193 - Elevate Your Guideline Knowledge, Not Your BP: The New 2025 Hypertension Guidelines

Welcome to Helix Talk, an educational podcast for healthcare students and providers covering real-life clinical pearls, professional pharmacy topics, and drug therapy discussions. This podcast is provided by pharmacists and faculty members at Roslyn Franklin University College of Pharmacy. This podcast contains general information for educational purposes only. This is not professional advice and should not be used in lieu of obtaining advice from a qualified healthcare provider. And now on to the show. Welcome to Helix Talk, episode 193. I'm your co-host, Dr. King, and I'm excited to have Dr. Shervastava or Dr. S. with us here today, who is a frequent contributor on Helix Talk, so Dr. S. Welcome. Thank you. I'm very excited to be here. And the title of today's episode is "Elevate Your Guideline Knowledge, Not Your Blood Pressure, The New 2025 Hypertension Guidelines." So Dr. S. why have you joined us today to talk about this important topic? Hypertension is so prevalent. Any pharmacists I would say working in most practice settings are coming across people who have hypertension, have family members who have hypertension, who knows maybe even have hypertension themselves. And so knowing that these new guidelines have come out, it's really important to know what are the experts saying. And for the listeners, you know, we had 2017 guidelines. And then the new 2025 ACCHA guidelines were recently published. So in this episode, we're going to review some of the key concepts that kind of came to the forefront for us in terms of what was important from those 2025 updates. But of course, there's a lot more than what we can cover in today's episode. So in our show notes, again, this is episode [email protected]. You can get a link for the full guidelines and take a look for yourself. But we're here to summarize them for you. So Dr. S, why don't we start with thinking about a new way to assess cardiovascular risk? So way back in 2013, we had what was called the pooled cohort equations or PCE. For more than a decade now, this was the equations that we use to determine what is the tenure risk of someone having a future first ASCVD event. And it sounds like this has now been updated. Is that right? Yes. So there is a new equation that we're using. It's called prevent, prevent stands for predicting risk of cardiovascular disease events. It was developed by the American Heart Association in 2023. What's interesting is from a performance standpoint, it's actually not dramatically better than the pooled cohort equations from 2013. The predictive nature is fairly similar. It's a little bit better. The prevent equations typically give you a number about two to four percentage points lower than what you would have gotten from the 2013 equations. But that's actually not the main reason why they chose to come up with the prevent equation. One of the things that it does is that it takes race out of the equation. And so we are able to really look to see what are the things that impact risk. And so what prevent has added is a social deprivation index. And it's based on zip code and it really goes into the social determinants of how that could definitely influence risk. And it's things like, you know, based on your zip code, you might be in a food desert and then you have less access to high quality food. Or based on the socioeconomic status of that zip code, those individuals might have less access to health care. Or whatever it is kind of the constellation of socioeconomic factors that may play a role is now incorporated based on zip code within the prevent equation. The other big change was that it was derived, the prevent equations were derived from a much larger data set. So it's more representative of multiple races within the US and multiple different communities that is just going to be a better representation than what the 2013 equations used. It also has a separate other features, if I may. And so it predicts not only a CVD, so am I in stroke, but it also gives the risk of heart failure to first tool to combine cardiovascular kidney and metabolic health measures. And also the age range change. So it can be used in people between the ages of 30 to 39. And as you know, we are seeing just more chronic conditions in a younger age set. So it's nice to have a tool that can predict the risk in that age as well. And you know, the PCE did include down to 40 years old, so we're just included in additional 10 years of people who can have their risk predicted. The other component that they added was EGFR and BMI. And these are pretty easy to capture metrics that do predict either cardiovascular risk or risk of heart failure. And then they also added in some optional metrics as well. So urine, I'll be able to crack and ratio would be an example or even hemoglobin A1C. So if those values are available, you can plug those in, but if they're not available, you don't have to have them to come up with that risk. And you may be wondering, where can you use this calculator? You can just go to the webpage and they have an online calculator that you just plug these numbers in and it will calculate the risk for you. So another section of the guidelines was lifestyle changes. And Dr. Essay knows that this is one of your areas of passion, right? Yes, absolutely. There's so much we can do by thinking about what lifestyle parts our health behaviors can influence chronic conditions. We've always had alcohol limits and those limits remain same. So the recommendation is an optimal goal would be no alcohol, but recognizing that that might not be a good fit for everyone. One goal could be if someone drinks quite a bit that you have a 50% reduction in daily intake or that you maintain the kind of the maximum recommended amount which is one serving per day and women of alcohol or two servings per day of alcohol and men or a number lower than those thresholds. So now let's talk about caffeine. This is probably something prevalent in many of our lives. So the maximum recommended amount for anybody is 300 milligrams per day. But if somebody presents with severe uncontrolled hypertension, that maximum is one cup of day. What's interesting about the caffeine thing is that even in other disease states, we generally haven't seen reasonable amounts of caffeine being associated with health problems. So for example, A-fib. This has come up a lot in terms of the hypothesis that if you over-indulge in caffeine that you're more prone to A-fib or more prone to having a rapid ventricular rate with your A-fib. And the evidence is actually not there surprisingly. And part of it could be that if you know that caffeine gives you palpitations that you just don't drink that much, right? And I also want to add, caffeine is everywhere these days. You know, it's not just your cup of coffee anymore. It is in water. It is in bars. And so as you're talking to your patients, you know, making sure that you ask the questions because we want to think beyond the traditional way people were getting caffeine, they may actually be cutting to pretty high amounts by having different types of caffeine. And then dietary sodium is also mentioned again. The thresholds are really not different from the previous guidelines, but it's worth just talking about. So the recommendation is less than 2,300 milligrams per day, but the ideal threshold, which is extremely difficult for many patients, is less than 1,500 milligrams per day of dietary sodium. And let's just talk about what 2,300 milligrams looks like. It is just one teaspoon. So you can see how easily that can be included in somebody's diet. If somebody has a lot of salts and is not ready to cut down to these numbers, even decreasing by 1,000 milligrams has shown to have positive impact. And to put a number to 1,000 milligrams is like not eating a can of soup, right? So it's definitely doable for a patient to substitute that soup for some fresh vegetables or a soup that they make on their own where they don't add a lot of sodium to it. So you might be wondering, what do we do for flavor? If salt's out of the equation, what do we have? There are other recommendations. We can use potassium-based salts. It needs to be used only in patients, though, if they're not taking aces or herbs, as aces or herbs can cause hyperculemia, or if they are using potassium substitutes for that, just making sure we know where their values are. And also in people with CKD, you want to be careful with potassium-based salts. For those patients, we can recommend other herbs and other flavorings to help offset the flavor of salt. We should note, because if tried the potassium-based salt substitutes, they usually don't taste very good. It has a very metallic taste, so it would be a very patient-specific thing if they even tolerate it in the first place. If they like it, then it's a great recommendation. And then just tell your patient, sometimes it takes time when you're going from a heavy salt diet to not having salt at first that taste change feels very dramatic, but over time, and pretty quickly, actually, the taste buds change on your tongue, and you can really get to enjoy food with less salt. And then the last lifestyle recommendation is a no-change, as well from the 2017 guidelines, which is exercise. So the recommendation is 90 to 150 minutes per week of moderate to vigorous intensity exercise, so that would be like a brisk walk. I think a good way to think about this is something that gets you a little bit out of breath or a little bit sweaty, so it can't be a super casual walk, although that may be helpful. It's not going to dramatically drop your blood pressure, so if the goal is to have a lifestyle change that decreases your blood pressure, you need to have some degree of intensity to that exercise every single week on a regular basis. I'm bringing it to your patients in a manageable way, right? 15 minutes, twice a day, five days a week can get us to that number, and so just finding ways where it feels more reasonable versus just telling them, hey, go to 150 minutes a week. So then the next kind of chunk of new guideline in the 2025 guidelines is when are you going to start a new anti-hypertensive medication for a patient. One recommendation, which is new, is that when the systolic blood pressure is at that stage two, so we're talking more than 140 systolic or more than 90 diastolic, the recommendation is that you're going to start no matter what. And that has been consistent. We'll talk later about how many drugs to start, but for stage two hypertension, you definitely start drug therapy. And then in stage one hypertension, so that's when the blood pressure is greater than or equal to 130 to 139, and then diastolic 80 to 89. This is where things changed a little bit, so we definitely start in people who have clinical CBD cardiovascular disease and people who have diabetes or CKD, and then this is where the prevent risk comes into play. And so if somebody's risk when they're in stage one hypertension is 7.5 percent or more, we want to go ahead and start the medication. Dr. Kim, what should we do if their risk is not 7.5 percent? So if they're less than 7.5 percent and they're still in that stage one realm, the recommendation now is try three to six months of lifestyle changes, and if those don't work, then you start drug therapy. And this is actually a change from the 2017 guidelines. So historically, if you were below whatever the threshold was, the recommendation was to not start drug therapy period. So if you're an otherwise healthy person with a low ASCVD risk in stage one, you would never be indicated for into hypertensive therapy. But now the recommendation is to go ahead and start after lifestyle modifications have failed for that patient. So some other changes, Dr. S, were previously we didn't have carve outs for if you had diabetes or CKD that you should definitely start at stage one. It was just based on your ASCVD risk. So at this point, if you have those comorbidities of clinical ASCVD, diabetes, chronic kidney disease, now it doesn't matter what your ASCVD risk is, the recommendation is to go ahead and start drug therapy. And then we're also seeing people who may have been considered to be low risk in stage one. So let's take a person who's 32 without any comorbidities. If they were in stage one, they would not have started on drug therapy. And we would have just said, hey, we can wait there young, but we now know that they can also benefit alongside lifestyle modifications with drug therapy. And, you know, Dr. S, I kind of dug into this a little bit more because it is interesting that you would recommend drug therapy and someone who, let's say, has a 1% risk in the next 10 years of having a heart attack or stroke. And where this evidence comes from is called the Prever Prevention Study, where they took this patient population. So low risk stage one hypertension. And they gave those patients either an anti-hypertensive or nothing. And what they found was their blood pressure got better if they got a drug, which is kind of the obvious outcome. But then they had some surrogate markers on an EKG for left ventricular mass or left ventricular hypertrophy that suggested that less left ventricular hypertrophy occurred. So it's not a clinical outcome. It's a surrogate marker. So I'd still say it's a little bit weaker evidence for this recommendation, but it is at least important to note that there is a signal that starting drug therapy earlier might prevent bad things from happening down the road, even in lower risk patients. And then the last change was the ASCVD threshold. So way back in 2017, the threshold we talked about was 10% and now it is 7.5%. And this aligns with the lipid guidelines as well where the set and threshold is 7.5%. So kind of nice that we're all in agreement of like what is a higher risk of ASCVD and we aren't arguing about 7 versus 7.5 versus 10%. Now basically all the guidelines recognize above 7.5% is typically the threshold where we're going to do something different. So now we know when to start the medications, which ones should we be starting? The good news is that there really is no change from the list of the four first line therapies that we've had in the past. So that's your thiozides, dihydroperidine, calcium channel blockers, ACE inhibitors and ARPs. The one big change though is back in 2017, there was a separate guideline recommendation stating that if the patient was black that you should favor a thiozide or calcium channel blocker first. And at the time that recommendation was based on the thought that black patients had lower levels of run and injuritins and aldosterone driving their hypertension. And really in the last five years we've kind of made a big change or shift in terms of race based medicine. So now that recommendation is absent from the 2025 guidelines. And then when we think about how many we should start, if somebody has stage one hypertension, we start with one medication. With stage two, the guidelines now do say to use two medications, ideally in a single pill combination. I know I have some thoughts about that. I know you have some thoughts about that, Dr. Kane, so I'd love to hear yours. Yeah, so it's one of those things that single pill combinations are really nice from a compliance standpoint and kind of ease of use standpoint. But I take a little bit exception to this because I do think that there's value when you initiate therapy and picking one med and then picking a second med. So that temporally you know if there's a side effect that happens that you can associate it with whatever med was recently started or increased in dose. And then once a patient is at a stable regimen, I think it's a great idea to kind of combo it up. But I do wonder if it's a good idea to start that combo early, especially with hypertension because there's no rush, right? Like of course we want to treat hypertension, but whether they get to their gold blood pressure in three months or nine months, the actual risk that we're looking at between three and nine months is basically the same. This is a chronic condition where the risks associated with hypertension occur over years, not in months. So I don't know that there's a huge rush to get them to their gold blood pressure. And I absolutely agree, especially a lot of times when patients are coming in, they're often hesitant and worried about starting medications and just working with the patient to figure out, well, what might be the ideal combination to start you on and what would make you feel more comfortable. I agree with Dr. Can I typically would prefer to start one often. And if I am going to start to to keep them separate, but it was very fascinating to me that throughout the guidelines, they really, really were pushing single pill combinations into the point where they actually have some really nice tables in the guidelines showing you, what are the single pill combinations in the US market? Is it generic or not? Because to be honest, I don't know that off the top of my head, I know a couple of them, like my centripetal hydrochloroethyazide is very frequently prescribed, but I don't know as many of the other combination products like Amelodoping combo products, for example. So it is nice as a resource to see what is available in the market. We should also note that the recommendation that stage two gets two drugs is new ish from the 2017 guidelines. So back in 2017, those guidelines said that if you're more than 20 over 10 millimeters of mercury above your goal, which basically meant if you were if your blood pressure was greater than 150 over 90 that that would justify initiating with two drugs. Now that threshold is drops to 140 over 90 that sage to goal. So a slight difference, but still notable in terms of a change from 2017. Absolutely. Then they had a new section as well. All of us pharmacists will love this strategy to improve medication adherence. And so it talked about things like the single pill combination to help patients with adherence. It also talked about favoring medications that have once daily options. They also mentioned education by a pharmacist and integration of shared decision making. And I like this because I'm a huge fan of shared decision making and I think our single combination product thing is a great example of that. So you have patient A that is really hesitant to take any blood pressure medications. You should probably be gentler in terms of how you initiate therapy with that patient versus someone who's extremely worried about their blood pressure. And they want it as low as possible yesterday. Right. So that shared decision making where you present kind of the risks and benefits of different treatment approaches unless it's a clear black and white you literally have a conversation about what would you prefer what do you think is best and you provide the patient with the evidence or the recommendations that help them make a more informed decision and conjunction with you versus you being kind of the end all to be all and saying this is what we're going to do and there's no input from the patient. Absolutely. And another example of that could be we know lifestyle can reduce systolic blood pressures anywhere from two to five six seven points in some patient. So they may come to you and just got diagnosed with hypertension and they're like, do I really have to start two meds. I know I'm at 142. But what do I do? And so that's another great conversation to have sure our guidelines say go ahead and start to the minute. But that patient's not in front of the guidelines are in front of you. And so having that conversation can really be helpful. Love it. And I mean, just to highlight that again, and we see this so often when we teach early learners of you have a threshold of seven and a half percent or 140 over 90 that changes how you manage that patient. But there is literally no clinical difference between a blood pressure of one thirty nine and one forty one. And yet you would treat those very differently with a one or two drug combo, right. So that's where your decision making really plays an important role of hey, do you want to start a stat and you're at 7.4% versus 7.5% or you're at 7.6% do you want to like hold off on the stat and try some lifestyle changes. It's not like these thresholds like are a black and white thing is just to give clinicians a general guidance of hey, like around this point, you should probably be thinking about something different than if you were dramatically below or dramatically about that point. And once we have these conversations and we start these medications, obviously our patients should be coming back. So how often is the question. So it really does depend. So one, it starts with where their blood pressure is at typically and so if there's somebody who has normal blood pressure less than 120 over 80 unless something dramatically changes in their risk, they can be seen every year and their blood pressure well not seen every year, but their blood pressure can be reassessed every year. For people that started lifestyle changes, so you know you have your people with elevated hypertension or stage one with a lower ascvd risk and they're starting the lifestyle, we would want to see them in three to six months. And that makes sense because like if you tell me to change my diet and start exercising, even if I do a really good job of that, it's going to take a while for that to really take a fact, right. So let's say that we're thinking about exercise causing weight loss and that weight loss causes your blood pressure to be better people don't lose a bunch of weight after like a week worth of exercising, right. So you need to give it time before you say whether that thing worked or not. In terms of drug therapy, once a patient is started on drug therapy, you really need to reassess their blood pressure and anything relevant to the drug that you started at a maximum one month after you've done the thing. So if you add a thiazide, four weeks later, you should be seeing the patient for a blood pressure check and then potentially getting labs for them. In other disease states, so heart filler would be a good example, we actually do it earlier. So one to two weeks and the reason for that is largely because we're starting a bunch of other drugs or combination of drugs at the same time. So maximum of one month for hypertension, but just note that other disease states you might get it a little bit earlier. And then once you're at goal and you know it is patients at their goal, they can be reassessed every three to six months. And then speaking of a goal blood pressure, basically the guidelines are not that different for most patients. So we've retained the same blood pressure goal of less than 130 over 80 basically for a default for most patients. What is new though is the guidelines do say that some patients may consider a goal of less than 120 over 80 quote when feasible. And they suggest that this more stringing goal might be more appropriate for those with higher prevent scores. So more than seven and a half percent or those with diabetes. I would say that this is pretty controversial because we do have some data showing failed trials in terms of more stringing goals and certain patient populations where it wasn't very effective. Or we have data where it was effective, but some of the benefit was offset by the side effects of having a lower blood pressure. So I do think it's important to note that the guidelines are not saying less than 120 over 80 for everyone. They're saying when feasible and it may be considered, which is a kind of a pro con shared decision making kind of approach, but definitely everyone has a blood pressure goal at least less than 130 over 80 if not the 120 over 80. And I just like to re-emphasize that because I know in previous guidelines or there's other that if you're an older adult maybe we should keep that goal a little bit higher and really these guidelines are again emphasizing less than 130 over 80 for most people. And then in terms of preferred therapies, we have some changes, but not that many. So among patients with diabetes, the recommendation is an ACE or an ARB for your initial preferred therapy recognizing that the best evidence is actually for patients with diabetes who have CKD. So in EGFR, less than 60 or who have Abuminaria. So you're in Abuminocratin ratio exceeding 30, but they also acknowledge that even if your Abuminocratin ratio is a little bit low so they don't have Abuminaria, adding that ACE or ARB might be helpful to prevent them from getting protein area in the future. But most of the data is with patients who currently have some degree of Abuminaria or CKD plus diabetes. And then even with patients without diabetes, if they have CKD, which they define as EGFR less than 60 or Abuminaria again above 30, we should be starting an ACE or an ARB in these patients as well. And the reason is to decrease cardiovascular disease and delay the progression of kidney disease. And then kind of entrusting, I'm not sure I fully agree with the guidelines here, they say among patients who have a history of stroke, that the best evidence is with three of the four therapies, so Thiazide, ACE or ARB. And they don't necessarily say that calcium channel blockers don't work, but they just acknowledge that there's less evidence in patients with stroke for calcium channel blockers versus the other three therapies. What doesn't mean that it's bad is that we don't have as much evidence supporting the calcium channel blocker in post stroke patients. I'm hesitant to put too much emphasis on that because I don't want to downplay the importance of, you know, if a patient needs to have a calcium channel blocker and they've had a stroke in the past, they still should have a calcium channel blocker because there's still going to be other benefits of treating them with a direct therapy beyond the stroke benefit. And then we have recommendations for resistant hypertension. Dr. Kane, wasn't there a podcast on this? Dr. Patel and I did one, a Helix talk episode 190 where we talked about resistant hypertension. So we've definitely covered this before. And just as a highlight from that episode, resistant hypertension means that you've maxed out three drug classes as much as possible or as tolerated. And then the guidelines go into, if your EGFR is 45 or higher, that Spurnal Actone or another Mineralo-Cortecord receptor antagonist should be added. And then if your EGFR is less than 45 or they don't tolerate an MRA, they basically say anything else is fine. There's a variety of different therapeutic options available. But the most important thing here is kind of what we covered in episode 190 that typically for that resistant hypertension patient, an MRA like Spurnal Actone, in most cases is what you're going to want to add for that patient. And this is of course after looking to see if there's any considerations with adherence and making sure it's not white coat, maybe having them check their blood pressure at home. So we want to do all the things before we make that determination that it is resistant hypertension. And if it is, then we know what treatment to use. And then another exciting area of the 2025 guidelines was looking at hypertensive emergency. And again, this is defined as a systolic greater than 180 or a diastolic greater than 120 where you have target organ damage, meaning that you have damage to one of your organs caused by that really high blood pressure. The management plan is basically the same, so there was no change. Acknowledging that there are some disease states that have lower blood pressure goals. So for example, less than 120 over 84 a Arctic dissection, but they've kept basically the same approach as the older guidelines, which is in the first hour you want to reduce mean arterial pressure by 15 to 25% and then you want to achieve a blood pressure around 160 over 100 in the 2 to 6 hour period after they present. And then generally want to get to a somewhat normal blood pressure within a couple days. The big exciting thing though is that they finally eliminated the term of hypertensive urgency. This was a misnomer. So hypertensive urgency was defined as having that high blood pressure, but not having any target organ damage. And the problem with the term is that urgency sounds like you should do something really exciting for the patient and there's actually more harm than good when you do that. So the new term for this is just severe hypertension, which is much more appropriate. There are guidelines already in existence that kind of cover this, but it's nice to see that the 2025 hypertension guidelines acknowledge the misnomer of a term. And again to highlight what you should not do, you should not give a print or anti hypertensive, you do not aggressively treat severe hypertension, formerly hypertensive urgency, and you don't send them to the hospital or admit them to the hospital. Just because of their blood pressure, they have to have target organ damage for you to really aggressively manage them. And then we have some of our unique patient population, so we will just go through a few that are mentioned in the guidelines. So one is people with acute spontaneous interest, cerebral hemorrhage, there is a new recommendation. So if the initial blood pressure is 150 to 220, the goal, systolic blood pressure is 130 to 140 for seven days. This recommendation is new in the evidence for optimal blood pressure goal after acute intercranial hemorrhage is controversial if you can go into that. Yeah, so there's a cup. There's two main trials that have looked at this. And generally speaking, we just don't know what the right blood pressure goal is for these patients. We do know that if we go less than 130, that that's harmful, but we also know if we let them go above 160, that's also harmful. So kind of picking a number between there, depending on their presenting blood pressure, acknowledging that the evidence isn't super clear. The guidelines also say that if for these intercranial hemorrhage patients, if their blood pressure is really high, more than 220, that keeping them at a systolic of 160 to 180 is reasonable and definitely avoiding less than 130, really in all patients, but especially those patients, because that's associated with harm. And then in terms of acute ischemic stroke, the main change is whether you do endovascular therapy for these patients. So kind of a new thing in stroke care is literally going in with a retrievable stent and pulling out the clot mechanically as opposed to just giving TPA like alteplase or connect to place. So the new guidelines just acknowledge that if you give TPA or you do endovascular treatment, your blood pressure goal should be what it's always been less than 185 over 110 before you do the intervention and then less than 180 over 105 for 24 hours after they receive TPA or endovascular treatment. There is no change to the guidelines in terms of if you don't do TPA or endovascular treatment, the goal blood pressure and this always sounds so crazy, the goal blood pressure if you don't do TPA is less than 220 over 120. That's really high. They have tried trials where they lowered it a little bit and it didn't matter, meaning it didn't improve clinical outcomes. If you're above 220 over 120, the recommendation is to lower it by about 15% for a day, but we do know that if we lower it too much or too quickly, that it can be harmful. So for the stroke patients that don't get TPA, we actually let them have what's called permissive hypertension where we let them run high for a couple of days because it is associated with perfusing the areas of the brain that have been damaged because auto regulation is usually impaired for these patients. And then pregnancy. Most of the pregnancy recommendations are new, as we all know, hypertension impacts, both the maternal and perinatal morbidity and mortality. And so really figuring out the best way to treat people who are pregnant without causing harm and what goal blood pressure should be as important. So the preferred therapies are now libato law and niphatopenexcel. They may be wondering why and where did methyldobago. Methyldopa isn't recommended anymore because it's less effective based on some meta analyses. It is safe to use and you could use it if you needed a second or a third therapy. It just is not as effective as libato law or niphatopenexcel in those meta analyses. The medications we should not use, of course, are aces and arbs. And that should be in both people that are pregnant or are planning to become pregnant as well. We should be working with them to change their therapies. We also shouldn't be using direct run-in inhibitors, nitroprocyde or MRAs to make sure to avoid fetal harm. And then they also have a section for a clampia, preeclampsia. So again, thinking about hypertensive emergency. If someone's pregnant and their blood pressure is more than 160 over 110, that is a hypertensive emergency. And blood pressure really needs to go down acutely. So the recommendation is to get it below the 160 over 110 within 30 to 60 minutes once it's recognized. So that's a pretty aggressive goal for some of these patients. And then just their everyday blood pressure goal for someone who had hypertension prior to pregnancy. So this is defined either having been diagnosed with hypertension before they got pregnant or if it's discovered that they have hypertension prior to 20 weeks' gestation. Their blood pressure goal is 140 over 90 during pregnancy. So that is different than our typical goal for our people. Then lastly, the guidelines do mention that a lotus aspirin among women who have chronic hypertension can be used during pregnancy planning or when they are pregnant. And the reason for that is that lotus aspirin can actually reduce the risk of preeclampsia and the sequela associated with that. So in selected patients, they may take a baby aspirin or a lotus aspirin to prevent that complication. So Dr. S, we've kind of covered a lot of different exciting new updates from the 2025 guidelines. But we go back and forth and talk about some of the key points that really stood out to us with the new update. And then as we mentioned, new is that for stage two hypertension, you're starting with two anti-hypertensive medications. And for stage one, you're starting with one anti-hypertensive medication. And we kind of went through some nuance there in terms of sure decision making and that you may not always follow that, but that's what the guidelines generally recommend for most patients. The next new recommendation is that guidelines no longer recommend specific first-line therapies based on race. Instead, all patients without compelling indications should be initiated either on a thizide, ACE, ARB or dihydroperidine calcium channel blocker. And then lastly, generally our blood pressure goal is going to be less than 130/80. In high-risk patients or those with diabetes, you might consider a more stringent goal less than 120/80. But again, it's something that you would consider and it would be as tolerated based on how they tolerate their anti-hypertensive medications. So Dr. S, thank you so much for your time and your expertise for today's episode. For the listener, you can check out the whole guidelines. So we have links in our show notes at helixtalk.com. This is episode 193. And again, thank you for your time. Thank you for having me. And with that, study hard. If you enjoyed the show, please help us climb the iTunes rankings for medical podcasts by giving us a five-star review in the iTunes store. Search for helixtalk and place your review there. To suggest an episode or contact us, we're online at helixtalk.com. Thank you for listening to this episode of helixtalk. This is an educational production, copyright, Rosalind Franklin University of Medicine and Science.