High blood pressure: what the guidelines say

High blood pressure, also called hypertension, is the condition of having blood push against artery walls with more force than is typical, measured as two numbers: systolic pressure (the higher number, pressure during a heartbeat) over diastolic pressure (the lower number, pressure between beats). It is common from midlife onward and it is a major driver of stroke, heart attack, heart failure, and kidney disease risk, which is why it has its own detailed guideline rather than being folded into general checkup advice.

In August 2025, the American College of Cardiology and American Heart Association, together with eleven co-sponsoring medical societies, published a new guideline that updates the widely used 2017 ACC/AHA guideline. This page describes what that current, 2025 guideline says.

The categories the guideline uses

The 2025 guideline keeps the same four blood pressure categories the 2017 guideline introduced. Based on the average of properly measured readings, not a single office check, the categories are:

• Normal: systolic below 120 mm Hg AND diastolic below 80 mm Hg
• Elevated: systolic 120 to 129 mm Hg AND diastolic below 80 mm Hg
• Stage 1 hypertension: systolic 130 to 139 mm Hg OR diastolic 80 to 89 mm Hg
• Stage 2 hypertension: systolic 140 mm Hg or higher OR diastolic 90 mm Hg or higher

A reading falls into whichever category the higher of the two numbers reaches. The guideline is explicit that a diagnosis should rest on multiple readings, ideally including measurements taken outside a clinical office such as home blood pressure monitoring, because office readings alone can overestimate or underestimate a person’s usual pressure. The guideline points clinicians toward validated home devices, listed publicly, as part of confirming a diagnosis rather than relying on one visit.

How the guideline frames the decision to treat

The 2025 guideline’s biggest change from 2017 is not the categories themselves but how it decides who gets medication. It replaces the older Pooled Cohort Equations with a newer tool called PREVENT, which estimates a person’s 10-year cardiovascular disease risk using a broader set of cardiovascular, kidney, and metabolic measures.

The guideline’s general framework, described here without prescribing anything for any individual reader, is:

• For Stage 2 hypertension (140/90 mm Hg or higher), the guideline describes starting pharmacologic therapy as appropriate for most adults, generally alongside lifestyle changes, and it notes that starting with two medication classes at once, ideally combined into a single pill, is often described as more effective for reaching a goal than starting with one and adding a second later.
• For Stage 1 hypertension (130 to 139 systolic or 80 to 89 diastolic), the guideline describes a risk-based approach: medication is described as appropriate when a person also has established cardiovascular disease, diabetes, chronic kidney disease, or a PREVENT-estimated 10-year cardiovascular risk of 7.5% or higher. Without those factors, the guideline describes an initial period, on the order of three to six months, of lifestyle-focused measures, with medication reconsidered if blood pressure has not come down into target range by then.
• The guideline reaffirms a treatment target of below 130/80 mm Hg for most adults already being treated, rather than a looser target.

On medication, the guideline describes several classes as appropriate first-line choices, applied without regard to race: thiazide-type diuretics, ACE inhibitors, angiotensin receptor blockers (ARBs), and dihydropyridine calcium channel blockers. It does not rank one of these above the others as a default; it describes them as options a clinician chooses among based on a person’s other health conditions. Separately, the guideline notes that GLP-1 medications, more familiar as diabetes and weight-management drugs, are described as a reasonable option for some patients who have both high blood pressure and overweight or obesity, an addition that was not part of the 2017 version. None of this page states a dose for any medication; dosing is a clinical decision, not something a guideline summary should specify.

The honest nuances

The move to the PREVENT risk calculator is a genuine, debated change, not a minor technical footnote. PREVENT drops race as an input, adds kidney and metabolic measures, and, for many people, produces a lower estimated risk than the older Pooled Cohort Equations did for the same numbers. That is part of why the risk threshold for starting medication in Stage 1 hypertension was set at a 10-year risk of 7.5% rather than the 10% figure used with the older tool: the two thresholds are not directly comparable, and a person’s calculated risk, and therefore the guideline’s suggested course, can differ depending on which era of calculator was used. The guideline also newly recommends a urine albumin-to-creatinine ratio test for all patients with high blood pressure, a test that used to be optional, to check for early kidney involvement. And while home blood pressure monitoring has long been described as useful, the 2025 guideline leans on it much more heavily as part of both diagnosis and tracking progress over time, which is a real shift in emphasis, not just a suggestion.

Age, kidney function, pregnancy status, and other medical conditions all change how this guideline applies to a specific person, and the guideline itself describes a different, lower treatment threshold (140/90 mm Hg) for pregnant women with chronic hypertension. None of the category thresholds or risk cutoffs above substitute for a clinician reviewing an individual’s own readings, history, and risk factors.

Questions to discuss with your clinician

• Where do my own readings, ideally including home measurements, fall in these categories, and how many readings has that assessment been based on?
• What is my PREVENT-estimated 10-year cardiovascular risk, and how did that number factor into what was recommended for me?
• If I am in the Stage 1 range, what would the lifestyle-focused window look like for me, and how would we know if it worked?
• If medication is being considered, which class or classes are being discussed for my situation, and why those over the alternatives?
• Do I have kidney, cardiovascular, or metabolic factors, including the newer urine albumin-to-creatinine test, that change how this guideline applies to me?
• How often should my blood pressure be rechecked, and what home-monitoring device would be appropriate for me to use?

For the related evidence on the everyday factors that influence blood pressure, see physical activity and dietary patterns, or read the separate screening guideline on who should be checked and how often.