Today, I review, link to, and excerpt from The Curbsiders‘ #509 Fresh Hypertension Guidelines. West Philadelphia Doc Jordy Cohen Keeps Our Hypertension Management Fresh.*

*Gorth DJ, Cohen J, Williams PN, Watto MF. “#509 Fresh Hypertension Guidelines”. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast December 22, 2025.

All that follows is from the above resource.

Transcript available via YouTube

Don’t get caught treating high blood pressure like it is 2024. Dr. Jordy Cohen (@jordybc.bsky.social, University of Pennsylvania) guides us through the new hypertension guidelines.

Claim CME for this episode at curbsiders.vcuhealth.org!

Show Segments

• Intro
• Case: Jeremy
• Wearable devices inaccuracies
• Ideal blood pressure measurement
• Diagnosis and workup
• Management and fixed-dose combination pills
• Case: Jolene and pregnancy
• Outro

Hypertension Guidelines Pearls

1. Hypertension (HTN) is the leading modifiable risk factor for morbidity and mortality (GBD 2019 Risk Factors Collaborators)
2. If you don’t accurately measure blood pressure, you are managing your patients’ HTN using a random number generator.
3. Home blood pressure monitoring now has a COR 1a recommendation (HTN Guidelines); having the patient monitor their own blood pressure can help reinforce the patient-physician commitment to co-management of HTN and lead to better outcomes (Tucker et al 2017).
4. For home monitoring, stick to a blood pressure device vetted by ValidateBP.org.
5. The phrase hypertensive urgency is no longer in use–it’s severe hypertension now–and PRN oral or IV antihypertensives should not be used to acutely lower blood pressure (HTN Guidelines).
6. There is a new COR 2b recommendation to screen for primary aldosteronism in anyone with stage 2 hypertension, and a COR 1 recommendation for testing in individuals with resistant hypertension regardless of their potassium level (HTN Guidelines).
7. The 2025 guidelines now note that abstinence from alcohol is optimal for HTN management (HTN Guidelines).
8. The new guidelines recommend starting treatment with a two-medication (ACEi/ARB, calcium channel blocker, and/or thiazide diuretic) fixed-dose combination pill (HTN Guidelines).
9. There are no longer race-based medication selection recommendations.
10. Patients who have hypertension prior to becoming pregnant and/or before 20 weeks gestation should receive medication to keep their blood pressure below 140/90 mm Hg.

Fresh Hypertension Treatment Guidance

Hypertension Defined and Measured

Hypertension (HTN) is the leading modifiable risk factor for morbidity and mortality (GBD 2019 Risk Factors Collaborators); HTN is linked to dementia (He et al 2025), and each additional 20-mm Hg of systolic blood pressure (BP) or 10-mm Hg of diastolic BP is associated with a doubling of the risk of stroke or cardiovascular mortality (Lewington et al 2002). Luckily, we have a veritable cornucopia of  tools to treat hypertension, so treating HTN is a (yummy?) low hanging fruit of making our patients healthier for longer!

The first challenge of treating HTN is accurately measuring your patient’s BP. If you don’t accurately measure blood pressure, you are managing your patients’ HTN using a random number generator. We could talk for episodes about getting an accurate BP reading–and we have. To get an accurate reading in the office, let patients rest for at least five minutes before averaging at least two readings taken at least a minute apart. Measure the BP with the correct size cuff on a bare arm at the level of their heart, and be sure that their back is supported and their legs are uncrossed with their feet flat on the floor. Things like cuff size (Ishigami et al 2023) and arm position (Liu et al 2024) really do affect the reading! Patients should avoid caffeine, exercise, and smoking for 30 minutes before the reading and have an empty bladder. Your patient should not talk during the reading, but be sure to tell them their BP verbally and in writing when you are done. The use of automated devices is recommended with the only exception being measuring the blood pressure of patients with persistent irregular heart rhythms (HTN Guidelines). 

Home blood pressure monitoring now has a COR 1a recommendation (HTN Guidelines); having the patient monitor their own blood pressure can help reinforce the patient-physician commitment to co-management of HTN and lead to better outcomes (Tucker et al 2017). For home BP monitoring, use a device approved by ValidateBP.org and have your patient get two readings in the morning and two in the evening 3-7 days a week. Dr. Cohen reminds us to have your patients wait two weeks after medication changes before monitoring for an effect. The 2025 HTN guidelines caution against using cuffless monitoring devices like smart watches because these are not yet accurate enough to guide treatment (Stergiou et al 2022). The Apple Watch 10’s FDA clearance is not based on it being a good way to measure BP; they list a sensitivity of 41% on their documents which means it is telling 59% of users that they do not have hypertension when they do, worse than a coin flip! Stick to a device vetted by ValidateBP.org.

	Systolic BP		Diastolic BP
Normal	< 120 mm Hg	and	< 80 mm Hg
Elevated	120 to 129 mm Hg	and	< 80 mm Hg
Stage 1	130 to 139 mm Hg	or	80 to 89 mm Hg
Stage 2	≥ 140 mm Hg	or	≥ 90 mm Hg

Normal BP is defined as a systolic BP < 120 mm Hg and a diastolic BP < 80 mm Hg. A systolic BP between 120 and 129 mm Hg is considered elevated. Stage 1 hypertension starts with a systolic BP between 130 and 139 mm Hg or a diastolic BP from 80-89. Once a patient has a systolic BP of 140 or higher or a diastolic BP of 90 or higher they have stage 2 hypertension. A systolic BP of 180 or higher with a diastolic BP of 120 or higher without end organ damage is severe hypertension, and should be treated with oral antihypertensives and close follow up. The phrase hypertensive urgency is no longer in use–it’s severe hypertension now–and PRN oral or IV antihypertensives should not be used to acutely lower blood pressure (HTN Guidelines).

Hypertension Treatment

History

In addition to an accurate blood pressure reading, don’t forget a good patient history that touches on medications (like NSAIDs, pseudoephedrine, and tizanidine), sodium intake, risk factors for sleep apnea, and substances like alcohol. The 2025 guidelines now note abstinence from alcohol as optimal (HTN Guidelines). 

(Candy) Sidebar: Excessive licorice intake can cause apparent mineralocorticoid excess from the glycyrrhizic acid found in some licorice. This syndrome is marked by hypokalemia, metabolic alkalosis, and hypertension (Awad et al 2020).

Testing

Patient evaluation should include a complete blood count, serum electrolytes, serum creatinine, lipid profile, hemoglobin A1C, thyroid-stimulating hormone, urinalysis, urine albumin-to-creatinine ratio, and an ECG. Laboratory testing should be repeated at least every year. Optional testing for cardiac biomarkers (high-sensitivity troponin, B-type natriuretic peptide), echocardiography, and/or coronary artery calcium may be useful for further risk stratification. There is a new COR 2b recommendation to screen for primary aldosteronism in anyone with stage 2 hypertension, and a COR 1 recommendation for testing in individuals with resistant hypertension regardless of their potassium level. Don’t worry about stopping HTN medications in these patients before testing unless they are on a minerocorticoid receptor antagonist(HTN Guidelines). 

Systolic BP		Diastolic BP
Normal	< 120 mm Hg	and	< 80 mm Hg
Elevated	120 to 129 mm Hg	and	< 80 mm Hg
Stage 1	130 to 139 mm Hg	or	80 to 89 mm Hg
Stage 2	≥ 140 mm Hg	or	≥ 90 mm Hg

Medication

Medication should be initiated in all adults with stage 2 hypertension (>140/90 mm Hg). For stage 1 hypertension (≥130/80 mm Hg), patients with existing CVD, diabetes, or CKD should be started on antihypertensives. Use the PREVENT-CVD score to risk stratify patients with stage 1 hypertension; patients with an estimated 10-year risk of CVD based on PREVENT should be started on antihypertensive agents. Patients with stage 1 hypertension without these factors can try 3-6 months of lifestyle intervention before initiating medications. The BP goal of <130 mm Hg systolic BP  is also for little old ladies to prevent mild cognitive impairment and dementia (COR 1 LOE A; HTN Guidelines).  Dr. Cohen is cautious of aggressively treating patients who she does not feel like would have been included in the original trials.