Blood pressure thresholds and targets: the 2025 guideline, not JNC 8

Study cases written by our editors, not BPS items. The real BCPS exam is computer-based multiple choice, answered in order with no going back.

1. Case 01

   A 46-year-old man has home BP readings averaging 136/84 mm Hg. BMI is 24 kg/m²; he has no diabetes, CKD, or ASCVD, and his PREVENT 10-year CVD risk is 4%. He walks 150 minutes per week, drinks one beer daily, and eats a diet low in fruits and vegetables and high in processed foods. Which plan is most appropriate?

   1. AOption A: Take calcium 1,200 mg daily and recheck BP in 1 year
   2. BOption B: Start amlodipine 5 mg daily and recheck BP in 1 month
   3. COption C: Adopt a DASH eating pattern; recheck BP in 3–6 months
   4. DOption D: Start a lisinopril/chlorthalidone single-pill combination

   Pick an option: the verdict and a note on every option open here.

   Best answer: C.

   He has stage 1 hypertension with PREVENT risk below 7.5%, so the 2025 AHA/ACC guideline calls for 3–6 months of lifestyle change first; the DASH pattern gives the largest single lifestyle reduction in SBP (about 11 mm Hg in hypertensive adults) and targets his actual diet. Starting a drug now is indicated only if risk is ≥7.5% or BP stays ≥130/80 after lifestyle change. Two-drug single-pill therapy is for stage 2 (≥140/90), and calcium supplements are not an evidence-based BP intervention.

   A

   Calcium supplements are not an evidence-based BP intervention, and waiting a year leaves stage 1 hypertension unmanaged.

   B

   With PREVENT risk under 7.5% and no diabetes, CKD or ASCVD, stage 1 hypertension gets a lifestyle trial first, not a drug.

   C

   Correct. Stage 1 BP with PREVENT risk below 7.5% means 3–6 months of lifestyle change, and DASH targets his actual diet.

   D

   A two-drug single pill is for stage 2 hypertension (140/90 or higher); 136/84 does not qualify.

2. Case 02

   A 48-year-old man with type 2 diabetes is seen in clinic. Average home BP over 2 weeks is 158/94 mm Hg, confirmed in the office. Labs: eGFR 42 mL/min/1.73 m², urine albumin-to-creatinine ratio 450 mg/g, K 4.4 mEq/L. He takes metformin 500 mg twice daily and empagliflozin 10 mg daily and no antihypertensive. Which antihypertensive regimen is most appropriate to start?

   1. AOption A: Amlodipine/hydrochlorothiazide single-pill combination
   2. BOption B: Lisinopril plus losartan
   3. COption C: Lisinopril/amlodipine single-pill combination
   4. DOption D: Lisinopril monotherapy

   Pick an option: the verdict and a note on every option open here.

   Best answer: C.

   BP of 158/94 mm Hg is stage 2 hypertension, for which the 2025 AHA/ACC guideline recommends starting two first-line classes, preferably as a single-pill combination, and the albuminuria makes a RAS inhibitor one of the two. Lisinopril alone is the tempting choice but is unlikely to reach the goal of below 130/80 mm Hg from this starting point. Amlodipine/hydrochlorothiazide omits the RAS inhibitor his albuminuric CKD needs, and lisinopril plus losartan is dual RAS blockade, which increases hyperkalemia and AKI without renal benefit.

   A

   This pair leaves out the RAS inhibitor that his albuminuric CKD needs.

   B

   Combining an ACE inhibitor with an ARB raises hyperkalemia and AKI risk without renal benefit.

   C

   Correct. Stage 2 BP calls for two first-line classes in one pill, and albuminuria makes a RAS inhibitor one of them.

   D

   From 158/94, a single drug is unlikely to reach a goal below 130/80; two agents are recommended at stage 2.

3. Case 03

   A 52-year-old man takes chlorthalidone 25 mg, amlodipine 10 mg, and olmesartan 40 mg daily; pill counts confirm adherence and home BP averages 148/92 mm Hg. K is 4.1 mEq/L, SCr 0.9 mg/dL, and he has no paroxysmal headaches, palpitations, or cushingoid features. Before further therapy changes, which diagnostic test is most appropriate?

   1. AOption A: Overnight dexamethasone suppression test
   2. BOption B: 24-hour urine metanephrines
   3. COption C: Plasma aldosterone-to-renin ratio
   4. DOption D: Renal artery duplex ultrasound

   Pick an option: the verdict and a note on every option open here.

   Best answer: C.

   He has resistant hypertension, and the 2025 AHA/ACC guideline recommends screening every such patient for primary aldosteronism—the most common secondary cause—regardless of the potassium level; testing before adding spironolactone avoids MRA interference with the result. Metanephrines are for suspected pheochromocytoma (paroxysmal symptoms). Renal artery imaging is for clues such as flash pulmonary edema or a large creatinine rise on RAAS blockade, and dexamethasone suppression is for suspected Cushing syndrome.

   A

   Dexamethasone suppression screens for Cushing syndrome, and he has no cushingoid features.

   B

   Metanephrines look for pheochromocytoma, which is suggested by paroxysmal headaches and palpitations he does not have.

   C

   Correct. Every patient with resistant hypertension should be screened for primary aldosteronism, whatever the potassium.

   D

   Renal artery imaging is for specific clues such as flash pulmonary edema or a creatinine jump on RAS blockade.

4. Case 04

   A 58-year-old man with hypertension takes lisinopril 20 mg and amlodipine 10 mg daily. Office BP has been 146/88, 144/86, and 148/90 mm Hg at three visits. His home readings with a validated upper-arm cuff (2 readings morning and evening for 7 days) average 124/76 mm Hg. He has no orthostatic symptoms, and labs are normal. Which action is most appropriate?

   1. AOption A: Add chlorthalidone 12.5 mg daily
   2. BOption B: Increase lisinopril to 40 mg daily
   3. COption C: Add spironolactone 25 mg daily
   4. DOption D: Continue the current regimen

   Pick an option: the verdict and a note on every option open here.

   Best answer: D.

   Properly measured home BP below 130/80 mm Hg with higher office readings indicates a white-coat effect, and home or ambulatory values better predict cardiovascular risk, so his therapy is working and should not be intensified. Adding chlorthalidone or increasing lisinopril would treat office numbers and risk hypotension. Spironolactone is the add-on for true resistant hypertension, which requires uncontrolled out-of-office BP.

   A

   Well-measured home BP is already below 130/80; adding a diuretic would treat office numbers and risk hypotension.

   B

   Raising lisinopril chases a white-coat effect rather than true uncontrolled BP.

   C

   Spironolactone is for true resistant hypertension, which requires uncontrolled out-of-office readings.

   D

   Correct. Home readings average 124/76, so office elevations reflect a white-coat effect and the current regimen is working.

5. Case 05

   A 58-year-old woman with type 2 diabetes, left ventricular hypertrophy and UACR 90 mg/g takes lisinopril 40 mg daily and amlodipine 10 mg daily with confirmed adherence. Home BP averages 142/88 mm Hg. Labs: K 4.1 mEq/L, Na 139 mEq/L, eGFR 64 mL/min/1.73 m². Which medication should be added?

   1. AOption A: Spironolactone 25 mg daily
   2. BOption B: Chlorthalidone 12.5 mg daily
   3. COption C: Metoprolol succinate 50 mg daily
   4. DOption D: Losartan 50 mg daily

   Pick an option: the verdict and a note on every option open here.

   Best answer: B.

   With BP above the goal of below 130/80 mm Hg on an ACE inhibitor plus a dihydropyridine CCB, the next step is the third first-line class, a thiazide-type diuretic, and chlorthalidone is preferred. Spironolactone is the tempting choice, but it is the fourth-line agent for resistant hypertension, defined as uncontrolled BP on three drugs including a diuretic. Losartan adds dual RAS blockade with hyperkalemia and AKI risk, and a β-blocker has no compelling indication here and does not regress LVH as well.

   A

   Spironolactone is the fourth agent for resistant hypertension, which is defined only after a thiazide-type diuretic is on board.

   B

   Correct. On an ACE inhibitor plus a dihydropyridine CCB, the next first-line class is a thiazide-type diuretic, and chlorthalidone is preferred.

   C

   A beta-blocker has no compelling indication here and regresses LVH less well than first-line agents.

   D

   Adding losartan to lisinopril is dual RAS blockade, raising hyperkalemia and AKI risk without benefit.

6. Case 06

   A 60-year-old man has apparent resistant hypertension (home BP 152/94 mm Hg) on chlorthalidone 25 mg, amlodipine 10 mg, and olmesartan 40 mg daily. He reports never missing doses, and his refill records show the bottles are picked up on time. Before adding spironolactone, the team wants objective confirmation that he is actually taking the medications. Which method is most appropriate?

   1. AOption A: Urine or blood drug-level adherence testing
   2. BOption B: Pharmacy refill records reviewed alone
   3. COption C: Pill counts at each of the next clinic visits
   4. DOption D: Morisky medication adherence questionnaire

   Pick an option: the verdict and a note on every option open here.

   Best answer: A.

   Detecting the prescribed drugs or their metabolites in urine or blood (LC-MS/MS) objectively shows whether he is ingesting them, and partial or complete nonadherence is found in a large share of patients labeled resistant. Self-report questionnaires overestimate adherence. Refill records and pill counts show possession, not ingestion—bottles can be filled on time and pills discarded or taken irregularly.

   A

   Correct. Finding the drugs or metabolites in urine or blood shows whether they are actually being taken, which refills cannot prove.

   B

   Refill records show the bottles were collected, not that the pills were swallowed.

   C

   Pill counts measure possession too; tablets can be discarded or taken irregularly between visits.

   D

   Self-report questionnaires tend to overestimate adherence and give no objective proof.

7. Case 07

   At a community pharmacy health fair, a 45-year-old patient with no medical history and no medications has a blood pressure of 148/94 mm Hg on two readings taken 5 minutes apart. Which recommendation is most appropriate?

   1. AOption A: Advise lifestyle changes and recheck only if headaches occur
   2. BOption B: Diagnose stage 2 hypertension and start a single-pill combination
   3. COption C: Reassure the patient and recheck at next year’s health fair
   4. DOption D: Refer for confirmation with home or ambulatory BP readings

   Pick an option: the verdict and a note on every option open here.

   Best answer: D.

   USPSTF recommends confirming an elevated screening BP with measurements outside the clinical setting (home or ambulatory monitoring) before a hypertension diagnosis and treatment. Starting two-drug therapy on screening readings from one visit risks treating white-coat hypertension. Waiting a year, or rechecking only if symptoms appear, ignores that hypertension is usually asymptomatic and that 148/94 mm Hg needs prompt confirmation.

   A

   Hypertension is usually silent, so waiting for headaches lets an elevated BP go unconfirmed and untreated.

   B

   A diagnosis and two-drug therapy based on screening readings at one visit risk treating white-coat hypertension.

   C

   148/94 mm Hg needs prompt confirmation, and a year’s delay is far too long.

   D

   Correct. A high screening BP should be confirmed out of the office, by home or ambulatory readings, before a diagnosis is made.