Introduction
This year the American Heart Association and the American College of Cardiology published new blood pressure guidelines for the prevention and treatment of hypertension. Importantly, these new blood pressure guidelines are an update from those previously published in 2018. Specifically, they are based on considerably more data collected in ethnic diverse individuals over a longer period.
Hypertension increases with age and affects 70% of those 60-74 years of age and more than 80% over 75 years. Therefore, understanding the meaning of new blood pressure guidelines for older adults is of prime importance. Furthermore, hypertension is a major modifiable risk factor for cardiovascular disease. The meaning of new blood pressure guidelines for older adults is the topic of this blog.
Established Blood Pressure Categories
Accepted blood pressure categories are given below. Results of clinical trials, numerous observational studies and meta-analyses of cardiovascular risk and benefits of lowering this risk support these values.
Normal – systolic <120 mm Hg and diastolic <80 mm Hg
Elevated – systolic 120-129 mm Hg and diastolic <80 mm Hg
Stage 1 hypertension – systolic 130-130 mm Hg or diastolic 80-89 mm Hg
Stage 2 hypertension – systolic 140 mm Hg or diastolic 90 mm Hg
The above categories remain unchanged. Significant changes are discussed below.
Significance of new blood pressure guidelines
1. The treatment threshold has been lowered in blood pressure guideline
In other word, those with a systolic blood pressure of 130 mm Hg, with or without a calculated 10 year cardiovascular risk assessment, will be encouraged to lower their pressure to below 130, preferable to 120 mm Hg. This is the target blood pressure to prevent heart and kidney disease and prevent strokes. Blood pressure should be verified on 2 doctor visits with 2 or more separate measurements per visit.
2. Treatment should begin earlier in blood pressure guidelines
If systolic blood pressure is in the range of 130 mmHg (Stage 1 hypertension) and there is no evidence of cardiovascular risk, nevertheless, this pressure should be reduced. Blood pressure guidelines recommend lifestyle changes as first step. However, persistent high blood pressure after 3-6 months necessitates antihypertensive medication.
According to the 2018 Guidelines, antihypertensive therapy was started only if cardiovascular risk factors and an elevated systolic pressure were both present. The reason for the change is data that show lowering blood pressure significantly decreases the risk for mild cognitive impairment and dementia.
The PREVENT calculator (see https://professional.heart.org/en/guidelines-and-statements/prevent-calculator) is the preferred means to determine 10 year cardiovascular risk. It is based on a wealth of data collected over 30 years up to 2022 and considers both heart and kidney risks. Thus, one may enter their laboratory values to determine a 10 year risk.
3. Monotherapy changes to dual therapy for Stage 2 hypertension in blood pressure guidelines
Higher systolic blood pressure (140 mmHg) now requires 2 anti-hypertensive drugs not just one in order to achieve the low blood pressure target. The medication of choice is a single daily pill containing two drugs of different classes. This recommendation achieves efficacy and improves compliance.
4. Lifestyle recommendations in blood pressure guidelines
Regardless of one’s blood pressure, a low sodium diet is important. Suggested target of added table salt should be below 1500 milligrams/day (3/4 teaspoon). Also, guidelines propose replacing table salt with potassium-enriched salt substitution, unless one is taking potassium-retaining medications e.g. spironolactone and similar diuretics The DASH diet (Dietary Approach to Stop Hypertension) is helpful (see https://www.nhlbi.nih.gov/education/dash-eating-plan).
For those who are overweight or obese, 5% body weight loss (or decrease body mass index (BMI) by 3 is required: see https://www.nhlbi.nih.gov/calculate-your-bmi for calculation of BMI. Serious physical activity assists with weight loss (see insight 2, insight 3, insight 4)
Additionally, guidelines propose a reduction in alcohol consumption to zero or maximum of 1 drink for women and 2 drinks for men (government recommendation). One drink is defined as 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of spirits.
5. Additional laboratory tests in blood pressure guidelines
Specifically, for those with stage 1 hypertension, the creatinine test for kidney function should be supplemented with the test for urine albumin. The latter test directly assesses the degree of kidney damage. Additionally, guidelines recommend another test, this one for production of excess aldosterone, now considered more prevalent than before. Hyperaldosteronism is a treatable cause of hypertension.
Accurate blood pressure measurements – adhere to the following:
a) Measure blood pressure after sitting quietly (legs uncrossed, feet flat on floor) for at least 5 minutes. This avoids inclusion of blood pressure change due to movement or stress.
b) Support arm with blood pressure cuff either with a table or other support. The cuff must approximate the level of the heart without the influence from gravity.
c) Empty your bladder prior to a blood pressure measurement. This eliminates undue sympathetic activity which elevates blood pressure.
d) Avoid caffeine, smoking or exercise for 30 minutes prior to blood pressure measurement. These also elevate blood pressure.
e) Take 2-3 blood pressure readings, one minute apart, and average.
The above key points apply to use of a home device and in the doctor’s office. Calibrate home devices with that of the doctor’s. Skin sensors e.g. smart watches are not accurate.
Major Message
The medical profession developed new blood pressure guidelines in an endeavor to keep the older adult free from disease for as long as possible. In other words, current guidelines recommend the maintenance of normal blood pressure throughout life to reduce the risk for cardiovascular and kidney diseases, stroke, mild cognitive impairment and dementia.
References
Abbasi J. What to Know About the New Blood Pressure Guidelines. .JAMA. 2025 Dec 2;334(21):1869-1871. doi: 10.1001/jama.2025.17664.
Santulli G.The 2025 AHA/ACC hypertension guidelines: implications for cardiovascular and renal risk in patients with diabetes. Cardiovasc Diabetol Endocrinol Rep. 2025 Aug 26;11(1):21. doi: 10.1186/s40842-025-00239-3.
Jones DW, Ferdinand KC, Taler SJ, Johnson HM, Shimbo D, Abdalla M, Altieri MM, Bansal N, Bello NA, Bress AP et al. 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: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Hypertension 2025.
Suzuki Y, Kaneko H, Okada A, Fujiu K, Takeda N et al., BP classification using the 2017 ACC/AHA BP guidelines with risk of cardiovascular events in older individuals Journal of Cardiology 84 (2024) 394–403