2025 Hypertension Guidelines: What’s New in the U.S. and Canada

By Dr. Abdelwahab Arrazaghi, MD, FABIM, FRCPC

High blood pressure management is entering a new chapter. Both the American College of Cardiology/American Heart Association (ACC/AHA) in the U.S. and Hypertension Canada have released their updated 2025 guidelines—and there are some important shifts that clinicians, patients, and healthcare teams should know about.

Here’s a clear breakdown of what’s new, what’s consistent, and what to watch for.

Big-Picture Shifts in Both Countries

Despite differences in detail, both U.S. and Canadian guidelines are moving in the same direction:

• Accuracy first: Stronger emphasis on proper in-office blood pressure measurement and confirmation with home (HBPM) or ambulatory monitoring (ABPM).

• Risk-guided treatment: Greater use of overall cardiovascular risk to guide drug initiation and treatment intensity.

• Combination therapy upfront: Both recommend starting with two medications—ideally as a single-pill combination (SPC)—for most patients.

• Systems thinking: Lifestyle, access to care, and adherence are now integrated into algorithms, recognizing that numbers alone don’t tell the whole story.

  
  

Highlights from the U.S. (ACC/AHA 2025)

The U.S. guidelines replace the 2017 version with a more detailed, risk-based approach.

• Risk tool: The new PREVENT risk calculator replaces the older pooled cohort equations. It now guides when to start medications and how aggressive treatment should be.

• Diagnosis: Categories remain (normal, elevated, Stage 1, Stage 2) but with stricter emphasis on technique. Resistant hypertension now triggers earlier testing for primary aldosteronism—even if potassium is normal.

• Treatment thresholds & targets: Generally unchanged from 2017—start meds at ≥130/80 mmHg if risk is high; ≥140/90 otherwise. Most patients should target <130/80 mmHg.

• Therapy: Begin with two agents (ACEi/ARB + thiazide-type diuretic or DHP-CCB). Structured algorithms are outlined for resistant hypertension, and renal denervation is mentioned as an option in select refractory cases.

• Special notes:

  • Pregnancy: Treat at ≥140/90 with labetalol, nifedipine ER, or methyldopa; avoid RAAS blockers.

  • CKD/Diabetes: Albuminuria testing is now part of the standard baseline labs.

  • Obesity: Recognizes the role of GLP-1 medications as adjuncts to weight and metabolic management (not first-line BP drugs).

    
    

Highlights from Canada (Hypertension Canada 2025)

The Canadian approach is more pragmatic and primary care–focused, with just nine core recommendations.

• Definition & confirmation: Hypertension is now defined as ≥130/80 mmHg using validated devices under ideal conditions. Diagnosis should be confirmed with HBPM or ABPM whenever possible.

• When to treat:

  • Start at ≥140/90 mmHg.

  • Start earlier (130–139 systolic) if high-risk (e.g., existing CVD, diabetes, CKD, Framingham ≥20%, or age ≥75).

• Treatment target: Almost everyone should aim for SBP <130 mmHg (if tolerated). There’s no fixed diastolic target, but DBP between 70–90 is considered acceptable.

• How to treat: Begin with a low-dose SPC (ACEi/ARB + thiazide-type or DHP-CCB). If still uncontrolled, step up to triple therapy, then add spironolactone.

• Lifestyle: Strong recommendations for sodium reduction, potassium-rich diets (when safe), weight reduction, aerobic exercise, smoking cessation, and moderated alcohol intake. GLP-1 therapies are noted as an option for weight management in appropriate patients.

  
  

Practical Differences You’ll Notice

• Risk assessment: U.S. adopts the PREVENT calculator; Canada relies on a high-risk conditions list plus Framingham score.

• Definition of hypertension: U.S. retains 2017 categories; Canada explicitly defines it at ≥130/80 with confirmation.

• Targets: U.S. keeps <130/80 risk-based; Canada simplifies to a universal SBP <130.

• Resistant hypertension: U.S. broadens aldosteronism screening and considers renal denervation; Canada sticks to spironolactone as step 4.

• Pregnancy: U.S. guidance is detailed; Canada generally defers to obstetric guidelines.

  
  

Bottom Line

Both sets of 2025 guidelines are pushing toward more personalized, risk-based care and earlier, more consistent treatment. For clinicians, the key takeaways are: measure accurately, think risk-first, start strong with combination therapy, and integrate lifestyle and patient context into every decision.

For patients, the message is simple: blood pressure control is about more than just numbers—it’s about risk reduction, prevention, and whole-person health.