Affecting nearly 48% of adults, hypertension is a leading risk factor for cardiovascular disease (CVD) and the most significant stroke risk factor.
Recent guidelines from the American College of Cardiology (ACC) and American Heart Association (AHA) encourage earlier use of antihypertensive medications and also drug combinations to help individuals with higher blood pressure gain control of it sooner.
“We have 10-plus drug classes to lower blood pressure,” says Luke J. Laffin, MD, Co-Director of Cleveland Clinic’s Center for Blood Pressure Disorders. “You just have to put them into practice, use combinations and have patients make lifestyle changes to get their blood pressure under control.”
What Is Hypertension?
Since 2017, hypertension has been defined as a systolic blood pressure of 130 millimeters of mercury (mmHg) or higher or a diastolic pressure of 80 mmHg or higher. The 2017 ACC/AHA blood pressure guidelines recommended that clinicians initiate antihypertensive therapy in people with stage 2 hypertension: a systolic blood pressure of 140 mmHg or higher or diastolic pressure of 90 mmHg or greater (see “Blood Pressure Categories”).
The updated guidelines (Hypertension, October 2025) maintain this recommendation, but they also call for treating people with an average pressure of 130/80 mmHg or higher who have CVD, diabetes, chronic kidney disease, a history of stroke or a higher risk of CVD (7.5% or greater) based on the AHA’s PREVENT equations (to gauge your risk, use the online calculator at tinyurl.com/67y4dzbh). For individuals at lower CVD risk, antihypertensive therapy should begin if blood pressure remains at 130/80 mmHg or higher after an initial three- to six-month trial of healthful lifestyle changes (see “Lifestyle Effects on Blood Pressure”), the guidelines recommend.
“If someone loses 50 pounds with diet and other lifestyle measures, then use of medications can always be reassessed,” Dr. Laffin says. “You just don’t want to keep ‘kicking the can down the road,’ and then it’s two years later and your blood pressure is still uncontrolled.”
Blood Pressure Categories
The ACC/AHA guidelines outline these blood pressure categories:
● Normal: Less than 120 mmHg systolic and less than 80 mmHg diastolic
● Elevated: 120–129 mmHg systolic and less than 80 mmHg diastolic
● Hypertension Stage 1: 130–139 mmHg systolic or 80–89 mmHg diastolic
● Hypertension Stage 2: systolic pressure of 140 mmHg or higher or diastolic pressure of 90 mmHg or higher
● Hypertensive Crisis: Systolic blood pressure higher than 180 mmHg and/or diastolic pressure higher than 120 mmHg
Lifestyle Effects on Blood Pressure
| BENEFICIAL BEHAVIOR | EFFECT ON SYSTOLIC BP* |
| Weight loss: Sustained >5% reduction in body weight or 3-point drop in BMI; 1 mmHg reduction for every 2.2 pounds (1 kg) in weight lost | -6 to -8 mmHg
-3 to -5 mmHg |
| Diet: Following a DASH dietary pattern rich in fruits, vegetables, whole grains and low-fat dairy; low in saturated/trans fat | -6 to -8 mmHg
-3 to -7 mmHg |
| Reduced sodium intake: <2,300 mg/day, but aim for ideal limit of <1,500 mg/day | -6 to -7 mmHg
-5 mmHg |
| Increased potassium intake: 3,500–5,000 mg/day, ideally through dietary sources | -6 mmHg
-3 to -6 mmHg |
| Physical activity: 90–150 minutes/week of aerobic exercise; 90–150 minutes/week of resistance (strength-training) exercise | -4 to -8 mmHg & -2 to -7 mmHg (aerobic)
-2 to -7 mmHg & -2 to -5 mmHg (resistance) |
| Alcohol in moderation: ≤2 standard drinks per day for men; ≤1 for women# | -4 to -6 mmHg
-3 mmHg |
| * Expected blood pressure reductions for individuals with (bold) and without hypertension; these behaviors are additive. In comparison, the average blood pressure medication lowers systolic blood pressure by 6–8 mmHg.
# Examples of standard drinks: 12 oz regular beer, 5 oz of wine, 1.5 oz of 80-proof distilled spirits (rum, whiskey, vodka) 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, October 2025 |
|
Drug Combos for Stage 2 Hypertension
Furthermore, individuals with stage 2 hypertension should begin antihypertensive treatment with two medications from different classes, with a single-pill, fixed-dose combination preferred over two separate pills, the guidelines note. Some physicians have been hesitant to prescribe single-pill combinations, due to concerns about the cost and the inability to make individual dosing adjustments to the constituent drugs, Dr. Laffin says.
However, only about 21% of people with hypertension achieve their target blood pressure, and 70% or more need at least two medications to control their blood pressure. Single-pill combinations can help overcome these challenges, improve adherence to treatment and increase targeted blood pressure control more quickly, and most insurance providers cover the cost of one or more combination products, Dr. Laffin emphasizes.
“We want to get people on fixed-dose combination therapy earlier because we know that using multiple low-to-medium doses of medicines are more effective than one medicine at a high dose, and they tend to have fewer side effects, too,” he says. “Rather than being risk-averse, we should be more proactive, and then we can always adjust the medications.”
How Low Should You Go?
Anyone with hypertension and at higher CVD risk should aim for a blood pressure target below 130/80 mmHg, and they should be encouraged to achieve a pressure below 120/80 mmHg, the guidelines note.
A landmark trial found that treating to a systolic blood pressure goal of less than 120 mmHg was associated with a 25% lower relative risk of adverse CVD events, compared with treatment to a systolic goal of 135 to 139 mmHg. Intensive treatment produced an average systolic pressure of 121 mmHg, but at the cost of an increased risk of low blood pressure, acute kidney injury or failure, syncope (fainting), and electrolyte imbalances.
“We clearly know that patients have more side effects the lower their blood pressure gets, so my advice is that we should aim for a systolic pressure right around 120 mmHg, if possible,” Dr. Laffin advises. “The data doesn’t support pushing blood pressure into the low one-teens, based on the risk-benefit profile.”
Other Hypertension Recommendations
The guidelines reaffirm the importance of home blood pressure monitoring and frequent interactions with your healthcare team to improve blood pressure control. Choose a reliable home blood pressure monitor (find a list at validatebp.org), and periodically have your monitor calibrated with the device at your doctor’s office to ensure accurate readings.
If your blood pressure remains high despite concurrent use of three or more primary classes of blood pressure medications (resistant hypertension), the guidelines recommend screening for primary aldosteronism (overproduction of the hormone aldosterone). Dr. Laffin notes that clinicians also should check for other causes, including kidney disease, narrowing of the renal arteries, obstructive sleep apnea and thyroid dysfunction.
“We think that about 20% to 30% of people with resistant hypertension have undiagnosed primary aldosteronism, and 5% to 15% of people with ‘primary’ hypertension have aldosterone dysregulation,” he says. “The big thing is if someone is diagnosed early with primary aldosteronism, sometimes there are surgical options that can cure them.”
The guidelines also note that renal denervation may be considered for carefully selected individuals with resistant hypertension. In this treatment, an interventional cardiologist feeds a catheter through an artery in the groin to the renal arteries, where it delivers energy to destroy overactive nerves that contribute to hypertension. On average, renal denervation can reduce blood pressure by 5 to 7 mmHg.
Final Advice
Dr. Laffin stresses the importance of getting the upper hand on hypertension early on and not allowing blood pressure to remain high: “Don’t tolerate ‘OK’ blood pressure. Talk to your treating clinician about ways to better control your blood pressure and measure it at home, because it is the number one modifiable risk factor for cardiovascular disease.”
