic Attack (TIA) Should Be Restarted on Antihypertensive Treatment After the First Few Days of the Index Event to Decrease the Risk of Recurrent Stroke and Other Vascular Events (Class of Recommendation: I; Level of Evidence: A)
Recommendations-American Heart Association (AHA)/American Stroke Association (ASA) 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke (Stroke, 2018) [MEDLINE]
Hypotension/Hypovolemia Should Be Corrected to Maintain Systemic Perfusion (Class of Recommendation: I; Level of Evidence: C-EO)
The Blood Pressure Level Which Should Be Maintained in Patients with Acute Ischemic Stroke to Ensure the Best Outcome is Unknown
Some Observational Studies Demonstrate an Association Between Worse Outcome and Lower Blood Pressure, Whereas Other Studies Have Not
No Studies Have Addressed the Treatment of Low Blood Pressure in Patients with Acute Ischemic Stroke
Type of Intravenous Fluid
In a Systematic Analysis of 12 Studies Comparing Colloids with Crystalloids, the Odds of Death/Dependency were Similar (Clinically Important Benefirs/Harms Could Not Be Excluded)
No Studies Have Compared Different Isotonic Intravenous Fluids
Volume/Duration of Intravenous Fluid
No Data to Guide Volume/Duration of Intravenous Fluid Delivery
Patients Who Have Elevated Blood Pressure and are Otherwise Eligible for Treatment with Thrombolytic Therapy Should Have Their Blood Carefully Lowered to <185/110 mm Hg Before Thrombolytic Therapy is Initiated (Class of Recommendation: I, Level of Evidence: B-NR)
The Randomized Controlled Trials of Intravenous Alteplase Required the Systolic Blood Pressure to Be <185 mm Hg and Diastolic Blood Pressure to Be <110 mm Hg Before Treatment and <180/105 mm Hg for the First 24 hrs After Treatment
Some Observational Studies Suggest that the Risk of Hemorrhage After Administration of Thrombolytics is Greater in Patients with Higher Blood Pressure and in Patients with More Blood Pressure Variability
The Exact Blood Pressure at which the Risk of Hemorrhage After Thrombolysis Increases is Unknown
Therefore, it is Reasonable to Target the Blood Pressures Used in the Randomized Controlled Trials of Intravenous Thrombolytics
The Usefulness of Drug-Induced Hypertension in the Setting of Acute Ischemic Stroke is Not Well Established (Class of Recommendation: IIb; Level of Evidence: C-LD)
Recommendations-American Heart Association (AHA)/American Stroke Association (ASA) 2019 Guidelines for the Early Management of Patients With Acute Ischemic Stroke (Stroke, 2019) [MEDLINE]
Hypotension/Hypovolemia Should Be Corrected to Maintain Systemic Perfusion Levels Necessary to Support Organ Function (Class of Recommendation: I; Level of Evidence: C-EO)
The Optimal Blood Pressure Level Which Should Be Maintained in Patients with Acute Ischemic Stroke is Unknown
Some Observational Studies Demonstrate an Association Between Worse Outcomes and Lower Blood Pressures, Whereas Other Studies Do Not
No Studies Address the Treatment of Hypotension in Patients with Stroke
Type of Intravenous Fluid
In a Systematic Analysis of 12 Studies Comparing Colloids with Crystalloids, the Odds of Death or Dependence were Similar (and Clinically Important Benefits or Harms Could Not Be Excluded)
No Studies Have Compared Different Isotonic Intravenous Fluids
Volume/Duration of Intravenous Fluid
No Data to Guide Volume/Duration of Intravenous Fluid Delivery
General Blood Pressure Management
In Patients with Acute Ischemic Stroke, Early Antihypertensive Treatment is Indicated When Required by the Presence of Comorbid Conditions (Such as Concomitant Acute Coronary Syndrome, Acute Congestive Heart Failure, Aortic Dissection, Hypertensive Encephalopathy, Post-Fibrinolysis Intracerebral Hemorrhage, Preeclampsia/Eclampsia) (Class of Recommendation: I; Level of Evidence: C-EO)
Patients with Acute Ischemic Stroke Can Present with Severe Acute Comorbidities Which Demand Emergency Blood Pressure Reduction to Prevent Serious Complications
However, Since Excessive Blood Pressure Reduction Can Exacerbate Cerebral Ischemia, Management Should Be Individualized
Initial Blood Pressure Reduction by 15% is a Reasonable Goal
There is No Data to Demonstrate Efficacy of One Blood Pressure Control Strategy Over Another After Acute Ischemic Stroke
The Usefulness of Drug-Induced Hypertension in the Setting of Acute Ischemic Stroke is Not Well Established (Class of Recommendation: IIb, Level of Evidence: B-NR)
Blood Pressure Management in the Setting of Thrombolytic Therapy
Patients Who Have Elevated Blood Pressure and are Otherwise Eligible for Treatment with Thrombolytic Therapy Should Have Their Blood Pressure Carefully Decreased so that Their Systolic Blood Pressure is <185 mm Hg and Their Diastolic Blood Pressure is <110 mm Hg Before Thrombolytic Therapy is Initiated (Class of Recommendation: I; Level of Evidence: B-NR)
The Randomized Controlled Trials of Intravenous Alteplase Required Systolic <185 mm Hg and Diastolic Blood Pressure <110 mm Hg Before Thrombolytic Therapy and <180/105 mm Hg for the First 24 hrs After Thrombolytic Therapy
Some Observational Studies Suggest that the Risk of Hemorrhage After Administration of Alteplase is Greater in Patients with Higher Blood Pressures and in Patients with More Blood Pressure Variability
The Exact Blood Pressure at Which the Risk of Hemorrhage After Thrombolytics Increases is Unknown
Therefore, it is Reasonable to Target the Blood Pressures Used in the Randomized Controlled Trials of Intravenous Alteplase
Blood Pressure Management in the Setting of Mechanical Thrombectomy
In Patients for Whom Mechanical Thrombectomy is Planned and Who Have Not Received Thrombolytic Therapy, it is Reasonable to Maintain Blood Pressure ≤185/110 mm Hg Before the Procedure (Class of Recommendation: IIa, Level of Evidence: B-NR)
Of the 6 Randomized Controlled trials Which Each Independently Demonstrated Clinical Benefit of Mechanical Thrombectomy with Stent Retrievers when Performed <6 hrs from Stroke Onset, the REVASCAT/SWIFT PRIME/EXTEND-IA/THRACE/MR CLEAN Trials Had Eligibility Exclusions for Blood Pressure >185/110 mm Hg, While the ESCAPE Trial Had No Blood Pressure Eligibility Exclusions
The DAWN Trial Also Used an Exclusion for Blood Pressure >185/110 mm Hg
Randomized Controlled trial Data for Optimal Blood Pressure Management Approaches in this Setting are Not Available
Because the Vast Majority of Patients Enrolled in these Randomized Controlled Trials Had Preprocedural Blood Pressure Managed <185/110 mm Hg, it is Reasonable to Use This Level as a Guideline Until Additional Data Become Available
In Patients Who Undergo Mechanical Thrombectomy with Successful Reperfusion, it is Reasonable to Maintain Blood Pressure at <180/105 mm Hg (Class of Recommendation: IIb; Level of Evidence: B-NR)
In Patients Who Undergo Mechanical Thrombectomy, it is Reasonable to Maintain the Blood Pressure at ≤180/105 mm Hg During and for 24 hrs After the Procedure (Class of Recommendation: IIa; Level of Evidence: B-NR)
Blood Pressure Management in the Absence of Thrombolytic Therapy
In Patients with BP ≥220/120 mm Hg Who Did Not Receive Reperfusion Therapy (Thrombolytic Therapy, Mechanical Thrombectomy) and Have No Comorbid Conditions Requiring Urgent Antihypertensive Treatment, the Benefit of Initiating/Reinitiating Antihypertensive Treatment within the First 48-72 hrs is Uncertain (Class of Recommendation: IIb; Level of Evidence: C-EO)
It is Reasonable to Lower Blood Pressure by 15% During the First 24 hrs After Onset of Acute Ischemic Stroke
Patients with Severe Hypertension (Most Commonly >220/120 mm Hg) were Excluded from Clinical Trials Evaluating Blood Pressure Reduction After Acute Ischemic Stroke
Rapid Blood Pressure Reduction Has Traditionally Been Advised for These Cases, But the Benefit of Such Treatment in the Absence of Comorbid Conditions Which May Be Acutely Exacerbated by Severe Hypertension Has Not Been Formally Studied
Ideal Management in These Situations Should Be Individualized, But an Initial Blood Pressure Reduction by 15% is a Reasonable Goal
Excessive Decrease in Blood Pressure Could Result in Complications, Such as Stroke Progression (by Compromising Cerebral Perfusion in Penumbral Tissue) and Acute Kidney Injury (from Renal Hypoperfusion)
There is No Data to Demonstrate Efficacy of One Blood Pressure Control Strategy Over Another After Acute Ischemic Stroke
In Patients with Blood Pressure <220/120 mm Hg Who Did Not Receive Reperfusion Therapy (Thrombolytic Therapy, Mechanical Thrombectomy) and Do Not Have a Comorbid Condition Requiring Urgent Antihypertensive Therapy (Aortic Dissection, Severe HELLP Syndrome/Preeclampsia/Eclampsia, Pheochromocytoma, etc), Initiating/Reinitiating Antihypertensive Treatment within the First 48-72 hrs After an Acute Ischemic Stroke is Not Effective to Prevent Death or Dependency (Class of Recommendation: III-No Benefit; Level of Evidence: A)
Multiple Randomized Controlled Trials and Meta-Analyses of These Trials Have Consistently Demonstrated that Initiating/Reinitiating Antihypertensive Treatment within the first 48-72 hrs After an Acute Ischemic Stroke is Safe, But This Strategy is Not Associated with Improved Mortality or Functional Outcomes
However, None of These Trials were Designed to Study Blood Pressure Reduction within the First 6 hrs After Stroke, and All Excluded Patients with Extreme Hypertension or Coexistent Indications for Rapid Blood Pressure Reduction
Recommendations-2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults (Circulation, 2025) MEDLINE]
General
In Acute Ischemic Stroke, Hypotension/Hypovolemia Should Be Corrected to Maintain Systemic Perfusion Levels Necessary to Support Organ Function (Class of Recommendation: 1; Level of Evidence: C-LD)
Intravenous Thrombolytic Treatment
In Acute Ischemic Stroke with Elevated Blood Pressure and Eligibility for Intravenous Thrombolytic Treatment, Blood Pressure Should Be Decreased to Systolic Blood Pressure (SBP) <185 mm Hg and Diastolic Blood Pressure (DBP) <110 mm Hg Before Intravenous Thrombolytic Therapy is Initiated and Should Be Maintained <180/105 mm Hg for at Least the First 24 hrs After Initiating Thrombolytic Therapy to Avoid Complications (Class of Recommendation: 1; Level of Evidence: B-NR)
Endovascular Treatment
In Acute Ischemic Stroke with Endovascular Treatment, it is Reasonable to Maintain the Blood Pressure at ≤180/105 mm Hg During and for 24 hrs After Endovascular Treatment to Improve Long-Term Functional Outcomes and Prevent Death (Class of Recommendation: 2a; Level of Evidence: B-NR)
In Acute Ischemic Stroke with Successful Brain Reperfusion with Endovascular Treatment for a Large Vessel Occlusion, Lowering the Systolic Blood Pressure (SBP) to <140 mm Hg within the First 24-72 hrs After Reperfusion Can Worsen Long-Term Functional Outcome (Class of Recommendation: 3 = Harm; Level of Evidence: A)
No Intravenous Thrombolytic or Endovascular Treatment
In Acute Ischemic Stroke with Blood Pressure of ≥220/120 mm Hg and No Intravenous Thrombolytic or Endovascular Treatment and No Comorbid Conditions Requiring Acute Antihypertensive Treatment, it Might Be Reasonable to Lower Blood Pressure by 15% During the First 24 hrs After the Onset of Stroke to Improve Outcomes (Class of Recommendation: 2b; Level of Evidence: C-LD)
In Acute Ischemic Stroke with Blood Pressure <220/120 mm Hg and No Intravenous Thrombolytic or Endovascular Treatment and No Comorbid Condition Requiring Urgent Antihypertensive Treatment, Initiating or Reinitiating Treatment of Hypertension within the First 48-72 hrs After an Acute Ischemic Stroke is Not Effective to Prevent Death or Disability (Class of Recommendation: 3 = No Benefit; Level of Evidence: A)
Secondary Stroke Prevention
No Prior History of Hypertension
With No Prior History of Hypertension and with an Acute Ischemic Stroke, Transient Ischemic Attack (TIA), or Intracerebral Hemorrhage and Average Office Systolic Blood Pressure (SBP)/Diastolic Blood Pressure (DBP) of ≥130/80 mm Hg, Antihypertensive Treatment Can Be Beneficial to Decrease the Risk of Recurrent Stroke, Intracerebral Hemorrhage, and Other Vascular Events (Class of Recommendation: 2; Level of Evidence: B-R)
Prior History of Hypertension
With Prior History of Hypertension and Occurence of Acute Ischemic Stroke, Transient Ischemic Attack (TIA), or Intracerebral Hemorrhage, Treatment with a Thiazide-Type Diuretic, Angiotensin Converting Enzyme (ACE) Inhibitor, or Angiotensin II Receptor Blocker (ARB) is Recommended for Lowering Blood Pressure and Reducing Recurrent Stroke and Intracerebral Hemorrhage Risk (Class of Recommendation: 1; Level of Evidence: A)
With Prior History of Hypertension and Occurence of Acute Ischemic Stroke, Transient Ischemic Attack (TIA), or Intracerebral Hemorrhage, an Office Systolic Blood Pressure (SBP)/Diastolic Blood Pressure (DBP) Goal of <130/80 mm Hg is Recommended to Decrease the Risk of Recurrent Stroke, Intracerebral Hemorrhage, and Other Vascular Events (Class of Recommendation: 1; Level of Evidence: B-R)
Management of Hypertension in the Setting of Intracerebral Hemorrhage (ICH) (see Intracerebral Hemorrhage)
Recommendations-2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults (Circulation, 2018) [MEDLINE]
In Adults with Intracerebral Hemorrhage Who Present with Systolic Blood Pressure (SBP) >220 mm Hg, Use Continuous Intravenous Antihypertensives (with Close Blood Pressure Monitoring to Decrease the Systolic Blood Pressure (SBP) (Class of Recommendation: IIa; Level of Evidence: C-EO)
In Adults with Spontaneous Intracerebral Hemorrhage Who Present within 6 hrs of the Acute Event and Have an Systolic Blood Pressure (SBP) Between 150-220 mm Hg, Immediately Decreasing the Systolic Blood Pressure (SBP) to <140 mm Hg Does Not Decrease the Mortality Rate/Risk of Severe Disability and Can Be Potentially Harmful (Class of Recommendation: III: Harm; Level of Evidence: A)
Recommendations-American Heart Association (AHA)/American Stroke Association (ASA) 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage (Stroke, 2022) [MEDLINE]
In Patients with Spontaneous Intracerebral Hemorrhage Requiring Acute Antihypertensive Therapy, Careful Titration to Ensure Continuous Smooth and Sustained Blood Pressure Control (Avoiding Peaks and Large Variability in Systolic Blood Pressure), Can Improve Functional Outcome (Class of Recommendation: 2a, Level of Evidence: B-NR)
In Patients with Spontaneous Intracerebral Hemorrhage in Whom Acute Blood Pressure Lowering is Considered, Initiating Treatment within 2 hrs of Intracerebral Hemorrhage Onset and Reaching the Blood Pressure Target within 1 hrs Can Decrease the Risk of Hematoma Expansion and Improve Functional Outcome (Class of Recommendation: 2a, Level of Evidence: C-LD)
In Patients with Spontaneous Mild-Moderate Intracerebral Hemorrhage Presenting with Systolic Blood Pressure between 150-220 mm Hg, Acute Decrease in the Systolic Blood Pressure to a Target of 140 mm Hg with the Goal of Maintaining Systolic Blood Pressure in the Range of 130-150 mm Hg is Safe and May Be Reasonable for Improving Functional Outcomes (Class of Recommendation: 2b, Level of Evidence: B-R)
In Patients with Spontaneous Large-Severe Intracerebral Hemorrhage or Those Requiring Surgical Decompression, the Safety and Efficacy of Intensive Blood Pressure Decrease are Not Well Established (Class of Recommendation: 2b, Level of Evidence: C-LD)
In Patients with Spontaneous Mild-Moderate Intracerebral Hemorrhage Presenting with SBP >150 mm Hg, Acute Decrease in Systolic Blood Pressure to <130 mm Hg is Potentially Harmful (Class of Recommendation: 3-Harm, Level of Evidence: B-R)
Recommendations-2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults (Circulation, 2025) MEDLINE]
During Acute Management of Intracerebral Hemorrhage
For Adult Patients with Acute Spontaneous Intracerebral Hemorrhage Who Present with Systolic Blood Pressure (SBP) Between 150-220 mm Hg, it Can Be Beneficial to Immediately Lower Systolic Blood Pressure (SBP) to 130-140 mm Hg for at Least 7 Days After Intracerebral Hemorrhage to Improve Functional Outcomes, But Stop Antihypertensives if Systolic Blood Pressure (SBP) is <130 mm Hg (Class of Recommendation: 2; Level of Evidence: A)
In Adults with Acute Spontaneous Intracerebral Hemorrhage Requiring Acute Blood Pressure Lowering, Careful Titration to Ensure Smooth, Non-Labile, and Sustained Control of Blood Pressure, Avoiding Peaks and Large Variability in Systolic Blood Pressure (SBP), Can Be Beneficial for Improving Functional Outcomes (Class of Recommendation: 2a; Level of Evidence: B-NR)
For Adult Patients with Acute Spontaneous Intracerebral Hemorrhage Who Present with Systolic Blood Pressure (SBP) >220 mm Hg, Systolic Blood Pressure (SBP) Should Not Be Lowered <130 mm Hg to Reduce Adverse Events (Class of Recommendation: 3 = Harm; Level of Evidence: B-NR)
Secondary Stroke Prevention
Prior History of Hypertension
With Prior History of Hypertension and Occurence of Acute Ischemic Stroke, Transient Ischemic Attack (TIA), or Intracerebral Hemorrhage, Treatment with a Thiazide-Type Diuretic, Angiotensin Converting Enzyme (ACE) Inhibitor, or Angiotensin II Receptor Blocker (ARB) is Recommended for Lowering Blood Pressure and Decreasing Recurrent Stroke and Intracerebral Hemorrhage Risk (Class of Recommendation: 1; Level of Evidence: A)
With Prior History of Hypertension and Occurence of Acute Ischemic Stroke, Transient Ischemic Attack (TIA), or Intracerebral Hemorrhage, an Office Systolic Blood Pressure (SBP)/Diastolic Blood Pressure (DBP) Goal of <130/80 mm Hg is Recommended to Decrease the Risk of Recurrent Stroke, Intracerebral Hemorrhage, and Other Vascular Events (Class of Recommendation: 1; Level of Evidence: B-R)
No Prior History of Hypertension
With No Prior History of Hypertension and with an Acute Ischemic Stroke, Transient Ischemic Attack (TIA), or Intracerebral Hemorrhage and Average Office Systolic Blood Pressure (SBP)/Diastolic Blood Pressure (DBP) of ≥130/80 mm Hg, Antihypertensive Treatment Can Be Beneficial to Decrease the Risk of Recurrent Stroke, Intracerebral Hemorrhage, and Other Vascular Events (Class of Recommendation: 2; Level of Evidence: B-R)
Management of Hypertension in the Prevention of Cognitive Decline/Dementia (see Dementia)
Recommendations-2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults (Circulation, 2025) MEDLINE]
In Adults with Hypertension, a Goal of <130 mm Hg Systolic Blood Pressure (SBP( is Recommended to Prevent Mild Cognitive Impairment and Dementia (Class of Recommendation: I, Level of Evidence: A)
Management of Hypertension in the Setting of Aortic Disease
Recommendations-2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults (Circulation, 2025) MEDLINE]
β-Blockers are Recommended as the Preferred Antihypertensive in Patients with Hypertension and Thoracic Aortic Disease (Class of Recommendation: I; Level of Evidence: C-EO)
Management of Hypertension in the Setting of Peripheral Arterial Disease (PAD) (see Peripheral Arterial Disease)
Recommendations-2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults (Circulation, 2018) [MEDLINE]
Adults with Hypertension and Peripheral Artery Disease (PAD) Should Be Treated Similarly to Patients with Hypertension without Peripheral Artery Disease (PAD) (Class of Recommendation: 1; Level of Evidence: B-NR)
Management of Hypertension in the Setting of Renal Disease
Recommendations-2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults (Circulation, 2018) [MEDLINE]
Treatment of Hypertension in the Setting of Chronic Kidney Disease (CKD) (see Chronic Kidney Disease)
Adults with Hypertension and Chronic Kidney Disease (CKD) Should Be Treated to a Blood Pressure Goal of <130/80 mm Hg (Systolic Blood Pressure: Class of Recommendation: I; Level of Evidence: B-R and Diastolic Blood Pressure: Class of Recommendation: I; Level of Evidence: C-EO)
In Adults with Hypertension and Chronic Kidney Disease (CKD) (≥Stage 3 or Stage 1/2 with Albuminuria (≥300 mg/d, or ≥300 mg/g Albumin-to-Creatinine Ratio or the Equivalent in the First Morning Void), Treatment with an Angiotensin Converting Enzyme (ACE) Inhibitor is Reasonable to Slow Kidney Disease Progression (Class of Recommendation: I; Level of Evidence: C-EO)
In Adults with Hypertension and Chronic Kidney Disease (CKD) (≥Stage 3 or Stage 1/2 with Albuminuria (≥300 mg/d, or ≥300 mg/g Albumin-to-Creatinine Ratio in the First Morning Void), Treatment with an Angiotensin II Receptor Blocker (ARB) May Be Reasonable if an Angiotensin Converting Enzyme (ACE) Inhibitor is Not Tolerated (Class of Recommendation: IIb; Level of Evidence: C-EO)
Treatment of Hypertension in the Setting of Renal Transplant (see Renal Transplant)
After Kidney Transplantation, Treat Patients with Hypertension to a Blood Pressure Goal of <130/80 mm Hg (Class of Recommendation: IIa; Level of Evidence: SBP: B-NR, DBP: C-EO)
After Kidney Transplantation, Treat Patients with Hypertension with a Calcium Channel Blocker on the Basis of Improved Glomerular Filtration Rate (GFR) and Kidney Survival (Class of Recommendation: IIa; Level of Evidence: B-R)
Recommendations-2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults (Circulation, 2025) MEDLINE]
Treatment of Hypertension in the Setting of Chronic Kidney Disease (CKD) (see Chronic Kidney Disease)
For Adults with Hypertension and Chronic Kidney Disease (CKD) (eGFR <60 mL/min/1.73 m2 or Albuminuria ≥30 mg Albumin/g Creatinine), Treatment Should Target a Systolic Blood Pressure (SBP) Goal of <130 mm Hg to Decrease All-Cause Mortality (Class of Recommendation: I; Level of Evidence: A)
For Adults with Hypertension and Chronic Kidney Disease (CKD) (eGFR <60 mL/min/1.73 m2 or Albuminuria ≥30 mg Albumin/g Creatinine), Renin-Angiotensin-Aldosterone System Inhibition (Either with Angiotensin Converting Enzyme Inhibitors or Angiotensin II Receptor Blockers/ARB’s, But Not Both) is Recommended to Decrease Cardiovascular Disease and Delay Progression of Kidney Disease (Class of Recommendation: I; Level of Evidence: B-R)
Treatment of Hypertension in the Setting of Renal Artery Stenosis (see Renal Artery Stenosis)
In Adults with Hypertension and Atherosclerotic Renal Artery Stenosis, Medical Therapy is Recommended to Reduce Renal and Cardiovascular Disease Morbidity and Mortality (Class of Recommendation: I; Level of Evidence: A)
In Adults with Hypertension and Atherosclerotic Renal Artery Stenosis for Whom Medical Management Has Failed (Such as Resistant Hypertension, Worsening Renal Function, and/or Acute Heart Failure), it is Reasonable to Refer Patient for Revascularization by Percutaneous Renal Artery Angioplasty and/or Stent Placement (Class of Recommendation: 2a; Level of Evidence: C-EO)
In Adults with Hypertension and Non-Atherosclerotic Renal Artery Stenosis (Including Fibromuscular Dysplasia), it May Be Reasonable to Refer Patient for Revascularization by Percutaneous Renal Artery Angioplasty (Class of Recommendation: 2b; Level of Evidence: C-LD)
References
Treatment
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Omega-3 polyunsaturated fatty acids intake and blood pressure: A dose-response meta-analysis of randomized controlled trials. J Am Heart Assoc. 2022 Jun 7;11(11):e025071. doi: 10.1161/JAHA.121.025071 [MEDLINE]
Feasibility and short-term effects of a multi-component emergency department blood pressure intervention: a pilot randomized trial. J Am Heart Assoc. 2022 Mar;11(5):e024339. doi: 10.1161/JAHA.121.024339 [MEDLINE]
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