Latest Guide Breakdown: Only the 10 key changes relevant to grassroots

Clinical guidelines often span dozens of pages, making it difficult for primary care physicians to read them in full. This article distills the latest version of the "National Primary Hypertension Prevention and Management Guidelines (2025 Edition)" (published by the National Center for Cardiovascular Diseases and the National Expert Committee on Primary Hypertension Management in *Chinese Circulation Journal*, 2025) into just 10 key points directly relevant to primary care: diagnosis, medication, referral, and follow-up. Changes compared to the 2020 edition are highlighted. Other conditions can be broken down using the same approach.

Item 1: Add two new independent sections: "Screening and Prevention" and "Health Education".

Key Change: Version 2025 adds a new section on screening, prevention, and health education to version 2020. It clarifies that all adults aged ≥18 years should have their blood pressure measured at the first outpatient visit each year, with follow-up measurement frequencies specified for different groups, including those suspected of hypertension, those with high-normal blood pressure, and those with normal blood pressure. Implementation at the Primary Care Level: Institutionalize "blood pressure measurement at first visit" as a standard practice, leverage family doctor contracts and health records for opportunistic screening, and ensure early detection and timely management.

Item 2: More aggressive blood pressure targets; age threshold adjusted from 65 to 80 years.

Key updates: Version 2020 sets general patient targets at 140/90, with 130/80 for those with comorbidities like diabetes, and 150/90 for ages 65–79. Version 2025 standardizes recommendations: <80 years—aim for <130/80; ≥80 years—target <150/90, or <140/90 if well-tolerated. Primary care approach: stratify targets by age; during follow-up, compare directly against 130/80 to assess control. For older or frail patients, individualize therapy and avoid rapid blood pressure reduction.

Item 3: Define three diagnostic thresholds for clinic, home, and dynamic monitoring.

Key Changes: Clinic blood pressure ≥140/90, home blood pressure mean ≥135/85, 24-hour ambulatory blood pressure mean ≥130/80 (daytime ≥135/85, nighttime ≥120/70). Diagnosis is confirmed by clinic measurements exceeding the threshold on at least 3 occasions within 4 weeks. Primary Care Approach: Rely primarily on clinic blood pressure, supplemented by out-of-clinic measurements. Guide patients to perform home self-monitoring correctly; use ambulatory blood pressure monitoring as needed for differential diagnosis.

Item 4: Added "Isolated Diastolic Hypertension" to blood pressure categories

Key changes: Added isolated diastolic hypertension (systolic BP < 140 and diastolic BP ≥ 90) to the existing category of isolated systolic hypertension, with clear guidance on managing white-coat and masked hypertension. Primary care approach: Elevated diastolic BP in young and middle-aged adults is no longer overlooked; isolated diastolic hypertension is first managed through lifestyle interventions with monitoring every six months, while high-risk patients receive pharmacologic treatment.

Item 5: Initiate pharmacotherapy upon diagnosis; delay of up to 3 month may be considered only for specific low-risk cases.

Key change: Initiate pharmacotherapy immediately upon diagnosis alongside lifestyle interventions for all patients. For those with systolic BP <150 and diastolic BP <90 without comorbidities (e.g., coronary heart disease, heart failure, atrial fibrillation, stroke, peripheral vascular disease, chronic kidney disease, retinopathy, or diabetes), medication may be deferred based on patient preference to pursue lifestyle intervention alone for up to 3 months; if targets remain unmet thereafter, start treatment. Primary care approach: Avoid a blanket "observe for six months" strategy. Base the decision to allow short-term observation on the presence of comorbidities and schedule a follow-up at 3 months.

Item 6: Single-pill fixed-dose combination recommended as first-line; new ARNI agents added

Key Changes: Five drug classes with strong evidence (ACEI/ARB, beta-blockers, CCBs, thiazide diuretics) are recommended; single-pill combinations of these agents are preferred first-line due to better adherence. Where available, ARNI (sacubitril/valsartan) may replace ACEI/ARB, with clear contraindications for combination use and a requirement to discontinue ACEI for at least 36 hours prior to switching. Primary Care Approach: Prioritize long-acting agents and fixed-dose combinations; select medications based on comorbidities; verify contraindications and drug interactions before initiating new therapies.

Item 7: Referral criteria are clearer; five categories of patients should be referred.

Key changes: Categorized into five types—"acute onset, severe symptoms, suspected secondary causes, difficult to control, and pregnant women"—and detailed referral criteria: 9 initial visit referrals, 5 follow-up referrals, and 6 severe conditions requiring ambulance transport. It is specified that pregnant and breastfeeding women should not seek care at primary care facilities. Primary care practice: Post the referral checklist in the clinic; refer patients promptly if they meet criteria; conduct active follow-up within 2–4 weeks after referral; and transfer management back to primary care once stable.

Item 8: There are clear "forbidden actions" for emergency management of blood pressure ≥180/110.

Key changes: For patients without acute complications, administer oral short-acting agents such as captopril or metoprolol tartrate. These may be repeated after 1 hours to lower blood pressure to below 160/100 within 24–48 hours. Sublingual nifedipine for rapid blood pressure reduction is strictly prohibited. Patients with acute cardiac, cerebral, or renal complications require immediate referral. Primary care practice: Remember the prohibition on sublingual nifedipine, follow established protocols, and promptly identify "red flag" symptoms requiring emergency intervention.

Item 9: Integrated management of lipid-lowering, antiplatelet therapy, and blood glucose control

Key changes: Set LDL-C targets based on ASCVD risk stratification and prioritize statins. Initiate aspirin only after blood pressure is stabilized below 150/90; do not use routinely in those without ASCVD. Annual assessments must include fasting glucose; if elevated, follow standard protocols for further diagnosis or referral. Primary care approach: Hypertension management should go beyond blood pressure control by simultaneously evaluating lipid levels, antiplatelet indications, and glucose, while monitoring medication effects.

Item 10: Measurement Equipment Requirements and Traditional Chinese Medicine Chapter

Key Updates: Use validated upper-arm electronic blood pressure monitors; mercury sphygmomanometers are not recommended, and wrist- or finger-based devices are discouraged. Refer patients if systolic blood pressure differs by more than 20 mmHg between arms. A dedicated TCM chapter is included, covering pattern differentiation and treatment, acupuncture, massage, auricular point therapy, and traditional exercises such as Tai Chi and Baduanjin. Implementation at the Primary Care Level: Standardize equipment and follow the "three key points" for measurement; apply TCM techniques appropriately and rigorously without overstating their efficacy.

Conclusion: Three Steps for Grassroots Implementation

• Step 1: Establish a fixed protocol for initial blood pressure measurement, confirmation on two separate occasions (3), and evaluation of target achievement based on 130/80.
• Step 2: Select medications based on comorbidities. Prioritize long-acting and fixed-dose combination therapies, with follow-up visits at 1 months and 3 months.
• Step 3: Use the referral checklist to identify high-risk patients, promptly refer them up and track their return, while simultaneously managing blood lipids and blood glucose.

The original text and accompanying manual are available for free download from the official website of the National Primary Hypertension Management Office. It is recommended to use them together with the "National Primary Hypertension Prevention and Management Manual."