Video

PUPC Recap—Raising the Bar, Lowering the Pressure: What's New in Resistant Hypertension

Keith Ferdinand, MD, FACC, FAHA,
Isabel Valdez, PA-C, MPAS


Key Highlights:

  • The 2025 ACC/AHA blood pressure guidelines emphasize earlier initiation of treatment, including medication for high-risk patients with cardiovascular disease, diabetes, or chronic kidney disease.
  • Combination therapy, preferably 2 agents in 1 pill, was highlighted as a strategy to improve adherence and blood pressure control in patients with readings of 140/90 mmHg or higher.
  • The experts emphasized that blood pressure control may help reduce risks beyond cardiovascular disease, including kidney disease, cognitive dysfunction, and dementia.
  • Persistent gaps include clinical inertia, limited implementation of team-based care, and the equitable application of guideline-based care across patient populations.

The 2025 ACC/AHA blood pressure guidelines may change how clinicians initiate and intensify hypertension treatment, according to insights presented by Isabel Valdez, PA-C, MPAS, and Keith Ferdinand, MD, FACC, FAHA, FASPC, FNLA, at Practical Updates in Primary Care (PUPC) 2026. The presenters emphasized earlier intervention for patients with elevated cardiovascular risk, greater use of combination therapy for patients with blood pressure of 140/90 mmHg or higher, and the importance of achieving blood pressure control to reduce the risk of cardiovascular disease, kidney disease, stroke, cognitive dysfunction, and dementia.

Additional Resource: https://www.hmpglobalevents.com/pupc 

Transcript

Isabel Valdez, PA-C, MPAS: Hi, I'm Physician Assistant Isabel Valdez, Associate Professor in Internal Medicine at Baylor College of Medicine in Houston, Texas.

Keith Ferdinand, MD, FACC, FAHA, FASPC, FNLA: Hi, I'm Dr. Keith C. Ferdinand, Professor of Medicine and the Gerald S. Berenson Endowed Chair in Preventive Cardiology at the Tulane University School of Medicine in New Orleans, Louisiana.

Consultant360: What are some of the key themes of your presentation?

Valdez: One of the most important topics we discovered, we really did focus on the 2025 ACC/AHA blood pressure guidelines. These guidelines just came out last year, and I think they're slowly rolling out to many primary care providers. We're getting new, new guidance as to how aggressive to be with our blood pressure management with folks. So, really, truly, clearly important to get ourselves up to date with the 2025 guidelines.

Ferdinand: The guideline was very important because it noted 130/80 mmHg as the initiation of therapy in those persons who are low risk, 3-6 months of lifestyle changes, but realistically, in most patients, even when they start a good lifestyle pattern, it's hard to maintain. So, after that, even in low-risk patients, medicines are needed. Of course, for the first time, we use the prevent risk calculator for high-risk persons with otherwise cardiovascular disease, diabetes, and chronic kidney disease—they need medicines, even if they're not 140/90 mmHg.

Consultant360: Why is this topic particularly relevant right now?

Valdez: Blood pressure is one of the most modifiable risks that patients can control. They can control their diet, they can control whether or not they smoke, they can control their physical activity, and all of those are also key components that help manage their blood pressure, and by managing their blood pressure, we can actually lower their risk of multiple issues, including stroke. We know now that blood pressure can lead to, or can contribute to, dementia. So, that's another step that patients can take towards reducing the risk of dementia, while also just caring for themselves and reducing the risk of kidney disease along the line.

Ferdinand: The effects of blood pressure are throughout the cardiovascular system. I think most clinicians are aware it leads, if uncontrolled, to hypertension, leading to heart failure, heart attack, strokes, chronic kidney disease, but for the first time, as has been pointed out, we now focus on dementia and cognitive dysfunction. So, treating blood pressure will help older persons not getting to the situation where they're dependent on others to take care of them because of dementia.

Consultant360: What are the most important takeaways from your session?

Valdez: So, one of the most important takeaways for me is the importance of starting patients on combination therapy, preferably 2 agents in 1 pill, when their blood pressure is still 140/90 mmHg. In fact, this very morning I saw that in one of my patients had 2 separate agents in 2 separate pills, and their blood pressure was still over goal. So, by helping the patient reduce polypharmacy by taking those 2 ingredients, those 2 agents in 1 pill, we're, hopefully, going to get to better adherence and better blood pressure control.

Ferdinand: I agree. Combination therapy was a big leap forward for those persons who are 140/90 mmHg and above, but also the guideline now suggests less than 130/80 mmHg, but ideally less than 120, if it can be achieved. We know that lowering blood pressure not only protects the cardiovascular system, but also the brain. It's an important leap forward for us to focus on not only protecting against heart attacks, strokes, heart failure, and kidney disease, but also now cognitive dysfunction and dementia. I think that's the biggest takeaway.

Consultant360: What gaps in our knowledge do you feel still remain on this topic?

Valdez: I think there continues to be a gap in implementing care, and aggressively, because there's this sense of clinical inertia that once you start something, you stick to it. If you always use the same agent, the same ACE inhibitor, or the same ARB, and you're not getting your patient to goal. Some folks just add more and more therapy rather than optimizing their care within that same class. So, this clinical inertia is one of those gaps that we still have to get past, and by implementing these new 2025 guidelines, I think we can inch ourselves towards getting rid of that inertia, so that we can help our patients get to goal.

Ferdinand: One of the biggest gaps is getting team-based care as a reality. It's not just enough for the magic 15-minute doctor's visit, but it's the team, registered nurses, advanced practice nurses, physician associates, the medical assistants, the patient, and the patient's significant others, all should work together as a team to control blood pressure. This is a condition the patient lives with 24/7, and the magic 15-minute visit is just not enough.

Consultant360: Is there any additional information you would like to share?

Valdez: One last thing I'd like to share is that uncontrolled blood pressure is not always a question of adherence or non-compliance, but it could actually be that the patient may have another medical condition, a secondary reason. So, getting your patients in when they're not at goal and doing additional diagnostics to see if there's a secondary source cause for their hypertension [is important]. Now we are used to thinking about hypertensive urgency, but that has gone away with the new guidelines. Now, if a patient has severe hypertension and they don't have any target organ damage, we can manage that in the outpatient setting instead of rushing the patient to the ER.

Ferdinand: Yeah, I think one of the biggest gaps is also making sure that we apply this guideline equally across all populations. We know disparities are real, and they're persistent and troubling. So, the guideline, the best practices, should be applied to all patients, regardless of race, ethnicity, sex, gender, socioeconomic status, geography, ability, or disability.

 

This transcript was edited for clarity.

 

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