Hypertension 2024–2025: ESC and AHA/ACC Guideline Updates

1. Slide 1 · Hypertension Guidelines 2024–2025: What Really Changed

   Hypertension Guidelines 2024–2025: What Really Changed

   Lower targets, earlier combinations and new drug classes from the 2024 ESC and 2025 AHA/ACC guidelines

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   Speaker notes

   Good morning, everyone. In just over a year we received two major hypertension guidelines: the 2024 ESC guideline and the 2025 AHA/ACC guideline. Instead of retelling either document, I want to focus on what changes our practice on Monday morning. We will cover three themes: how low we should now go with blood pressure, why most patients should start on two drugs in a single pill, and which new drug classes are arriving for resistant hypertension. Throughout, I will point out where the Europeans and Americans converge, and where they still differ, so you can apply both sensibly in your own patients.

2. Slide 2 · ESC 2024 vs AHA/ACC 2025 at a glance

   ESC 2024 vs AHA/ACC 2025 at a glance

   Domain	ESC 2024	AHA/ACC 2025
   Categories	Non-elevated <120/70; elevated 120–139/70–89; hypertension ≥140/90	Elevated 120–129/<80; stage 1 130–139/80–89; stage 2 ≥140/90
   Risk tool	SCORE2 / SCORE2-OP plus risk modifiers	PREVENT 10-year CVD risk
   On-treatment target	SBP 120–129 mmHg if tolerated (ALARA principle)	<130/80 mmHg for most; SBP <120 encouraged
   Initial drug therapy	Low-dose dual SPC for most with BP ≥140/90	Two first-line classes, preferably SPC, in stage 2
   Primary aldosteronism	Screening considered in all confirmed hypertension	Broader screening, especially resistant hypertension

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   Speaker notes

   Here is the side-by-side summary. The ESC introduces a new intermediate category, elevated blood pressure, while keeping the hypertension label at 140/90. The Americans keep their 2017 staging, with hypertension starting at 130/80. But look at the bottom rows: in practice the two documents now converge. Both push systolic values well below 130 in treated patients, both favour single-pill combinations from the start, and both broaden screening for primary aldosteronism. The main structural difference is the risk engine: SCORE2 in Europe versus PREVENT in the United States. Tip: use the risk tool your guideline was calibrated for, as thresholds are not interchangeable.

3. Slide 3 · Systolic targets now converge below 130 mmHg

   Systolic targets now converge below 130 mmHg

   ESC 2024

   Target SBP 120–129 mmHg in most treated adults

   Applies regardless of age if well tolerated

   ALARA: as low as reasonably achievable if intolerant

   Individualise at ≥85 years, frailty or orthostatic hypotension

   AHA/ACC 2025

   Target <130/80 mmHg for most adults

   SBP <120 mmHg encouraged where tolerated

   Same target across diabetes, CKD and established CVD

   Hypertension Canada 2025 also adopts SBP <130 mmHg

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   Speaker notes

   The biggest conceptual shift is the target. The ESC now recommends a systolic of 120 to 129 for most treated patients, including older adults, provided treatment is tolerated. If not, they introduce the ALARA principle: as low as reasonably achievable. The AHA/ACC sets less than 130/80 and explicitly encourages systolic values below 120. This reflects the accumulated intensive-treatment trials such as SPRINT and STEP. Hypertension Canada reached a similar conclusion in 2025. Practical tip: measure standing blood pressure in older or diabetic patients before intensifying, because symptomatic orthostatic hypotension is the main reason to relax the target.

4. Slide 4 · Treat the 130–139 range according to CV risk

   Treat the 130–139 range according to CV risk

   ESC: elevated BP 130–139/80–89 treated if SCORE2 risk ≥10% after lifestyle

   Established CVD, CKD, diabetes, HMOD or FH automatically count as high risk

   AHA/ACC: PREVENT ≥7.5%, CVD, diabetes or CKD warrant drugs at ≥130/80

   Low-risk stage 1: 3–6 months lifestyle, then drugs if BP persists

   Confirm with home or ambulatory BP before labelling and treating

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   Speaker notes

   Now, who should be treated in that grey zone between 130 and 139 systolic? Both guidelines answer with risk. The ESC recommends three months of lifestyle intervention, then drug therapy if blood pressure remains at or above 130/80 and ten-year risk by SCORE2 is at least 10 percent, or if a high-risk condition is present. The AHA/ACC uses the new PREVENT equations with a 7.5 percent threshold, and now also suggests medication in low-risk stage 1 patients who remain above 130/80 after lifestyle measures. Practical tip: never start treatment on a single office reading; home or ambulatory monitoring prevents treating white-coat hypertension.

5. Slide 5 · Start most patients on a dual single-pill combination

   Start most patients on a dual single-pill combination

   ESC: low-dose dual SPC for most patients with confirmed BP ≥140/90

   Preferred pairs: RAS blocker plus dihydropyridine CCB or thiazide-type diuretic

   AHA/ACC: two first-line classes, preferably one pill, in stage 2

   Consider monotherapy at ≥85 years, frailty, orthostatic hypotension or BP 130–139

   Escalate to triple SPC, then spironolactone; never combine ACEi with ARB

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   Combination therapy is no longer a step; it is the starting point. The ESC recommends a low-dose dual single-pill combination for most patients with confirmed hypertension, typically an ACE inhibitor or ARB with a dihydropyridine calcium channel blocker or a thiazide or thiazide-like diuretic. The AHA/ACC now recommends the same approach for stage 2. Monotherapy remains reasonable in the very old, frail patients, those with orthostatic hypotension, and in the 130 to 139 range. If uncontrolled, move to a triple pill, then add spironolactone. Beta-blockers enter at any step when there is a compelling indication such as heart failure or angina.

6. Slide 6 · Single-pill combinations improve control early

   Single-pill combinations improve control early

   51% vs 35%

   BP goal <140/90 at 8 weeks: olmesartan dual SPC vs monotherapy

   −22.7 vs −16.0

   Mean SBP change (mmHg): dual combination vs monotherapy

   76% vs 60%

   Target BP at 8–12 weeks: low-dose triple pill vs standard care

   9% vs 7%

   Hypokalaemia with low-dose triple pill vs control

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   Speaker notes

   Why the shift? The data are consistent. In a meta-analysis of seven double-blind trials with almost 5,900 patients, olmesartan-based dual combinations achieved goal in about half of patients versus one-third with monotherapy, with similar adverse events. Going further, the low-dose triple pill of telmisartan, amlodipine and indapamide, known as GMRx2, improved target achievement to about three-quarters of patients at 8 to 12 weeks. The trade-off is electrolyte disturbance: hypokalaemia and hyponatraemia were modestly more frequent. Practical tip: check potassium and sodium four to six weeks after starting any diuretic-containing combination, particularly in older women.

7. Slide 7 · Beyond triple therapy: new drug classes

   Beyond triple therapy: new drug classes

   Endothelin, aldosterone synthase and angiotensinogen as new targets

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   Let us now move to the patient who remains uncontrolled despite a well-taken triple combination. For decades our toolbox stopped at spironolactone, alpha-blockers and centrally acting drugs. That is changing. Three new mechanisms are now in late development or already approved: endothelin receptor antagonism, selective aldosterone synthase inhibition, and silencing of hepatic angiotensinogen. These target pathways that conventional drugs leave partly unopposed. In the next slides I will summarise the key trial evidence, the safety issues you need to monitor, and where these agents fit relative to aldosterone screening and renal denervation.

8. Slide 8 · New agents target unopposed pathways in resistant hypertension

   New agents target unopposed pathways in resistant hypertension

   Agent	Mechanism	Key evidence	Practical caveats
   Aprocitentan	Dual endothelin A/B receptor antagonist	PRECISION: sustained SBP reduction on top of triple SPC	Fluid retention, oedema; teratogenic, contraception required
   Baxdrostat	Selective aldosterone synthase inhibitor	BaxHTN: placebo-corrected SBP −8.7 to −9.8 mmHg at 12 weeks	Hyperkalaemia; monitor potassium and eGFR
   Lorundrostat	Selective aldosterone synthase inhibitor	Phase 2–3 SBP reductions in uncontrolled hypertension	Hyperkalaemia; outcome data pending
   Zilebesiran	siRNA silencing hepatic angiotensinogen	Phase 2: sustained SBP lowering with infrequent dosing	Investigational; outcome trials ongoing

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   Speaker notes

   Aprocitentan, a dual endothelin antagonist, lowered blood pressure in PRECISION when added to a standardised triple pill, with a rebound on withdrawal confirming durability; oedema is the main limitation and it is contraindicated in pregnancy. Aldosterone synthase inhibitors are the most exciting class: in the phase 3 BaxHTN trial, baxdrostat produced a placebo-corrected systolic reduction of about 9 to 10 mmHg, and Bax24 confirmed effects on ambulatory pressure. Selectivity avoids cortisol suppression, but hyperkalaemia occurs, so check potassium early. Zilebesiran remains investigational. None yet has cardiovascular outcome data, so spironolactone remains the established fourth-line drug.

9. Slide 9 · Resistant hypertension: find aldosterone, then escalate

   Resistant hypertension: find aldosterone, then escalate

   Screen for primary aldosteronism

   Aldosterone-to-renin ratio, ideally before or regardless of medication changes

   ESC: consider screening in all confirmed hypertension

   Endocrine Society 2025 suggests screening every hypertensive patient

   Lateralised disease: adrenalectomy; bilateral: MRA-based therapy

   Escalate and intervene

   Exclude pseudoresistance: ABPM, adherence, interfering drugs

   Spironolactone remains preferred fourth-line agent

   Renal denervation: option in experienced centres, eGFR >40 (ESC)

   Ultrasound denervation beat sham after standardised triple SPC

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   Speaker notes

   Before reaching for new drugs, ask two questions. First, is this truly resistant? In PRECISION, almost two-thirds of screened patients failed inclusion, mostly because blood pressure was not actually uncontrolled, a reminder of how common pseudoresistance is. Use ambulatory monitoring and check adherence. Second, is aldosterone the driver? Primary aldosteronism is common and underdiagnosed; the 2025 Endocrine Society guideline now suggests screening everyone with hypertension using the aldosterone-to-renin ratio. Finally, renal denervation has matured: RADIANCE-HTN TRIO showed benefit over sham, and the ESC endorses it as an option in experienced centres. Refer when three drugs plus spironolactone fail.

10. Slide 10 · References

    References

    1. 1.McEvoy JW, McCarthy CP, Bruno RM, et al. 2024 ESC Guidelines for the management of elevated blood pressure and hypertension. Eur Heart J. 2024. doi:10.1093/eurheartj/ehae178
    2. 2.Goupil R, Tsuyuki RT, Santesso N, et al. Hypertension Canada guideline for the diagnosis and treatment of hypertension in adults in primary care. CMAJ. 2025. doi:10.1503/cmaj.241770
    3. 3.Deedwania P, Weber M, Reimitz PE, et al. Olmesartan-based monotherapy vs combination therapy in hypertension: A meta-analysis based on age and chronic kidney disease status. J Clin Hypertens (Greenwich). 2017. doi:10.1111/jch.13103
    4. 4.Shubietah A, Elgendy MS, Emara A, et al. Low-Dose Triple-Pill of Telmisartan, Amlodipine, and Indapamide for Initial Hypertension Treatment: A GRADE-Assessed Meta-analysis of Randomized Trials. High Blood Press Cardiovasc Prev. 2026. doi:10.1007/s40292-025-00751-8
    5. 5.Schlaich MP, Bellet M, Weber MA, et al. Dual endothelin antagonist aprocitentan for resistant hypertension (PRECISION): a multicentre, blinded, randomised, parallel-group, phase 3 trial. Lancet. 2022. doi:10.1016/S0140-6736(22)02034-7
    6. 6.Flack JM, Azizi M, Brown JM, et al. Efficacy and Safety of Baxdrostat in Uncontrolled and Resistant Hypertension. N Engl J Med. 2025. doi:10.1056/NEJMoa2507109
    7. 7.Freeman MW, Halvorsen YD, Marshall W, et al. Phase 2 Trial of Baxdrostat for Treatment-Resistant Hypertension. N Engl J Med. 2023. doi:10.1056/NEJMoa2213169
    8. 8.Azizi M, Brown JM, Dwyer JP, et al. Effect of baxdrostat on ambulatory blood pressure in patients with resistant hypertension (Bax24): a phase 3, randomised, double-blind, placebo-controlled trial. Lancet. 2026. doi:10.1016/S0140-6736(25)02549-8
    9. 9.Adler GK, Stowasser M, Correa RR, et al. Primary Aldosteronism: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2025. doi:10.1210/clinem/dgaf284
    10. 10.Azizi M, Sanghvi K, Saxena M, et al. Ultrasound renal denervation for hypertension resistant to a triple medication pill (RADIANCE-HTN TRIO): a randomised, multicentre, single-blind, sham-controlled trial. Lancet. 2021. doi:10.1016/S0140-6736(21)00788-1
    11. 11.Danaietash P, Verweij P, Wang JG, et al. Identifying and treating resistant hypertension in PRECISION: A randomized long-term clinical trial with aprocitentan. J Clin Hypertens (Greenwich). 2022. doi:10.1111/jch.14517

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11. Slide 11 · Questions?

    Questions?

    Aim for SBP 120–129, start with a single-pill combination, and screen for aldosterone

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    Speaker notes

    To close, three messages. One: targets have moved; for most treated patients we now aim for a systolic between 120 and 129, as low as reasonably achievable if tolerated. Two: start most patients with confirmed hypertension on a low-dose dual single-pill combination, and escalate to a triple pill rather than titrating monotherapy. Three: in resistant hypertension, confirm it with ambulatory monitoring, look for primary aldosteronism, use spironolactone, and keep an eye on aldosterone synthase inhibitors and renal denervation. Thank you; I am happy to take your questions or discuss challenging cases from your practice.

This presentation was generated automatically to show what Doctoria can do and has not been reviewed as clinical guidance. Clinical cases in the examples are fictional.