On The Cover
Loren Bonner
Hypertension is the most common and significant risk factor for diseases of the heart, kidneys, and brain, yet in the United States, it continues to be an uphill battle getting patients to goal. Out of over 122 U.S. adults living with high BP, only a quarter of them have it under control, according to the latest 2025 statistics from the American Heart Association (AHA).
There’s always more work to do—both for clinicians and patients.
Armed with new evidence, AHA along with the American College of Cardiology Joint Committee on Clinical Practice Guidelines, released an updated guideline on managing BP. The full guideline, published August 14, 2025, is available in AHA’s journal Circulation.
Changes to the guidelines, which were last updated in 2017, include reducing the risk of cognitive decline and dementia through early treatment for high BP and recommendations for managing high BP before, during, and after pregnancy.
Treating BP to prevent mild cognitive impairment and dementia is now a Class I recommendation, which means early treatment with a goal systolic BP of less than 130 mm Hg for adults with high BP to prevent cognitive impairment and dementia.
In the new guidance, experts also emphasize the use of AHA’s new PREVENT risk calculator to estimate CVD risk.
“The most significant update to me is the change to the PREVENT calculator from the ASCVD risk calculator,” said Courtney Doyle-Campbell, PharmD, from Western New England University’s College of Pharmacy and Health Sciences. “PREVENT estimates both 10-year and 30-year cardiovascular risk and incorporates social determinants of health factors.”
For hypertension management, this is primarily useful when determining whether to treat stage 1 hypertension, according to Doyle-Campbell.
Daniel Jones, MD, guideline chair, and dean and professor emeritus of the University of Mississippi School of Medicine, said the PREVENT risk calculator is based on a larger and more diverse group of patient data than previous calculators. It also considers social drivers of health.
Pharmacists can find the calculator—which combines measures of cardiovascular, kidney, and metabolic health—on AHA’s website and use it to counsel patients about their individual risk for CVD.
Overall, the guideline authors stress that high BP can be managed and prevented with lifestyle behaviors, such as healthy eating, staying physically active, maintaining a healthy weight, and managing stress, combined with early treatment with medication to lower BP, if necessary.
Medications
Little has changed in the 2025 recommendations for most clinical situations as it relates to medications.
The same four classes of medications previously recommended for initial BP therapy remain the same: thiazide-type diuretics, long acting dihydropyridine calcium antagonists, ACEs, and ARBs.
The guideline authors recommend a change in managing stage 1 hypertension (130–139 mm Hg systolic/80–89 mm Hg diastolic). For patients with an increased 10-year CVD risk, a history of heart disease or stroke, CKD, or diabetes, medication should be initiated with lifestyle modifications. For others, the recommendation is a 3- to 6-month trial of lifestyle therapy with the addition of medication if goal BP is not met.
“More patients with stage 1 hypertension will be encouraged to use medication to lower BP,” said Jones.
Also, the new goal of at least less than 130 mm Hg systolic BP with encouragement to 120 mm Hg will require more medication, according to Jones.
2025 guideline takeaways for pregnancy
For the evaluation and management of resistant hypertension and hypertension during pregnancy, AHA said the change in guidance reflects growing evidence that tighter BP control for some individuals during pregnancy may help to reduce the risk of serious complications.
For patients who are pregnant and who have chronic hypertension, defined as high BP before pregnancy or diagnosed before 20 weeks of pregnancy, the new guideline recommends treatment with certain medications when systolic BP reaches 140 mm Hg or higher and/or diastolic BP reaches 90 mm Hg or higher.
The target is now less than 140/90 mm Hg for hypertension in pregnancy, which is lower than older thresholds.
Guideline authors also recommend that patients with high BP who are planning a pregnancy or are pregnant receive counseling about the potential benefits of low-dose aspirin (81 mg/day) to reduce the risk of preeclampsia.
Team-based care
As hypertension targets have changed over time, pharmacists can help patients understand why the goals have shifted and how the changes are rooted in new evidence.
“Hypertension is a condition where the connection between pathophysiology and treatment strategies is clear and easy to explain, making pharmacists’ expertise especially valuable,” said Doyle-Campbell. “Pharmacists stay current with evolving research and guidelines, and they can clearly explain to patients the rationale behind therapy choices. This education improves adherence and trust.”
The 2025 guideline continues to reinforce the importance of team-based care to improve BP control, and research has consistently shown that pharmacists contribute to lowering BP, with national guidelines specifically recommending a team-based approach for this reason.
“We know there is a shortage of primary care providers and current recommendations call for frequent follow-up, especially with stage 2, and at least monthly for stage 1, until BP is controlled, but in practice, this is difficult to achieve, and patients often go months without adjustments. By incorporating a pharmacist into the care team, clinics can improve time to BP control and quality of care,” said Doyle-Campell.
Managing treatment-resistant hypertension was the primary focus of the hypertension clinic that Doyle-Campell ran for years in Springfield, MA.
“During the initial consult, I would begin by evaluating potential underlying causes such as white coat hypertension, renal artery stenosis, or sleep apnea,” said Doyle-Campbell. The clinic, housed within a patient-centered medical home, provided ambulatory BP monitoring, allowing her to assess 24-hour control and confirm true resistance.
Once resistant hypertension was established, which is defined as uncontrolled BP despite three medications—including a diuretic—Doyle-Campbell said next steps are guided by patient profile and current evidence.
The first step is ensuring the use of a thiazide-type diuretic rather than hydrochlorothiazide, she said. “If additional therapy is required, a mineralocorticoid receptor antagonist, such as spironolactone or eplerenone, is typically the preferred fourth-line agent,” Doyle-Campbell said.
“Many providers are hesitant to initiate this class due to concerns about potassium or renal function, but in my experience, spironolactone has been particularly effective for many patients,” she said.
When spironolactone is not an option, or if further therapy is needed, Doyle-Campbell said the choice depends on the individual case. Options may include a b-blocker, a clonidine patch, or hydralazine.
“If patients fail to improve or show rapid decline in renal function, I would refer them to nephrology for further management,” Doyle-Campbell said.
Authors of the 2025 guideline recommend screening for primary hyperaldosteronism, especially in patients with resistant hypertension, even when hypokalemia is not present.
If left unaddressed, treatment-resistant hypertension increases the risk of cardiovascular incidents and end-stage renal disease.
“I hope we see more opportunities for pharmacists in hypertension care, especially as it relates to managing treatment-resistant hypertension,” said Dave Dixon, PharmD, from the VCU School of Pharmacy.
BP control in the community
Just like ambulatory care pharmacists, community pharmacists possess the same clinical skills to help patients with hypertension, said Doyle-Campbell.
“Community pharmacists are the most accessible [health care provider], and if their skills were better utilized, blood pressure control rates could improve substantially,” said Doyle-Campell.
The 2018 landmark barbershop study remains one of the best examples of how this is lived out. That study, published in NEJM, found that 63.3% of Black men with uncontrolled hypertension who were part of a cluster-randomized trial saw a drop in BP of less than 130/80 mm Hg when specialty-trained pharmacists led interventions in Black-owned barbershops. Only 11.7% of the control group achieved a reduction.
“The barbershop study remains a powerful reminder of what happens when pharmacists bring their expertise into trusted community spaces like barbershops,” said Nana Entsuah-Boateng PharmD, from the University of California Irvine. “Its relevance today is a call for us to continue seeking out and partnering with community anchors such as barbershops, churches, and/or neighborhood centers and use these trusted spaces as sites for health empowerment.”
Entsuah-Boateng and colleagues published a paper in the November– December issue of JAPhA about the pharmacist’s role in providing culturally competent care, and they propose policy recommendations to improve disparities in BP outcomes.
“Despite advancements in chronic disease management, blood pressure control among the African American population remains unoptimized,” said Entsuah-Boateng. “African Americans continue to carry a disproportionate burden of high blood pressure, but we know that when pharmacists bring their expertise directly into patient care through education, medication optimization, and community partnerships, lives are changed and patient outcomes are improved.”
One policy solution they propose is incentivizing telehealth and making sure pharmacists are reimbursed for the clinical services they provide through telehealth.
“Telehealth is a chance to amplify pharmacists’ reach and impact,” said Entsuah-Boateng. “With the right incentives and support, pharmacists can monitor blood pressure, adjust therapies, and counsel patients in real time, eliminating barriers like transportation and inflexible schedules.”
Remote physiologic monitoring (RPM) has also been shown to improve BP control—especially with pharmacists involved.
Based on an analysis of 5,057 patients who used remote pharmacist–physician collaborative care including RPM with lifestyle, medication, and care gap management, intervention compared to controls had higher rates of BP control across all racial subpopulations. Results, which were published in the Journal of General Internal Medicine on September 19, 2025, also showed that patients in the intervention versus control group had higher odds of medication adherence, lower rates of inpatient and emergency department utilization, and no significant changes in primary care visits. ■
Reinforcing BP criteria
“Implementation is always a challenge,” said Dave Dixon, PharmD, from the VCU School of Pharmacy.
While a systolic BP goal of less than 130 mm Hg was initially recommended in the 2017 hypertension guideline—and reinforced in the new guideline—this goal is not necessarily widely adopted by all clinicians, said Dixon.
“This leads to confusion among our patients, so I think we have to continue to help disseminate appropriate messaging around what the treatment goal is,” he said.
BP criteria remain the same as the 2017 guideline:
- Normal BP is <120/80 mm Hg.
- Elevated BP is 120–129 mm Hg/>80 mm Hg.
- Stage 1 hypertension is 130–139 mm Hg/80–89 mm Hg.
- Stage 2 hypertension is ≥140/90 mm Hg. ■
Home BP monitoring musts:
- Use a validated cuff and the correct cuff size to fit arm.
- Do not smoke, consume caffeine, or engage in exercise 30 minutes before taking a measurement.
- Sit in a supported chair with legs uncrossed, feet on the floor.
- Place cuff on a bare arm, directly above bend of elbow, with arm supported at heart level.
- Take the measurement when relaxed, not while talking, watching TV, or looking at one’s phone. ■
Reinforcing correct home BP measurement
“Accurate BP monitoring, especially out-of-office monitoring, remains a critical area where pharmacists can help by educating patients on proper BP measurement and helping patients identify an appropriate, validated home BP monitor,” said Dave Dixon, PharmD, from the VCU School of Pharmacy.
A January 2025 study published in Hypertension investigated whether Australian patients followed AHA’s home BP measurement guideline recommendations accurately. Of 350 middle-aged patients, 90% reported measuring their BP while seated, and 77% said they position the BP cuff on their bare arm rather than over clothing—indicating that most patients understand generally how to position themselves and their BP cuff to obtain an accurate BP reading.
Only one-third of study participants reported receiving home BP measurement education. Patients generally indicated that they only received vague verbal instructions on appropriate home BP measurement from a health care provider.
AHA recommends that patients avoid smoking, exercising, and consuming caffeinated or alcoholic beverages 30 minutes prior to home BP measurement. Additionally, AHA directs patients to sit upright with uncrossed legs and their arm resting comfortably on a flat surface at heart level while the reading is being taken. Patients should wrap the BP cuff just above the bend of their elbow on bare skin and take two separate BP readings 1 minute apart both in the morning before taking any medication and in the evening just before going to sleep.
A December 2024 study published in JAMA Internal Medicine found that commonly used arm positions—arm resting on the lap or unsupported on the side—resulted in substantial overestimation of BP readings and may lead to misdiagnosis and overestimation of hypertension. Authors noted that these nonstandard positions. ■
Time of day should not dictate when to take BP medication
Does the time of day—morning or evening—make a difference with BP medication administration?
Findings from the BedMed trial found that when 3,357 Canadian patients with hypertension were followed for a median of 4.6 years, they experienced no difference in death or major cardiovascular events when they took their BP medication at bedtime.
“The clinical implications are that patients can decide for themselves when they use their blood pressure medication,” said lead author Scott Garrison, MD. “A lot of people like to take all of their medications at the same time to remember them better. Blood pressure medications can be flexible in that way.”
Similarly, if a patient has an adverse effect that seems timing related, they can adjust the timing to minimize it, Garrison noted, such as taking calcium channel blockers at bedtime to reduce pedal edema.
The 2022 TIME trial demonstrated similar findings to BedMed: Patients experienced no cardiovascular benefit from switching BP medications to bedtime. Also, there was no suggestion of harm.
Garrison and colleagues carried out a separate but related trial of the same intervention, known as BedMed-Frail, in nursing home patients.
“We did this because frail older adults are often poorly represented in randomized trials, and they are a group for whom risks and benefits could have differed meaningfully,” Garrison said.
Hypothetically, Garrison said decubitus ulcers, falls or fractures, and cognition—especially in those with vascular dementia—may have worsened.
“However, we found the same results in BedMed-Frail—no obvious benefit to bedtime prescribing and no signs of harm,” he said.
“Together BedMed and BedMed-Frail make us pretty confident in saying that there doesn’t appear to be any harm in taking antihypertensives at bedtime,” said Garrison. “There just also doesn’t seem to be any benefit.”
BedMed was published May 12, 2025, in JAMA, and BedMed-Frail in JAMA Network Open on May 12, 2025.
These more recent findings are in contrast to those from the MAPEC and Hygia trials. Results from the 2010 MAPEC trial found a 61% reduction in a composite of death and other cardiovascular outcomes for patients who switched at least one BP medication to bedtime. The same authors went on to publish results of a second trial, Hygia, in 2020 that similarly reported a 45% reduction in a composite of major adverse cardiovascular events. ■