Debate on the 2025 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Emphasis on Defense Against the BP Threshold and Why We May Not Get There Easily

Elevated blood pressure (BP) is the most important noncommunicable disorder worldwide. Finding and effectively managing elevated BP is the single greatest public health benefit we can accomplish, as it will reduce premature death and enable patients to live longer free of the disabilities that target organ damage inflicts on the brain, heart, kidneys, and legs. Hypertension guidelines are an invaluable source of information on how to detect elevated BP, how to evaluate people for situations where hypertension is a symptom of other disorders, and how to apply the various treatments that lower BP effectively in patients. Determining the point at which treating high BP is more likely to result in benefit than harm is a marriage of science and art. There is no right answer to what clearly constitutes hypertension when using a systolic or diastolic BP to define it. The science shows the mathematics behind the reduction of BP and the number of lives saved and target organs preserved. The art comes into play when a decision is made that, when a systolic or diastolic BP exceeds a certain level, it becomes reasonable to intervene at that point with treatment. Caregivers play an important role in monitoring and educating patients with hypertension—especially in the detection of unintended effects of treatment, such as excessive BP lowering, symptomatic hypotension, and impacts on laboratory tests and well-being. Nonadherence to prescribed therapies is a barrier to effectively managing chronic disorders like hypertension. Having a solid foundation in the science behind the guidelines and recognizing that the application of guidelines requires some clinical judgment gleaned from balancing the risks and benefits of treatment in each individual patient, is the basis for healthy exchanges of ideas, like this pro and con series which discusses the science and furthers the art. This review has taken the con side of several issues in the latest American College of Cardiology/American Heart Association 2025 Hypertension Guidelines.