Guidelines no longer agree on what counts as high blood pressure

Below 120/80 mmHg, every major guideline in the world agrees: that is normal blood pressure. Above it, they stop agreeing. The 2025 American guideline classifies 130–139/80–89 mmHg as stage 1 hypertension — a diagnosis — while the 2024 European Society of Cardiology guideline calls the overlapping band of 120–139/70–89 mmHg "elevated blood pressure" and reserves the word hypertension for readings above 140/90 mmHg [s1].

The reading is the same. What differs is the name attached to it and, more consequentially, the number at which a guideline says medication should start.

The three classifications, side by side

A review published in the Journal of Clinical Medicine in October 2025 set the three most recent sets of recommendations against each other [s1]. The 2025 AHA/ACC guideline classifies blood pressure as normal (below 120/80 mmHg), elevated (systolic 120–129 mmHg), stage 1 hypertension (130–139/80–89 mmHg) and stage 2 hypertension (140/90 mmHg or above) — the same categories the 2017 American guideline introduced [s1]. The 2024 ESC guideline uses three categories instead of four: non-elevated blood pressure below 120/70 mmHg, elevated blood pressure from 120–139/70–89 mmHg, and hypertension above 140/90 mmHg [s1]. The 2023 European Society of Hypertension guideline keeps the older European scheme: optimal below 120/80, normal at 120–130/80–85, high–normal at 130–140/85–90, and grade 1 hypertension at 140–160/90–100 mmHg [s1].

Most national guidelines in the Asia–Pacific region set the diagnostic threshold at an office reading of 140/90 mmHg or above [s1].

Where the disagreement actually bites

Naming a reading is not the same as treating it, and the treatment thresholds diverge less than the labels suggest. The ESC and ESH guidelines both recommend starting blood-pressure-lowering medication at 140/90 mmHg irrespective of age [s1]. The 2025 AHA/ACC guideline does the same for adults aged 18 to 79 — but drops the threshold to 130/80 mmHg for people with established cardiovascular disease, diabetes or chronic kidney disease, or an estimated 10-year cardiovascular risk of 7.5% or higher on the PREVENT calculator [s1]. The ESC has a parallel lower threshold at 130–139/80–89 mmHg, applied after three months of lifestyle intervention, for people with established cardiovascular disease, organ damage, diabetes, moderate-to-severe kidney disease, familial hypercholesterolaemia, or a 10-year SCORE2 risk above 10% [s1].

In other words, both systems reserve drug treatment at the lower reading for people whose overall risk is already elevated. The American guideline gets there by calling the reading a disease; the European one gets there by calling it a risk factor. The population captured is similar but not identical, because the risk calculators and their cut-offs differ.

Targets once treatment has started diverge again. The ESC recommends aiming for 120–129/70–79 mmHg where treatment is well tolerated, with more lenient targets — for example below 140 mmHg systolic — considered for people with pre-treatment symptomatic orthostatic hypotension, aged 85 or older, with moderate-to-severe frailty at any age, or with a predicted lifespan under three years [s1]. The 2025 AHA/ACC target is below 130/80 mmHg [s1].

The trial that moved the American threshold

The 2017 reclassification, which the 2025 guideline explicitly retains, rested heavily on SPRINT [s1] [s2]. That trial randomised 9,361 people with a systolic pressure of 130 mmHg or higher and raised cardiovascular risk, but without diabetes, to a systolic target below 120 mmHg or below 140 mmHg [s3]. At one year, mean systolic pressure was 121.4 mmHg in the intensive group and 136.2 mmHg in the standard group [s3]. The trial was stopped early, after a median 3.26 years, because the primary composite outcome occurred at 1.65% per year with intensive treatment against 2.19% per year with standard treatment (hazard ratio 0.75, 95% CI 0.64 to 0.89), and all-cause mortality was also lower (hazard ratio 0.73, 95% CI 0.60 to 0.90) [s3].

SPRINT is also the source of the counter-argument. Serious adverse events of hypotension, syncope, electrolyte abnormalities and acute kidney injury or failure were all more common in the intensive group, though injurious falls were not [s3]. A guideline committee weighing the same trial can reasonably land on a different threshold depending on how heavily it weights those harms, and how much it worries about labelling tens of millions of people as having a disease.

The 2025 AHA/ACC document states that it "retires and replaces" the 2017 guideline [s2]. Its literature search ran from December 2023 to June 2024, covering evidence published since February 2015 [s2].

What all of them agree on

Three things are common ground, and they matter more for an individual reading than the threshold argument does.

First, a single office measurement is not a diagnosis. Both the ESC and the AHA/ACC guidelines recommend confirming suspected hypertension with out-of-office measurement — ambulatory monitoring or home monitoring — before treating [s1]. The 2025 American guideline also says it is reasonable to use an automated oscillometric device rather than the older auscultatory method for office readings [s1].

Second, screening should be routine. The ESC recommends opportunistic screening at least every three years for adults under 40 and at least annually for adults 40 and over [s1].

Third, the underlying problem is not definitional. The World Health Organization puts global hypertension prevalence at 33% among adults aged 30 to 79, with 44% of that group unaware they have it [s1]. Whichever threshold a country adopts, unawareness is the larger gap.

None of the above is a rule for any particular reader. Which threshold applies to a given person, and whether a reading calls for monitoring, lifestyle change or medication, depends on age, other conditions and calculated risk — a judgement that belongs with a clinician who has the full picture.