The latest JACC focus issue on the 2025 ACC/AHA High Blood Pressure (BP) Guideline dives into the implementation failures that have led to hypertension going undiagnosed, untreated and inadequately controlled in the U.S. and charts a path forward where uncontrolled hypertension can become medicine's next "never event."

"Hypertension's story is one of scientific triumph shadowed by implementation failure," writes JACC Editor-in-Chief Harlan M. Krumholz, MD, SM, FACC, in an Editor's Page. "Severe uncontrolled hypertension should be unthinkable in modern medicine."

What's the solution? Krumholz lays out a coordinated approach involving 1) reliable detection protocols, 2) simplified treatment algorithms, 3) affordable medications, 4) accountability systems and 5) patient and community empowerment.

The commentaries in this focus issue from leading hypertension authorities explore the evidence, rationale behind the latest recommendations and clinical application. In an accompanying Editor's Note, Erica S. Spatz, MD, MHS, FACC, writes, "Our hope at JACC is that they challenge and refresh your thinking about hypertension…A reboot is overdue, and this guideline, together with the expert insights that accompany it, deliver exactly that."

Highlights from some of the 24 viewpoints in the latest JACC focus issue are below.

Why Can't We Get There? Understanding Persistent HTN in Real-World Care: A viewpoint by Yuan Lu, DSc, FACC, identifies real-world contributors to persistent hypertension broken up into three domains: failure to initiate/intensify treatment, failure to implement treatment and nonresponse to treatment. Lu writes that "improving hypertension control at scale will require system-level strategies that align with how persistent hypertension presents in practice," including technology-enabled targeting, community-integrated outreach and team-based simplification.

The Systolic BP Intervention Trial – 10 Years Later: A viewpoint authored by Jackson T. Wright Jr., MD, PhD, and Mahboob Rahman, MD, MS, provides context into how the SPRINT trial, which found "a clear benefit of the lower [systolic BP] target on cardiovascular outcomes and mortality, very suggestive benefit in slowing decline in cognition, and safety on renal outcomes," prompted the ACC and AHA to redefine the level for high BP diagnosis in the 2017 hypertension guideline. "We now have substantial evidence on the risk of elevated BP from extensive observational data, agents that are safe and effective in reducing BP and preventing the morbidity and mortality of hypertension from trials, and now the optimal BP targets for treatment," they write.

Home BP Monitoring: Getting It Right This Time: According to a viewpoint from Jordana B. Cohen, MD, MSCE, et al., home BP monitoring (HBPM) is valuable in providing "important BP management and prognostic information distinctive from office BP visits." The 2025 High BP Guideline "strengthens and elaborates" recommendations relating to out-of-office BP monitoring. "Ideally, this emphasis on the vital role of HBPM in BP management, along with guidance on how and when to use HBPM, will help to improve its accessibility and drive its widespread implementation in routine clinical practice," note Cohen and colleagues.

Treating With the Goal in Mind – The Role of Low-Dose Combinations: According to a viewpoint by Nelson Wang, PhD, and Anthony Rodgers, PhD, "The recommendation to start with dual therapy for most individuals is a welcome step forward and aligns with other major guidelines such as the European Society of Cardiology 2024." They write that meaningful improvement of hypertension control in the U.S. requires "a fundamental shift in our treatment approach, one that begins with the end goal in mind."

Policy Agenda to Close the HTN Gap: A viewpoint by Karen E. Joynt Maddox, MD, MPH, FACC, Ezekiel J. Emanuel, MD, PhD, and Robert A. Berenson, MD, notes that "Although many scientific advances in medical and procedural treatments of hypertension are highlighted in the new high BP guideline, the policy context surrounding hypertension lags behind." Efforts to date have centered around measuring and rewarding BP control through pay-for-performance programs. They call on federal health policy to make hypertension a priority through multistakeholder efforts, create a payment environment that rewards hypertension control, facilitate the use of emerging technologies for hypertension, encourage cross-sector collaboration and preserve access to preventive care.

Read more viewpoints in the full issue. For more on the guideline, visit the High Blood Pressure Guideline Hub.

Clinical Topics: Prevention, Hypertension

Keywords: Blood Pressure, Practice Guideline, Health Policy, Hypertension, Treatment Failure