1. Thiazide diuretics (e.g., hydrochlorothiazide, chlorthalidone)
2. ACE inhibitors (e.g., lisinopril, enalapril)
3. ARBs - Angiotensin Receptor Blockers (e.g., losartan, valsartan)
4. Calcium channel blockers (e.g., amlodipine, diltiazem)

• In Black patients (without CKD), thiazide diuretics or CCBs are generally preferred as initial therapy over ACE inhibitors/ARBs, based on trial data showing better outcomes.
• ACE inhibitors and ARBs are not combined together due to increased risk of hyperkalemia and renal impairment.
• In patients with CKD or proteinuria, an ACE inhibitor or ARB is preferred regardless of race, for renal protective effects.
• In patients with diabetes, ACE inhibitors/ARBs are often favored, especially with albuminuria.
• Beta-blockers are no longer considered first-line for uncomplicated hypertension (based on outcome data showing less stroke reduction compared to other agents), but remain first-line when a compelling indication exists (e.g., post-MI, heart failure with reduced ejection fraction, arrhythmia control).
• Treatment often starts with monotherapy for stage 1 hypertension, but many guidelines now favor starting with a two-drug combination (e.g., ACE inhibitor/ARB + CCB or thiazide) for stage 2 hypertension or higher baseline BP.

Latest Guideline: 2025 AHA/ACC Guideline

• The US guideline now aligns diagnostic and treatment thresholds at 130/80 mmHg (previously staged differently), moving toward a "lower is better" philosophy.
• For high-risk patients, the guideline gives a Class I, Evidence A recommendation to target SBP < 120 mmHg (informed by SPRINT and the STEP trial in elderly hypertensives).
• Older adults (75-85+), if robust or mildly frail, are now recommended the same <130/80 mmHg target regardless of age - a shift from prior age-stratified, more lenient targets.
• For frail older patients, AHA/ACC 2025 emphasizes shared decision-making rather than a fixed numerical target.

• Strong push toward early combination therapy (single-pill/fixed-dose combinations) rather than sequential monotherapy titration - though real-world data presented at ACC 2026 showed only 13.8% of patients actually receive fixed-dose combinations, revealing a large implementation gap.
• First-line agent classes remain thiazide/thiazide-like diuretics, ACE inhibitors, ARBs, and calcium channel blockers, consistent with prior guidance.

International comparison

• ESC 2024 / ESH 2023 (Europe): Slightly more conservative than the US approach; ESH2023 and ESC2024 recommend individualized, less aggressive targets in frail patients (140-150 mmHg and <140 mmHg respectively).
• JSH 2025 (Japan): The most aggressive target globally - home BP goal <125/75 mmHg, office target 130/80 mmHg - and explicitly supports intensive control in older adults based on its own meta-analysis (SPRINT, STEP trials).
• Acute stroke BP management is well-aligned across guidelines: BP should be lowered to <185/110 mmHg before IV thrombolysis and kept <180/105 mmHg for the first 24 hours (2025 AHA, 2024 ESC, 2023 ESH, 2025 JSH all agree). JSH 2025 specifically favors IV micro-drip calcium channel blockers (nicardipine, diltiazem) as first-line in this setting.

Bottom line differences from older (2017/2018) guidelines

1. Treatment targets are lower and more uniform across age groups.
2. Combination therapy from the start is now favored over stepwise monotherapy.
3. Home/ambulatory BP monitoring is weighted more heavily in target-setting (especially in JSH2025).
4. Frailty and shared decision-making are explicit considerations rather than being left to clinical judgment alone.