Medical Basis: 2025 ACC/AHA Multi-Society Hypertension Guideline and Related Authoritative Guidelines and Scientific Statements up to 2026
Updated: August 2026

Hypertension treatment is evolving from a relatively simple "add a drug if blood pressure is high" approach to a more systematic management strategy:

Accurate blood pressure confirmation → Overall cardiovascular risk assessment → Decision on need for medication → Drug selection based on comorbidities → Early combination therapy if necessary → Home blood pressure monitoring → Continuous adjustment to target.

In 2025, the American Heart Association (AHA) and the American College of Cardiology (ACC), along with several professional societies, released a new guideline for adult hypertension, replacing the 2017 version.

The new guideline continues to emphasize the importance of blood pressure itself, but a notable change is that: treatment decisions are increasingly focused on the patient's overall risk of future cardiovascular disease, rather than just a single blood pressure reading.

This article provides an introduction in Chinese to the most important principles of current adult hypertension treatment in the United States and common antihypertensive medications.

Important Note: This article is for general health and medication knowledge education, not for personal diagnosis, and cannot replace individualized treatment advice from a physician, pharmacist, or other qualified healthcare professional. Most antihypertensive drugs are prescription medications; please do not self-initiate, discontinue, change, or adjust medications based on this article.

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I. How is Hypertension Defined in the U.S. in 2026?

The 2025 ACC/AHA guideline continues to use the following classification:

Classification	Systolic BP (SBP)	Diastolic BP (DBP)
Normal	<120	and <80
Elevated	120–129	and <80
Stage 1 Hypertension	130–139	or 80–89
Stage 2 Hypertension	≥140	or ≥90

Note:

A single blood pressure reading of 130/80 mmHg does not, by itself, confirm a diagnosis of hypertension.

Accurate diagnosis requires reliable blood pressure measurement, combined with repeated measurements and, if necessary, home blood pressure monitoring or ambulatory blood pressure monitoring.

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II. Treatment Goal is No Longer Just "Below 140/90"

The 2025 ACC/AHA guideline proposes that for most adults:

The overall treatment goal is <130/80 mmHg

However, clinical treatment is not simply about requiring all patients to mechanically reach the same number.

For example:

• Age and overall health status

• Presence of cardiovascular disease

• Chronic kidney disease (CKD)

• Diabetes

• Pregnancy

• Risk of falls or hypotension

• Life expectancy

• Need for institutional long-term care

All these factors influence the specific treatment goals and intensity.

Therefore, whether "my blood pressure must reach a certain number" ultimately still needs to be determined based on individual circumstances.

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III. 130–139/80–89, Do I Need to Take Medication Immediately?

Not necessarily.

This is a crucial part of the 2025 new guideline to understand.

For Stage 1 hypertension, meaning an average blood pressure of:

130–139 mmHg systolic

or

80–89 mmHg diastolic

The decision to start medication depends on the patient's overall risk.

If the patient already has one of the following conditions:

• Clinical cardiovascular disease

• History of stroke

• Diabetes

• Chronic kidney disease

• Higher future cardiovascular risk

The threshold for drug treatment will be lower.

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IV. What is PREVENT? Why is it Important Now?

The new ACC/AHA guideline adopts the American Heart Association's:

PREVENT™

which stands for Predicting Risk of Cardiovascular Disease EVENTs risk prediction model.

It is used to estimate an individual's risk of developing cardiovascular disease in the future.

For some adults with Stage 1 hypertension who do not have the high-risk diseases mentioned above, the new guideline uses:

10-year PREVENT-CVD risk ≥7.5%

as an important risk threshold for initiating antihypertensive drug treatment.

This means that modern hypertension treatment is increasingly not about:

"Is 130/80 really serious?"

but rather:

"What kind of person has this blood pressure? What is their overall risk of future cardiovascular events?"

The same 135/85 mmHg might lead to different treatment strategies depending on the patient.

For patients with lower-risk Stage 1 hypertension, lifestyle interventions can be tried first; if the target is still not reached after approximately 3–6 months, medication can then be considered based on the situation.

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V. The Treatment Approach for Stage 2 Hypertension Has Significantly Changed

If the average blood pressure reaches:

≥140/90 mmHg

It is classified as Stage 2 hypertension.

Modern treatment increasingly emphasizes:

Do not continue the slow, stepwise approach of "one drug → wait a long time → add a little more if not enough → wait again."

Many Stage 2 patients need from the start of treatment:

Two first-line antihypertensive drugs with different mechanisms

And where appropriate, increasingly recommend:

Single-Pill Combination (SPC)

Single-pill combination antihypertensive drugs

which means combining two antihypertensive components in one pill.

The purpose of this is not just to lower blood pressure, but also to:

• Reach blood pressure targets faster

• Reduce the number of pills taken daily

• Improve long-term medication adherence

• Reduce missed doses

• Improve long-term blood pressure control rates

The 2025 AHA scientific statement on single-pill combination therapy further indicates that most hypertensive patients requiring medication will eventually need two to four antihypertensive drugs to reach guideline targets.

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VI. What Are the Current First-Line Antihypertensive Drugs in the U.S.?

According to the 2025 ACC/AHA guideline, for primary hypertension, the first-line medications with sufficient randomized clinical trial evidence primarily include four classes:

1. ACE Inhibitors

ACE inhibitors

For example:

• Lisinopril

• Ramipril

• Enalapril

• Benazepril

2. ARBs

Angiotensin II Receptor Blockers

For example:

• Losartan

• Valsartan

• Irbesartan

• Olmesartan

• Telmisartan

3. Long-acting Dihydropyridine CCBs

Long-acting dihydropyridine calcium channel blockers

For example:

• Amlodipine

4. Thiazide-type / Thiazide-like Diuretics

Thiazide-type or thiazide-like diuretics

For example:

• Chlorthalidone

• Hydrochlorothiazide

• Indapamide

Here is a very important concept:

"First-line drugs" does not mean "all patients should take the same drug."

Doctors first need to assess whether the patient has certain conditions that give a particular class of drugs an additional advantage or specific indication.

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VII. ACEI and ARB: Why Are They So Important?

Both ACE inhibitors and ARBs act on the:

Renin-Angiotensin System (RAS)

This is an important system in the human body that regulates blood pressure, blood volume, and kidney function.

Common ACEIs:

Lisinopril, Ramipril, Enalapril

Common ARBs:

Losartan, Valsartan, Olmesartan, Irbesartan

Both can effectively lower blood pressure.

However:

ACEI + ARB generally should not be used together.

Because dual blockade of the RAS does not simply provide "double protection," but may instead increase the risk of:

• Hyperkalemia

• Renal dysfunction

• Hypotension

and other risks.

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VIII. Why Do Some People Cough When Taking Lisinopril?

One of the more typical side effects of ACE inhibitors is:

Dry cough

If a patient develops a persistent, unexplained dry cough after taking an ACEI, the doctor may consider whether it is drug-related.

ARBs are generally less likely to cause this type of cough associated with ACEIs, so some patients may switch to an ARB after medical evaluation.

Another issue, although rare, that must be taken seriously is:

Angioedema

If there is:

• Swelling of the lips

• Swelling of the tongue

• Significant facial swelling

• Difficulty breathing or swallowing

Medical evaluation should be sought promptly; severe symptoms such as difficulty breathing constitute an emergency.

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IX. Why Are ARBs Very Common in Clinical Practice?

ARBs generally have good blood pressure-lowering effects and are well-tolerated.

Common medications include:

Losartan, Valsartan, Olmesartan, Irbesartan, Telmisartan.

For some patients who also have:

• Chronic kidney disease

• Proteinuria/albuminuria

• Diabetes

• Coronary artery disease

RAS blocking drugs may have particularly important clinical value.

However, the choice between ACEI or ARB, which specific one, and what dosage to use, all need to be determined based on the patient's individual circumstances.

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X. Amlodipine's Position in Modern Hypertension Treatment

Amlodipine belongs to:

Long-acting dihydropyridine calcium channel blocker

This class of medication is still considered a first-line antihypertensive drug explicitly recognized by the 2025 ACC/AHA guideline.

However, the focus of modern treatment should no longer be simply understood as:

"Is Amlodipine the most commonly used antihypertensive drug?"

A more meaningful question is:

"What mechanism of drug is most suitable for this patient, and should combination therapy be initiated from the outset?"

One common adverse effect of Amlodipine is:

Peripheral edema

especially ankle edema.

This type of edema is not simply equivalent to "too much fluid in the body."

Therefore, if a patient develops ankle edema, they should not self-administer diuretics or discontinue the medication on their own. Instead, a doctor should determine the cause and adjust the treatment plan.

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XI. Diuretics: Hydrochlorothiazide and Chlorthalidone

Thiazide and thiazide-like diuretics have long been important components of hypertension treatment.

Common ones include:

• Hydrochlorothiazide (HCTZ)

• Chlorthalidone

• Indapamide

They can help lower blood pressure and have a substantial body of evidence from cardiovascular outcome studies.

However, during treatment, monitoring may be required for:

• Sodium

• Potassium

• Kidney function

• Uric acid

• Glucose

Therefore, the idea that "diuretics just remove some water and are relatively simple" is a misunderstanding.

They are true antihypertensive medications and require formal clinical monitoring.

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XII. Why are Beta Blockers Not Included in the Four Main First-Line Drugs for General Hypertension?

Many patients take:

• Metoprolol

• Carvedilol

• Atenolol

• Bisoprolol

This often leads to the question:

"Aren't beta blockers antihypertensive drugs?"

Of course, they can lower blood pressure.

However, for simple primary hypertension without other clear indications, beta blockers are not currently listed as one of the four regular first-line initiating drug classes by the ACC/AHA.

They remain very important for certain patients, for example, those who also have specific:

• Coronary artery disease

• History of myocardial infarction

• Heart failure

• Arrhythmias

and other conditions.

So, it cannot simply be said:

"Beta blockers are old drugs, so they are no longer used."

The correct understanding should be:

Drug selection is determined by the patient's overall cardiovascular disease status.

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XIII. Modern Combination Therapy: Why Are RAS Blocker + CCB Increasingly Important?

The 2025 AHA scientific statement on single-pill combination therapy further emphasizes that:

Single-Pill Combination Therapy

has significant advantages for most patients requiring medication, especially when initiated early.

The AHA scientific statement specifically highlights:

RAS blocker + CCB

as one of the preferred single-pill combination options for most patients.

For example, from a pharmacological mechanism perspective:

ARB/ACEI + long-acting CCB

lower blood pressure through different mechanisms.

Also common are:

RAS blocker + thiazide/thiazide-like diuretic

and other combination strategies.

The specific combination must be determined based on the patient's condition, kidney function, electrolytes, drug tolerability, and insurance coverage.

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XIV. What's Different About Hypertension Treatment for Diabetics?

Diabetes is a good example of why modern hypertension treatment cannot solely focus on blood pressure numbers.

According to the 2026 American Diabetes Association Standards of Care, treatment for diabetic patients needs to consider:

• Cardiovascular risk

• Coronary artery disease

• Kidney function

• Albuminuria

• Drug tolerability

and other factors.

For diabetic patients who also have albuminuria or coronary artery disease:

ACE inhibitors or ARBs hold a particularly important position.

For patients with significantly increased albuminuria and/or declining kidney function, RAS blockade therapy is especially important, while also requiring monitoring of:

• Creatinine / eGFR

• Potassium

Therefore, diabetic patients cannot simply apply the rule:

"Use whichever antihypertensive drug lowers blood pressure fastest."

The treatment goal is not only to lower blood pressure, but also to reduce:

the risk of cardiovascular events and progression of kidney disease.

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XV. Why Do CKD Patients Especially Need to Pay Attention to Drug Selection?

Hypertension can promote CKD progression, and CKD itself can make blood pressure harder to control.

For CKD patients, doctors pay special attention to:

• eGFR

• Urine Albumin-to-Creatinine Ratio (UACR)

• Potassium

• Creatinine

• Presence of diabetes

• Presence of other cardiovascular diseases

Especially for CKD patients with albuminuria, ACEIs or ARBs often play a crucial role.

However:

"Having kidney disease so ACEI/ARB cannot be used" is also a common misconception.

For some patients, creatinine and potassium need to be monitored after initiating or adjusting a RAS blocker, but medication should not be discontinued solely based on the idea that "this drug affects the kidneys."

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XVI. Why is Blood Pressure Still High After Taking Three Medications?

At this point, simply adding more medication indefinitely is not the solution.

The doctor needs to consider:

Resistant Hypertension

and simultaneously re-evaluate:

• Accuracy of blood pressure measurement

• Presence of white-coat effect

• Medication adherence

• Dietary sodium intake

• Alcohol consumption

• Other medications that may raise blood pressure

• Sleep apnea

• Kidney disease

• Primary aldosteronism

• Other causes of secondary hypertension

Some patients with true resistant hypertension may also require:

Mineralocorticoid Receptor Antagonist (MRA)

For example:

Spironolactone

However, this treatment requires special attention to:

Potassium and kidney function.

So, "poor blood pressure control" does not necessarily mean the existing antihypertensive medication is "not strong enough."

Sometimes what is truly needed is to find out:

Why is blood pressure so difficult to control?

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XVII. Which OTC Medications Can Affect Blood Pressure?

This is a very important aspect for pharmacies.

Hypertensive patients should be particularly careful when purchasing OTC medications, as some products may affect blood pressure control.

For example, some:

Decongestants

and:

NSAIDs

may raise blood pressure, affect kidney function, or interfere with antihypertensive treatment in some patients.

Additionally, attention should be paid to:

• Certain stimulants

• Some herbal remedies or supplements

• High-sodium products

• Products that interact with prescription medications

Therefore, if you are taking two, three, or even more antihypertensive medications, it is best to provide a complete list of your medications to the pharmacist when purchasing OTC cold medicines, pain relievers, or supplements.

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XVIII. How Should a Home Blood Pressure Monitor Be Chosen?

The AHA still recommends that home blood pressure monitoring prioritize:

Validated automatic upper arm cuff blood pressure monitors

rather than relying on:

• Finger blood pressure monitors

• Ordinary wrist devices

• Unvalidated cuffless smart devices

Cuff size is also very important.

A cuff that is too small can lead to higher readings, while a cuff that is too large can also affect accuracy.

When purchasing a blood pressure monitor, ensure the device is validated and choose a cuff size that fits your upper arm circumference.

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XIX. Can Smartwatches Replace Blood Pressure Monitors?

As of 2026, the answer remains:

Ordinary cuffless smart devices should not be used as a substitute for standard home blood pressure monitoring.

The AHA's 2025 scientific statement on cuffless BP devices notes that these devices have potential, but their real-world accuracy and clinical application still have important limitations.

For hypertension diagnosis, medication adjustment, and evaluating treatment effectiveness:

Validated upper arm cuff devices remain the more reliable choice.

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