Updates on the Clinical Management of Hypertension: A Narrative Review

Saheed E. Sanyaolu¹ , Adekoyejo A. Sowunmi1,², Peyibomi Z. Kadejo¹, Rilwan A. Mabadeje¹, Ajibola A. Sotannde¹ and Diana O. Wilson³
1. Faculty of Pharmacy, Olabisi Onabanjo University, Ago-Iwoye, Ogun State, Nigeria
2. Department of Health Promotion and Education, Faculty of Public Health, College of Medicine, University of Ibadan, Nigeria
3. Department of Clinical Pharmacy, Niger Delta University, Wilberforce Island, Bayelsa, Nigeria
Correspondence to: Saheed E. Sanyaolu, saheed.e.sanyaolu@gmail.com

DOI:  https://doi.org/10.70389/PJS.100158

Additional information

• Ethical approval: The main ethical consideration in this study was ensuring responsible and accurate use of secondary data. All sources were properly cited and referenced, and the data were used in a way that respected intellectual property and data protection regulations.
• Consent: N/a
• Funding: No industry funding
• Conflicts of interest: N/a
• Author contribution: Saheed E. Sanyaolu, Adekoyejo A. Sowunmi, Peyibomi Z. Kadejo, Rilwan A. Mabadeje, Ajibola A. Sotannde and Diana O. Wilson – Conceptualization, Writing – original draft, review and editing.
• Guarantor: Saheed E. Sanyaolu
• Provenance and peer-review: Unsolicited and externally peer-reviewed
• Data availability statement: N/a

Keywords: Zilebesiran, Renal denervation, Lorundrostat, Baroreflex activation therapy, Aprocitentan.

Peer Review
Received: 5 September 2025
Last revised: 11 October 2025
Accepted: 12 October 2025
Version accepted: 5
Published: 14 November 2025

Plain Language Summary Infographic

Highlights

• Combination antihypertensive therapy has shown greater efficacy and tolerability than monotherapy
• Early-phase evidence suggests potential benefit with zilebesiran and lorundrostat
• Lifestyle modifications, including physical exercise, the DASH diet, and stress management, produce modest blood pressure reductions that are associated with lower cardiovascular risk.
• The absolute mortality effects of lifestyle modifications depend on baseline risk and adherence

Practical Takeaways

Diagnostic thresholds & treatment targets

• ACC/AHA (2025): Hypertension: ≥130/80 mmHg. Target: <130/80 mmHg in most adults.
• ESC (2024): Hypertension: ≥140/90 mmHg; Target: 120–129 mmHg systolic BP when tolerated, with relaxed targets for frail/older patients.

Initial pharmacologic choices

• General first line: Angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB) + calcium channel blocker (CCB) + thiazide/thiazide-like diuretic (monotherapy or combination per patient).
• Comorbidity:
  – Diabetes/albuminuria/chronic kidney disease: ACEI/ARB preferred.
  – Coronary artery disease/post-stroke/heart failure: ACEI/ARB ± beta-blocker ± mineralocorticoid receptor antagonist as indicated.

Spironolactone

• Indications: Consider spironolactone as the preferred fourth-line agent in true resistant hypertension (blood pressure uncontrolled on ACEI/ARB + CCB + diuretic).
• Contraindications: Baseline hyperkalemia, significant renal impairment, and concomitant use with other potassium-sparing agents or high-dose potassium supplements.
• Monitoring notes: monitor potassium, creatinine, estimated glomerular filtration rate, and blood pressure

Renal denervation

• Indications: Consider renal denervation for selected patients with persistent uncontrolled or resistant hypertension despite maximal tolerated pharmacotherapy.
• Contraindications: Renal impairment, primary aldosteronism, and pheochromocytoma
• Monitoring notes: Monitor renal function and renal artery anatomy.

Baroreflex approaches

• Baroreflex activation therapy remains investigational for many indications.

Ambulatory blood pressure monitoring (ABPM)/Home blood pressure monitoring (HBPM)

• Use ABPM (24-hour) or standardized HBPM to confirm diagnosis (avoid white-coat/masked hypertension), guide treatment decisions, and monitor therapy response.

Introduction

Hypertension is a chronic medical condition characterized by a persistent elevation in arterial pressure. It represents one of the most significant comorbidities contributing to the development of stroke, myocardial infarction, heart failure, and renal failure.¹ The overall prevalence of hypertension in adults globally is approximately 30–45%, with over 1.13 billion people worldwide living with hypertension as of 2015, nearly doubling from 594 million in 1975. This prevalence increases with age and varies with gender, as women are reported to have a 2% higher prevalence of the disease than men.² Notably, hypertension is the most important modifiable risk factor for all-cause morbidity and mortality worldwide and is associated with an increased risk of cardiovascular disease. This represents a significant global burden, especially as fewer than half of those with hypertension are aware of their condition, and many others are not adequately treated.³

The etiology of hypertension involves a complex interplay of genetic, environmental, and physiological factors that affect multiple systems. Modern lifestyle transitions, particularly in urbanized and economically developing societies, have accelerated the incidence of hypertension. Factors such as excessive sodium intake, insufficient dietary potassium, obesity, alcohol consumption, and physical inactivity have been strongly associated with increasing blood pressure levels across populations. Additionally, adverse intrauterine environments, such as exposure to gestational hypertension or pre-eclampsia, have demonstrable long-term effects on blood pressure regulation in adulthood.⁴

Although essential hypertension remains a heterogeneous condition, genetics also plays a significant role, with heritability estimates ranging from 35% to 50%, reinforcing the significance of genetic susceptibility of individuals to the condition.³ Further, malignant or accelerated hypertension involves a rapid rise in blood pressure above 180/110 mmHg, often leading to acute microvascular damage and life-threatening consequences if untreated. This underscores the evolving clinical landscape where the definition of hypertension is not only focused on risk assessment but also on treatment urgency. While previous international guidelines classified hypertension solely by threshold values correlated with long-term outcomes, contemporary perspectives now advocate for definitions that consider immediate threats and response needs.⁵

Clinical Presentation

The clinical definition and categorization of hypertension have evolved over the years, reflecting growing insights into its pathophysiology and prognostic implications. Currently, the consensus on hypertension indicates that persistent blood pressure readings at or above 140/90 mmHg warrant medical intervention, with a therapeutic goal of achieving levels below 130/80 mmHg.⁶ These targets aim to minimize the long-term risk of cardiovascular and renal complications and align with updated global guidelines⁷ that emphasize individualized, risk-based treatment approaches. The majority of individuals with hypertension experience no noticeable symptoms until significant end-organ damage occurs. In cases where symptoms do emerge, depending on the underlying cardiac function, symptoms may include chest pain, fatigue, worsening shortness of breath, or syncope.⁸ Nonetheless, the hallmark diagnostic criterion remains a sustained elevation in blood pressure confirmed across multiple readings under standardized conditions, typically ≥140/90 mmHg in adults.

If left undetected or inadequately managed, elevated blood pressure exerts mechanical strain on the vascular system, leading to progressive arterial stiffness, compromised myocardial perfusion, and eventual ischemic injury. Over time, such hemodynamic stress contributes to a wide spectrum of hypertensive complications, including ischemic and hemorrhagic strokes, hypertensive retinopathy leading to visual loss, chronic kidney disease, cardiac arrest, aortic aneurysms, and vascular dementia. Increasingly, hypertension is also recognized as a central contributor to the development of metabolic syndromes, further amplifying its burden across organ systems.⁹ Left untreated, the prognosis of hypertension is severe, usually associated with an elevated risk of multi-organ dysfunction and premature mortality.¹⁰ This underscores the critical importance of early detection, consistent monitoring, and targeted treatment strategies. Furthermore, in light of the evolving understanding of hypertension’s clinical spectrum and its systemic implications, current research emphasizes the need for broader integration of diagnostic precision and preventive care to mitigate adverse outcomes and improve population health.

Clinical Assessment

The need to manage hypertension demands not only precise diagnostic techniques but also a proactive and individualized approach to care. Early detection and accurate clinical assessment of hypertension are essential for effective management and the prevention of complications such as stroke, heart failure, renal disease, and sudden cardiac death. Traditionally, the diagnostic threshold for hypertension is defined as sustained blood pressure readings of 140/90 mmHg or higher, measured under standardized clinical conditions.¹¹ This threshold remains widely accepted, although recent guidelines, such as the 2023 European Society of Hypertension (ESH) Guidelines, have acknowledged intermediate stages, including “high-normal blood pressure” ranging from 130–139/85–89 mmHg, which merits preventive attention.¹ Severity is further categorized into grade 1 (140–159/90–99 mmHg), grade 2 (160–179/100–109 mmHg), and grade 3 (≥180/110 mmHg) hypertension.¹ This categorization reflects progressively increased risks of organ damage and cardiovascular events, thereby enhancing management modalities. Conversely, the American Heart Association (AHA)/American College of Cardiology (ACC) hypertension guidelines utilize stages to classify blood pressures: normal, <120/80 mmHg; elevated, 120–129/<80 mmHg; stage 1 hypertension, 130–139/80–89 mmHg, and stage 2 hypertension ≥140/90 mmHg.¹²

Specifically, accurate diagnosis of hypertension requires multiple blood pressure measurements taken across two to three separate clinical encounters, with patients at rest and using validated, properly calibrated equipment and appropriately sized cuffs. Factors such as recent physical activity, caffeine intake, bladder fullness, emotional stress, or smoking may temporarily influence readings and must be carefully controlled.¹³ It is therefore important for these measurements to be taken at rest, ideally during different clinical visits, using validated equipment and appropriate cuff sizes to ensure accuracy. Upon assessment, readings showing persistent elevation of blood pressure reflect a chronic pathological condition, indicative of hypertension. However, enhancing hypertension diagnosis requires a reliable, portable system capable of providing continuous 24-h blood pressure monitoring.

A comprehensive evaluation of patients with hypertension extends beyond blood pressure readings. Continuous innovation in monitoring tools, integration of biomarkers, and guideline-driven risk stratification now offer promising pathways toward improved hypertension screening. In line with this, it has become important for clinicians to also assess long-term hypertension-mediated organ damage and evaluate cardiovascular risk using validated tools such as SCORE2 for individuals aged 40–69 years and SCORE2-OP for patients aged ≥70 years.¹⁴ Additionally, recent guidelines underscore the need to screen for potential secondary causes of hypertension, especially in young patients or those with resistant hypertension, as the presence of comorbid conditions such as diabetes, dyslipidemia, or chronic kidney disease can further complicate
management and influence therapeutic decisions.¹⁵

Further, recent clinical research has highlighted the emerging role of cardiovascular biomarkers, including N-terminal pro–B-type natriuretic peptide and high-sensitivity troponins, in risk stratification and early detection of myocardial strain or injury, particularly in individuals with longstanding or poorly controlled hypertension.¹⁶ The diagnostic advancements, coupled with current evidence regarding the clinical management of hypertension, can enhance disease management and consequent patient outcomes.

Study Rationale

Despite the critical public health implications of hypertension and ongoing advancements in genomics and precision medicine, there remains a considerable gap in the literature for a comprehensive capture of the updates in hypertension management. Previous focus had been narrowed down to isolated pharmacological or lifestyle management of the disease, without integrating recent multidisciplinary insights into a cohesive clinical framework. Moreover, studies highlighting the translation of emerging biomarkers and molecular targets into real-world clinical practice remain limited. This narrative review, therefore, aimed to provide a comprehensive synthesis of the current evidence regarding the clinical management of hypertension. It highlights recent advancements in diagnostic approaches, pharmacological therapies, and non-pharmacological treatment modalities. By providing insights into recent management modalities for hypertension, this study can inform health practitioners, researchers, and policymakers on improving hypertension care and outcomes across diverse patient populations.

Methods

Study Design and Search Strategy

A narrative review approach was employed in this study. A search was conducted across three major databases: PubMed, Scopus, and the Cochrane Library. The search covered recent articles published from 1st January 2010 to 30th June 2025, targeting studies related to the clinical management of hypertension. Search terms were developed using a combination of MeSH headings, keyword mapping, and subject-specific terminology. Boolean operators (“AND,” “OR,” “NOT”) were employed to optimize sensitivity and specificity, with representative search strings including: “hypertension” AND (“treatment” OR “management” OR “guidelines”).  Search terms were adapted to suit the syntax and indexing of each database. In addition to peer-reviewed literature, we reviewed clinical guidelines and position statements from professional organizations such as the AHA, ACC, ESH, and European Society of Cardiology (ESC), on the current evidence on the clinical management of hypertension and cardiac arrhythmias. Manual reference checks of selected articles were also performed to identify additional relevant studies.

Study Selection

Given the narrative (not systematic) design of this review, the focus was on capturing key developments and representative findings, rather than achieving exhaustive coverage of the developments in the management of hypertension. Therefore, across the 15-year study period (1st January 2010 to 30th June 2025), only 26 articles were included based on their relevance to the review objectives and the depth of evidence they provided.

Inclusion Criteria

Eligible studies were those published in English between 1st January 2010 to 30th June 2025, focusing on the clinical management of hypertension. We included randomized controlled trials, observational studies, and clinical studies that provided evidence on pharmacologic and non-pharmacologic interventions, emerging therapeutic strategies, and real-world implementation. Studies involving adult patients in clinical settings were prioritized to ensure relevance to current medical practice.

Exclusion Criteria

We excluded articles published before 2010, as well as those not written in English. We also excluded publications that addressed unrelated cardiovascular conditions, such as heart failure or coronary artery disease, unless they explicitly discussed blood pressure. Editorials, commentaries, and opinion pieces lacking original data or clinical recommendations were not included.

Study Outcomes

We focused on outcomes that reflect current trends in the clinical management of hypertension and examined outcomes such as changes in blood pressure control, reduction in cardiovascular risk, adherence to updated treatment guidelines, effectiveness of newer antihypertensive agents, and the integration of lifestyle modifications in routine care. We also considered studies that reported on patient-centered outcomes, such as medication adherence, quality of life, and adverse drug events.

Results

Study Characteristics

The search strategy and the screening workflow are indicated in Supplementary Table S1 and Figure S1, respectively. Overall, 26 studies were reviewed in this study. The characteristics of the included studies are outlined in Table 1. Of the 26 studies included in this review, 20 were randomized controlled trials. One open-label sequential single ascending dose study and five observational studies, including one longitudinal analysis, one cross-sectional study, and two retrospective analyses, were also included. Four studies focused on non-pharmacological interventions, including diet, exercise, mindfulness, and stress management. Thirteen studies focused on pharmacological therapies, highlighting current and novel modalities for disease management, and nine studies indicated procedural therapies for hypertension care. 

Table 1: Overview of recent studies on hypertension management.
S/N	Citation	Study Design	Treatment Approach	Number of Participants	Population Characteristics	Follow-Up Duration	Study Outcomes	Adverse Events	Funding/Conflicts
1.	Vasei et al., 202217	Double blind randomized controlled trial	Effect of replacing plant proteins with animal proteins on cardiometabolic risks	90	Obese patients with metabolic syndrome, aged 30–70 years	8 weeks	Reduction in FPG, systolic and diastolic blood pressure, weight, and waist circumference.	No reported side effects	National Nutrition and Food Technology Research Institute, Shahid Beheshti University of Medical Sciences, Tehran, Iran
2.	Lopes et al., 202118	Single-blind Randomized controlled trial	Effect of aerobic exercise training on ambulatory blood pressure among patients with resistant hypertension.	60	Patients with a diagnosis of resistant hypertension aged 40 to 75 years	12 weeks	Reduction in 24-hour ambulatory systolic and diastolic blood pressure from baseline by 7.1 mmHg and 5.1 mmHg, respectively.	No reported adverse effects	European union and the Portuguese government
3.	Gamage and Seneviratne, 201619	Cross-sectional survey	Effect of overcommitment and effort-reward ratio of job stress on hypertension in administrative officers.	1035	Randomly selected senior officers (SOs) and managerial assistants (MAs) aged between 30 and 60 years	2 weeks	Effort-reward imbalance and high efforts increased the risk of hypertension by 2-fold. Job stress was significantly associated with hypertension	No reported adverse effects	Noncommunicable Disease Unit, Ministry of Health Sri Lanka
4.	Babak et al., 202220	Randomized controlled trial	12 weeks of mindfulness-based stress reduction (MBSR) and routine care	80	Hypertensive adult women (age =30–59 years)	12 weeks	Mean systolic and diastolic blood pressures decreased by 9 mmHg and 8 mmHg, respectively.	No reported adverse effects	–
5.	Zhu et al., 202222	Observational study	Effects of ACEIs and ARBs in patients with hypertension	19,074	Average age: 67.52 years	2008 to 2019	Decreased risk of mortality in those who received ACEI/ARBs compared to those who did not, and higher risk of acute kidney injury.	increased risk of re-dialysis	Changsha Municipal Natural Science Foundation
6.	Harrison et al., 202523	Retrospective study	Impact of CCB, ACEi/ARB, and Diuretics on the risk of cardiovascular events	14,836	Patients with hypertension aged ≥ 40 years	2017 to 2023	CCB vs. ACEi/ARBs or diuretics = 1:1.17 ACE/ARB vs. diuretics = 0.66:1	Risks of all-cause mortality, acute MI, and stroke	HCA Healthcare and/or an HCA Healthcare-affiliated entity
7.	Desai et al., 202324	Randomized clinical trial	Zilebesiran (≥200mg)	107	Patients with hypertension (18 to 65 years of age)	24 weeks	Decreased systolic (>10 mmHg) and diastolic blood pressure (>5 mmHg)	headache, injection-site reaction, and upper respiratory tract infection	Alnylam Pharmaceuticals
8.	Bakris et al., 202125 (KARDIA-1)	Phase 2, randomized, double-blind trial	Different zilebesiran dosing regimens	394	Adults with mild to moderate hypertension (Mean age: 56.8 ± 10.6 years)	6 months	Reduced 24-hour mean ambulatory systolic blood pressure at month 3	Injection site reactions and mild hyperkalemia	Alnylam Pharmaceuticals
9.	Desai et al., 202526 (KARDIA-2)	Phase 2, randomized, double-blinded trial	safety of zilebesiran + standard antihypertensive medication	1491	Adults with uncontrolled hypertension (18 to 75 years)	6 months	Significant systolic blood pressure reductions. Low rates of serious adverse events	Hyperkalemia, hypotension, and acute kidney failure	Alnylam Pharmaceuticals
10.	Laffin et al., 202527	Double blind randomized controlled trial	Efficacy and safety of lorundrostat in patients with uncontrolled and treatment-resistant hypertension	285	Participants who were receiving two to five antihypertensive medications and had a blood-pressure measurement ≥140/90 mmHg	12 weeks	Mean change in 24-h systolic blood pressure in Stable group =-15.4 mmHg Dose adjustment group =-13.9 mmHg Placebo =-7.4 mmHg.	Increased serum aldosterone, hyperkalemia, hyponatremia, hypercortisolism, hypocortisolism, reduced in kidney function, symptomatic hypotension.	Mineralys Therapeutics
11.	Ghofrani et al., 201328 (PATENT-1 trial)	Double blind randomized controlled trial	Riociguat for pulmonary arterial hypertension	443	Patients with symptomatic pulmonary arterial hypertension	12 weeks	30 m increase in 6-minute walking distance by week 12	increased hepatic enzyme levels, dizziness, presyncope, acute renal failure, and hypotension	Bayer HealthCare
12.	Wong et al., 202429	Randomized clinical trial	Safety, tolerability, pharmacokinetics, and pharmacodynamics of soluble guanylyl cyclase inhibitor	24	Healthy men aged 18–50 years with a body mass index (BMI) of 18.5 to < 30 kg/m2	20 days	Multiple dosing resulted in Increased plasma cyclic guanosine monophosphate and decreased blood pressure	orthostatic dysregulation, fatigue, headache, nausea, oropharyngeal pain, hyperhidrosis, diarrhea, abdominal distension, asthenia.	Boehringer Ingelheim
13.	Chen et al., 202230	Open-label sequential single ascending dose study	Safety, tolerability, neurohumoral, renal, and blood pressure-lowering properties of MANP in hypertension	12	Patients with essential hypertension withdrawn from antihypertensive medications for 2 weeks	2 weeks	induced natriuresis, reduced aldosterone, and decreased blood pressure	Mild headache, transient light-headedness, transient orthostatic vasovagal syncope.	Mayo Clinic, Broadview Ventures, and RO1 HL136340.
14.	Schlaich et al., 202231	Double blind randomized controlled trial	Effect of aprocitentan for resistant hypertension	730	Patients with sitting systolic blood pressure ≥140 mmHg despite taking standardised background therapy consisting of three antihypertensive drugs, including a diuretic	40 weeks	24 h ambulatory systolic blood pressure decrease of -5·9 mmHg	mild-to-moderate oedema,	Idorsia Pharmaceuticals and Janssen Biotech
15.	Danaietash et al., 202232	Single blind randomized controlled trial	Effect of aprocitentan for uncontrolled blood pressure despite the use of three or more antihypertensives	730	Patients with uncontrolled blood pressure despite the use of three or more antihypertensive medications for at least 1 year	48 weeks	Sustained decrease in systolic and diastolic pressure By 6.7 mmHg and 0.3 mmHg, respectively, in no pseudo RHT, and	Headache, and nasopharyngitis, Mild-to-moderate peripheral edema	Idorsia Pharmaceuticals Ltd
16.	Verweij et al., 202033	Double blind randomized controlled trial	Dose-Response effect of Aprocitentan in Hypertension Compared with unattended automated office blood pressure and lisinopril 20 mg	409	Patients with a sitting diastolic blood pressure of 90–109 mmHg	8 weeks	Aprocitentan 10, 25, and 50 mg decreased sitting systolic/diastolic unattended automated office blood pressure from baseline to week 8 (placebo-corrected decreases: 7.05/4.93, 9.90/6.99, and 7.58/4.95 mmHg, respectively. Lisinopril-corrected decrease 4.4/3.81	Headache, and nasopharyngitis, Mild-to-moderate peripheral edema, increased liver aminotransferases.	Idorsia Pharmaceuticals, Ltd
17.	Williams et al., 201534 (PATHWAY-2 trial)	double-blind, placebo-controlled trial	Spironolactone	335	Patients with hypertension (age: 18–79 years)	5 years	The most effective add-on drug for the treatment of resistant hypertension	Hyperkalemia	British Heart Foundation and National Institute for Health Research
18.	Bhatt et al., 201435 (SYMPLICITY HTN-3 trial)	Randomized clinical trial	Catheter-based renal-artery denervation	535	Patients with severe resistant hypertension	6 months	Change in systolic blood pressure: −14.13 ± 23.93 mmHg vs. −11.74 ± 25.94 mmHg (Control group)	Elevated serum creatinine, vascular complications, etc.	Medtronic
19.	Böhm et al., 202036 (SPYRAL HTN-OFF MED Pivotal trial)	Single-blinded, randomized sham-controlled trial	Catheter-based renal denervation	331	Patients with hypertension (age: 20–80 years)	3 months	24-h systolic blood pressure difference: −3·9 mm Hg (Bayesian 95% credible interval −6·2 to −1·6) and office systolic blood pressure difference: −6·5 mm Hg (−9·6 to −3·5)	None reported	Medtronic
20.	Kandzari et al., 201837 (SPYRAL HTN-ON MED trial)	Randomised, single-blind, sham-control trial	Catheter-based renal denervation	467	Patients with uncontrolled hypertension on antihypertensive medications (aged 20–80 years)	6 months	Significant blood pressure reduction	None reported.	Medtronic.
21.	Azizi et al., 202138 (RADIANCE-HTN TRIO trial)	Randomised, single-blind, sham-controlled trial	Ultrasound renal denervation	136	Patients aged 18–75 years with hypertension	2 months	Reduced blood pressure	None reported.	ReCor Medical.
22.	Alnima et al., 201539	Randomized phase II/III trial	Effect of baroreflex activation therapy on carotid chemoreflex activation	15	Patients implanted with the Rheos system	13 months	Decrease in mean arterial pressure (P < 0.001). No appreciable coactivation of carotid body chemoreceptors during device therapy. No change in end-tidal and partial pressure of carbon dioxide, breath duration, and breathing frequency.	Throat sensations and cough	CVRx, Inc.
23.	Piayda et al., 202240	Observational study	Endovascular Baroreflex Amplification With the MobiusHD Device	29	Patients with heart failure with reduced ejection fraction	24 months	Improved mean KCCQ OSS = 17.4 ± 9.1 Increased mean 6MWD =97.6 ± 51.1 m Improved mean LVEF = 5.6% ± 2.9 Reduced mean from baseline N-terminal pro–B-type natriuretic peptide conc = 28.4%	No adverse event reported	No funding, but multiple conflicts of interest declared
24.	Gordin et al., 201741	Double blind randomized controlled trial	Baroreflex activation therapy on blood pressure and sympathetic function in patients with resistant hypertension	100	Patients with resistant hypertension	8 months	Reduction in 24-hour systolic ambulatory blood pressure at 8 months, compared to pharmacotherapy	No adverse event reported	Folkhälsan Research Foundation, the Wilhelm and Else Stockmann Foundation, the Liv och Hälsa Foundation, the Finnish Medical Society (Finska Läkaresällskapet), the Finnish Medical Foundation, The Swedish Cultural Foundation in Finland, and the Dorothea Olivia, Karl Walter och Jarl Walter Perkléns Foundation
25.	de Leeuw et al., 201742	Longitudinal analysis	Baroreflex activation therapy on blood pressure reduction after 6 years follow up	383	Treatment-resistant hypertensive patients	6 years	Sustained decrease in office systolic blood pressure from 179±24 mm Hg to 144±28 mm Hg (P<0.0001), Decreased office diastolic pressure dropped from 103±16 mm Hg to 85±18 mm Hg (P<0.0001)	IPG migration, lead tension or migration, surgical complication after IPG replacement, hypotension with AKI, neck spasms, UTI, seizures, hypertensive crisis.	CVRx (Minneapolis, MN).
26.	Wang et al., 202543	Randomized controlled trial	Assessment of the effectiveness of wearable devices for hypertension management in elderly patients.	400	Elderly patients with primary hypertension	September 2022 to November 2023	Significantly better outcomes in the experimental than control groups, including improved medication adherence, enhanced blood pressure control, and better quality of life.	Cost	–
In this review, 20 studies were randomized controlled trials, forming a relatively strong evidence base. The remaining six studies included one open-label sequential single-ascending-dose trial and five observational studies. Across all studies, differences in design, sample size, and follow-up duration made direct comparison difficult. In some cases, inconsistencies in blood pressure measurement and limited information on adherence or background therapy reduced clarity. Potential conflicts of interest, particularly in industry-funded trials, and publication bias may also have influenced the overall evidence. Furthermore, selective reporting and optimistic interpretation of results in a few studies suggest that treatment effects may have been overstated. Finally, most research was conducted in high-resource settings, which limits how broadly the results can be applied to low- and middle-income regions where access and affordability remain major challenges. CCB, Calcium Channel Blocker; ACEi, Angiotensin-Converting Enzyme Inhibitor; ARB, Angiotensin II Receptor Blocker; MI, Myocardial Infarction; RCT, Randomized Controlled Trial.

Study Findings

The studies included in the results provide details across three major areas of hypertension management, including lifestyle modalities, pharmacologic management, and procedural therapies. Hypertension is a chronic, non-communicable condition that, while incurable, is highly manageable through evidence-based interventions.¹ The study findings demonstrated the importance of optimal care in patients with hypertension using a multifaceted approach that integrates regular cardiovascular monitoring, lifestyle modification, and pharmacologic therapy.

Lifestyle Management

Lifestyle and non-pharmacologic modalities, such as reducing and managing stress, as well as the management of psychosocial stressors and comorbid conditions, are essential for improving patient outcomes and reducing long-term cardiovascular risk. The primary studies report lifestyle changes to have consistently demonstrated efficacy in lowering blood pressure and preventing the progression of hypertension and its cardiovascular sequelae. Identified modifiable risk factors to be addressed included physical inactivity, tobacco use, excessive alcohol consumption, elevated body mass index, and poor dietary habits (Figure 1). Additionally, environmental exposures, including ambient air pollution and chronic psychological stress, were reported as contributors to vascular dysfunction and hypertension progression, particularly in urban and industrialized settings.

Nutritional Management

The Dietary Approaches to Stop Hypertension (DASH) diet was identified to be the most endorsed nutritional strategy and lifestyle modification approach for managing hypertension. The DASH diet emphasizes a high intake of fruits, vegetables, whole grains, lean proteins, and low-fat dairy, while limiting sodium, saturated fats, and added sugars. Although traditional recommendations restrict sodium intake to 2.4 g/day, a more aggressive reduction to 1.5 g/day, particularly in salt-sensitive individuals and those with chronic kidney disease, has been reported. Further dietary modifications include DASH variants that substitute 10% of daily carbohydrates with unsaturated fats or plant-based proteins. The randomized controlled trial by Vasei et al.¹⁷ demonstrated the effect of replacing plant proteins with animal proteins in the DASH diet, showing additional benefits in reducing systolic blood pressure and improving lipid profiles. In addition, diets rich in potassium, magnesium, and calcium were identified to demonstrate protective effects on vascular tone and cardiac excitability, as potassium supplementation may be particularly effective in populations with high sodium intake.

Physical Activity

Another study highlighted exercise and resistance training as important physical modalities for managing hypertension in a dose-dependent manner, with exercise therapy of 150 min/week, such as brisk walking, swimming, or cycling, primarily reported. Resistance training, performed two to three times weekly, was also shown to improve insulin sensitivity, reduce arterial stiffness, and support weight loss.¹⁸

Stress Management

In addition to diet and exercise, stress management was highlighted by two studies as a critical lifestyle modality for hypertension management. According to Gamage and Seneviratne¹⁹ Chronic psychological stress, such as that from a job or mental health issues, is now considered a direct contributor to sympathetic overactivity and endothelial dysfunction, requiring mindfulness-based interventions, cognitive behavioral therapy, and structured relaxation techniques. The 12-week mindfulness-based stress reduction trial by Babak et al.²⁰ further revealed a significant reduction in the mean systolic and diastolic blood pressures and improvement in mental health and quality of life.

Guideline-Based Lifestyle Approaches and Benefits

This section reports quantitative benefits of specific lifestyle approaches based on the 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults.²¹ On average, systolic/diastolic blood pressure falls by about 1/1 mmHg for each kilogram of weight lost, with greater reductions seen with ≥5% weight loss, and the DASH diet lowers systolic blood pressure by 1–13 mmHg and diastolic blood pressure by 1–10 mmHg, particularly in Black adults, those with higher baseline blood pressure, and high sodium intake. Sodium reduction to 1500–2300 mg/day produces average decreases of 3/2 mmHg in normotensive and 7/3 mmHg in hypertensive adults, with additive benefits when combined with DASH or weight loss, while potassium-enriched salt substitutes lower blood pressure by 5/1.5 mmHg. Moderate potassium supplementation further reduces blood pressure by 6/4 mmHg, though excessive intake (>80 mmol/day) may be harmful. Alcohol reduction yields meaningful reductions (5.5/4.0 mmHg) in heavy drinkers. Structured physical activity is strongly supported, with aerobic exercise lowering systolic blood pressure by 4–7 mmHg. Stress-reduction techniques, including transcendental meditation and breathing control, confer modest additional lowering (5/2 to 5/3 mmHg), with weaker evidence for yoga and other mindfulness practices.

Pharmacological Management

Pharmacological management represents a proactive approach for treating hypertension and associated comorbidities, particularly if lifestyle interventions fail to achieve target levels. In this review, 10 studies reported pharmacologic management modalities. Recommendations of the 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults regarding when to initiate pharmacologic therapy are indicated in Figure 2.

Traditional Pharmacologic Therapies

The studies demonstrated the superior efficacy of combination therapy in achieving blood pressure targets more rapidly than monotherapy, with comparable tolerability. Traditional therapies include diuretics, calcium channel blockers, angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), beta blockers, vasodilators, central sympatholytic, and mineralocorticoid receptor antagonists, among others.  However, using the MIMIC database, Zhu et al.²² discouraged the concurrent use of ACEIs and ARBs due to the risk of adverse renal and electrolyte effects. For patients of African descent, Harrison et al.²³ report the importance of ensuring that at least one agent is either a thiazide diuretic or a calcium channel blocker, given the reduced efficacy of ACEIs in this population. Further, guidelines vary in patients with comorbidities, and single-pill combinations were reported to enhance adherence and reduce pill burden, especially in patients requiring multiple agents.

Recent Developments in Pharmacological Management

Recent advances in cardiovascular pharmacotherapy have shown promise for the management of hypertension. Notably, five emerging pharmacological developments for hypertension management were captured, including zilebesiran, a small interfering RNA-based therapeutic²⁴; lorundrostat, an aldosterone synthase inhibitor²⁵; riociguat, a soluble guanylate cyclase (sGC) agonist^26-27; M-atrial natriuretic peptide (MANP), a natriuretic peptide analog²⁸; and aprocitentan, a dual endothelin receptor antagonist.²⁹⁻³¹

The phase I clinical trial by Desai et al.²⁴ demonstrated dose-dependent reduction effects of zilebesiran in circulating angiotensinogen and systolic blood pressure, with therapeutic effects persisting for up to 24 weeks following a single subcutaneous administration. Although phase 1 (KARDIA-1)²⁵ and 2 (KARDIA-2)²⁶ studies demonstrated sustained reductions in blood pressure and an encouraging safety profile with zilebesiran, the drug remains investigational and has not yet received regulatory approval; phase 3 studies are underway. Similarly, lorundrostat was reported to demonstrate moderate 24-h blood pressure reduction, especially in patients with uncontrolled hypertension.²⁷  However, both zilebesiran and lorundrostat remain investigational drugs and have not
received formal approval for use in the management of hypertension.

Riociguat is indicated for pulmonary hypertension, including pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension. Ghofrani et al.²⁸ and Wong et al.²⁹ report that this sGC agonist represents a distinct pharmacologic strategy associated with vasodilatory and antifibrotic mechanisms linked to the nitric oxide–cGMP pathway. However, riociguat’s role in systemic arterial hypertension remains investigational, with only limited evidence available, and current clinical guidelines do not endorse its use for systemic arterial hypertension. Correspondingly, MANP has also been reported to augment natriuresis and vasodilation by boosting guanylyl cyclase-receptor activity and increasing intracellular cGMP, with significant blood pressure reductions up to nearly 40 mmHg.³⁰ It is important to note that MANP is at an early stage of clinical development. Despite the reported favorable short-term findings, long-term safety data are lacking, and it is not approved for use in hypertension management yet. Larger, longer trials will be required to establish its efficacy, safety profile, and regulatory potential. Finally, by inhibiting both endothelin-A and endothelin-B receptors, aprocitentan represents a novel therapy for resistant hypertension.³¹ This dual-target approach also marks a strategic shift toward mechanism-based combination therapies for patients struggling with multifactorial hypertension.^32,33 However, even with supportive phase 3 evidence, the drug’s regulatory approval remains inconsistent across countries.

Although spironolactone is not a novel agent, it has gained renewed attention for its role in resistant hypertension. Evidence from the PATHWAY-2 trial demonstrated that spironolactone produced significantly greater reductions in systolic blood pressure compared with alternative add-on agents such as bisoprolol and doxazosin.³⁴ These findings suggest that aldosterone excess and sodium retention play key roles in resistant hypertension, supporting the use of spironolactone as an effective fourth-line therapy. Nonetheless, its use requires careful monitoring of serum potassium and renal function, particularly in patients with chronic kidney disease or those receiving concurrent renin–angiotensin system inhibitors.

Procedural Therapies

Six studies reported recent procedural therapies for hypertension management and control, including renal denervation, baroreflex activation therapy, and the use of digital health tools.  

Renal Denervation

Renal denervation is newly recommended as a procedural option for resistant hypertension or uncontrolled blood pressure despite adherence to maximally tolerated doses of three or more antihypertensive agents and was investigated in the SYMPLICITY HTN-3 trial.³⁵ The intervention involves a catheter-based technique that disrupts renal sympathetic nerve activity. The trial found no significant difference in blood pressure reduction between the renal denervation and sham control groups at 6 months. These neutral findings highlighted critical methodological limitations, which informed the design of subsequent trials such as SPYRAL HTN and RADIANCE-HTN. Subsequent studies have further refined the understanding of renal denervation. The SPYRAL HTN-OFF MED³⁶ and SPYRAL HTN-ON MED³⁷ trials employed a second-generation radiofrequency catheter with circumferential ablation and demonstrated modest but consistent reductions in both office and ambulatory blood pressure, in the absence and presence of background antihypertensive therapy, respectively. Similarly, the RADIANCE-HTN TRIO trial, which utilized ultrasound-based denervation in patients with treatment-resistant hypertension, reported meaningful reductions in daytime ambulatory systolic blood pressure compared with sham control.³⁸ These findings informed the 2023 U.S. Food and Drug Administration (FDA) approvals of the Paradise and Symplicity Spyral renal denervation systems.

Baroreflex Activation Therapy

Alnima et al.³⁹ also report a recent development in the procedural management of hypertension, indicating the role of the baroreflex activation therapy in enhancing baroreceptor sensitivity and reducing sympathetic tone. This may involve the use of devices such as Rheos and Neo for sustained blood pressure reductions and improved autonomic balance. More recently, endovascular baroreflex amplification using the MobiusHD implant has emerged as a less invasive alternative. It is inserted via catheter into the carotid artery to mechanically amplify baroreceptor signaling.⁴⁰ Early-phase studies further suggest favorable hemodynamic effects with minimal procedural risk,^41,42 though larger trials are still ongoing to validate efficacy and safety. Baroreflex activation remains investigational for many indications.

Digital Health Tools

Wang et al.⁴³ highlights the potential of wearable device-based chronic disease management platforms in significantly improving hypertension control, treatment adherence, quality of life, and self-management capabilities among older individuals, providing a critical tool for long-term disease management. Implantable monitoring systems, including subcutaneous sensors, mobile apps, telehealth coaching platforms, and other remote monitoring platforms, were reported as now being integrated into procedural care for patients. These technologies enable continuous blood pressure tracking, early detection of hypertensive crises, and real-time feedback for medication titration.

Guideline Comparison: ESC (2024) vs ACC/AHA (2025)

The 2024 ESC⁴⁴ and 2025 ACC/AHA²¹ guidelines adopt different diagnostic thresholds for blood-pressure management. ACC/AHA defines hypertension at ≥130/80 mmHg and generally recommends an on-treatment goal of <130/80 mmHg for most adults, prioritizing earlier intervention to reduce CVD risk. The 2024 ESC guidelines retain a diagnostic threshold of ≥140/90 mmHg but introduces an “elevated blood pressure” category (120–139/70–89 mmHg) and recommends a target systolic blood pressure of 120–129 mmHg, while explicitly allowing more relaxed targets in older, frail, or symptomatic patients under an “as low as reasonably achievable” principle.

These differing recommendations reflect how experts have interpreted key clinical evidence over time. One of the most influential studies, the SPRINT trial,⁴⁵ found that aiming for a systolic blood pressure below 120 mmHg, rather than the traditional 140 mmHg, led to fewer cardiovascular events and deaths among high-risk adults without diabetes. However, these benefits came with a greater risk of side effects such as dizziness, kidney injury, and electrolyte problems. Similarly, the STEP trial,⁴⁶ conducted in a Chinese population aged 60–80 years, reported that intensive blood pressure control (targeting 110–129 mmHg) lowered the risk of major cardiovascular events without substantially increasing adverse effects. Together, these findings support the potential benefits of stricter control but also highlight the need for careful patient selection and monitoring.

Blood Pressure Monitoring

White-coat hypertension, where blood pressure is elevated in the clinic but normal outside, and masked hypertension, where office readings are normal but out-of-office values are high, highlight the limitations of clinic measurements of blood pressure. White-coat hypertension may lead to overtreatment, while masked hypertension may cause sustained hypertension. To address the shortcomings of clinic measurements, the 2024 ESC guidelines underscore ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM) as complementary tools.⁴⁴ ABPM involves the use of a portable device that records BP at regular intervals (typically every 15–30 minutes during the day and 30–60 minutes at night) over a 24-hour period. Conversely, HBPM refers to patient self-measurements taken with a validated device at home over several days. According to the 2024 ESC guidelines, diagnostic thresholds for hypertension are set at ≥130/80 mmHg for 24-hour ABPM, ≥135/85 mmHg for daytime ABPM and HBPM, and ≥120/70 mmHg for nighttime ABPM.⁴⁴

Study Quality

The reviewed evidence includes data from randomized controlled trials and observational studies, with varying methodological rigor. Randomized trials provided stronger internal validity but were limited by small sample sizes, while observational studies contributed longer follow-up data but carried inherent confounding risks (Table 1). Furthermore, as highlighted in Table 1, several trials were industry-funded, primarily those evaluating novel agents, which may introduce potential bias in study design or outcome reporting.

Discussion

Together, the highlighted therapies illustrate a sophisticated move away from traditional monotherapies toward personalized, pathway-specific interventions, reflecting how clinicians may soon approach complex cardiovascular and renal comorbidities, especially in populations historically underserved by existing options. The study findings highlight new modalities in lifestyle management, pharmacotherapy, and procedural interventions. In parallel with the evolution of pharmacologic therapies, procedural interventions are increasingly redefining the landscape of hypertension management, particularly for patients with resistant disease who fail to achieve target blood pressure despite optimal medical therapy. These approaches reflect a broader shift toward mechanism-based, minimally invasive strategies that target neurovascular pathways implicated in blood pressure regulation.

Recent updates from the 2024 ESC⁴⁴ and 2024 International Society of Hypertension guidelines emphasize a more personalized and modular approach to lifestyle intervention, tailored to individual risk profiles and comorbidities.⁴⁷ The DASH diet continues to be the most endorsed nutritional strategy.⁴⁸ Further dietary modifications include DASH variants that substitute 10% of daily carbohydrates with unsaturated fats or plant-based proteins.⁴⁹ and an emphasis on diets rich in potassium, magnesium, and calcium,^50,51 which has been shown to significantly improve outcomes in patients with primary hypertension. Beyond nutritional adjustments, routine physical activity remains a critical component of lifestyle therapy. Studies have revealed that aerobic exercise can lead to a large and clinically important reduction in blood pressure in a dose-dependent manner, with the greatest reduction at 150 min/week.¹⁷  Current guidelines therefore recommend resistance training 2−3 times weekly, and at least 150 min of moderate-intensity aerobic exercise per week to improve post-exercise blood pressure for up to 24 h.^52,53 Overall, 5 mmHg decrease in systolic blood pressure with regular exercise may be ensured, leading to a reduction in mortality due to coronary heart disease by 9%, mortality due to stroke by 14%, and all-cause mortality by 7%.¹⁸ This evidence emphasizes the need for employing moderate-intensity aerobic exercise as a standard adjunct therapy targeting patients with resistant hypertension.

Stress management has also become increasingly recognized as an important aspect of hypertension care. Mindfulness-based interventions, cognitive behavioral therapy, and structured relaxation techniques have been employed, demonstrating modest but clinically meaningful reductions in blood pressure.²⁰ However, mindfulness-based interventions have been shown to consistently outperform non-evidence-based treatments and active control conditions, such as health education, relaxation training, and supportive psychotherapy. They also perform comparably to cognitive-behavioral therapy.⁵⁴

However, despite significant advancements in the prevention and lifestyle management of hypertension, pharmacotherapeutic interventions remain essential for achieving optimal blood pressure control and reducing cardiovascular risk. Current guidelines recommend initiating antihypertensive treatment in patients with stage 1 hypertension, even when their 10-year atherosclerotic cardiovascular disease risk is below 10%, particularly if lifestyle interventions fail to achieve target levels. This proactive approach is especially critical for individuals with comorbidities such as diabetes, heart failure, stroke, or chronic kidney disease, as it demonstrably prevents complications in patients.According to ACC and AHA,¹² drugs for treating hypertension can be classified into different classes for first, second, and third-line treatments, which may present with varying side effects. The target blood pressure, patient-specific factors, and the presence of comorbidities should therefore guide the choice of agent. Notably, the 2024 ESC guidelines now emphasize a systolic blood pressure target of 120–129 mmHg for most patients, reflecting a shift toward more intensive control in high-risk populations.⁴⁴

According to this recent guideline, more than 70% of adults with primary hypertension will ultimately require at least two antihypertensive medications, either as initial combination therapy or through stepwise escalation.⁵⁵ While monotherapy may eventually attain similar control as combination therapy in some patients,⁵⁵  the study findings demonstrate superior efficacy with combination therapy in achieving blood pressure targets more rapidly than monotherapy in a considerable number of individuals.^22,23 Individualized treatment plans are therefore important for navigating these variabilities. These evolving recommendations reflect a growing emphasis on precision medicine and patient-centered care to improve long-term cardiovascular outcomes. With novel therapies like zilebesiran²⁴ and lorundrostat,²⁷ the potential for infrequent dosing, possibly every 6 months, has emerged, which could significantly improve adherence and long-term outcomes. By avoiding the broader endocrine disruptions associated with mineralocorticoid receptor antagonists, lorundrostat presents a focused and well-tolerated option, particularly beneficial for populations with high aldosterone-driven pathology, including Black patients disproportionately affected by resistant hypertension.⁵⁷ However, limitations such as poor oral bioavailability and concerns about off-target effects persist, prompting ongoing research into advanced delivery systems, chemical optimization, and nanoparticle-based targeting to minimize complications.

Similar efforts have also focused on riociguat,²⁸⁻²⁹ indicated for pulmonary hypertension, aprocitentan^31,33 for patients struggling with multifactorial hypertension, and MANP,²⁸ which holds particular promise for African American patients who frequently exhibit low endogenous atrial natriuretic peptide levels and salt-sensitive hypertension.^58,59 While generally well-tolerated, riociguat can cause hypotension, headache, and gastrointestinal discomfort, warranting careful titration and monitoring in clinical use.²⁹ To address this, next-generation agents, including praliciguat and ataciguat, are undergoing evaluation for broader applications in resistant hypertension, diabetic nephropathy, and systemic sclerosis, promising greater tissue selectivity and durable hemodynamic effects.⁶⁰   

Procedural therapies like renal denervation have also been integrated into hypertensive care to aid management, especially in cases of resistant hypertension or uncontrolled blood pressure. In 2023, the FDA approved two renal denervation systems, Medtronic’s Symplicity Spyral (radiofrequency-based) and Recor Medical’s Paradise system (ultrasound-based), as adjunctive therapies for uncontrolled hypertension,⁶¹ offering a solution for patients with poor compliance or intolerable side effects. Notably, the 2025 updates from the European Society of Hypertension now cautiously endorse renal denervation as a second-line procedural option in select patients, especially those intolerant to polypharmacy or with sympathetic overactivity.⁶² However, despite the advanced potential of this therapy, its long-term durability and cost-effectiveness remain under investigation, and further studies are needed to explore multi-organ denervation modalities, particularly in renal and hepatic arteries, to enhance efficacy. Similarly, experimental and clinical studies on baroreflex activation therapy have shown sustained blood pressure reductions and improved autonomic balance,^39,40 nonetheless with associated technical challenges.⁶³

 Implantable monitoring systems, including subcutaneous sensors, wearable devices, and remote monitoring platforms, are now being integrated into procedural care for patients. These technologies enable continuous blood pressure tracking, enhance adherence, track progress, and facilitate clinician-patient engagement.⁶⁴ Coupled with telehealth platforms, they offer a scalable solution for remote management and have shown promise in improving self-monitoring and sustaining long-term behavioral change, especially in underserved populations. However, additional studies are needed, focusing on the development of universally applicable and consistent digital therapeutic strategies designed with inputs from healthcare professionals toward objective endpoints. It is expected that the momentum for digital therapeutics triggered by the COVID-19 pandemic can stimulate advancements in this field and drive widespread implementation.⁶⁵

Collectively, these procedural innovations underscore a paradigm shift from reactive pharmacologic escalation to proactive, targeted intervention. They complement emerging drug therapies by addressing neurovascular dysregulation and enhancing long-term control in patients with complex comorbidities. As clinical guidelines evolve, the integration of procedural options into standard care will likely expand, offering new hope for individuals historically underserved by conventional treatment algorithms.

Challenges of Clinical Management

Despite substantial advancements in clinical cardiology, the management of hypertension still faces significant limitations. First, due to individual variability, lifestyle modifications are inconsistently effective. For instance, access to heart-healthy foods, safe exercise environments, and regular follow-up care may be restricted in underserved or resource-constrained settings, ultimately contributing to disparities in lifestyle implementations and outcomes. In cases involving genetically mediated hypertension, lifestyle interventions alone are insufficient. Therefore, such recommendations should be approached with caution and tailored to the individual.

Hypertension care in low and middle-income countries is shaped by several systemic challenges. Drug access remains a major barrier, as essential antihypertensives are often unaffordable for patients, leading to poor adherence and treatment gaps. ABPM devices are costly and are rarely available outside urban or tertiary centers. The cost of device-based therapies, such as renal denervation or baroreflex activation therapy, poses an additional barrier, as these procedures require a high upfront investment. While clinical trial support their efficacy in resistant hypertension, economic evaluations show that they are cost-effective only in selected patients with true treatment-resistant disease after optimization of pharmacologic therapy.⁶⁶ Thus, careful patient selection, supported by out-of-office BP monitoring where feasible, is crucial to maximize clinical benefit and ensure efficient use of limited healthcare resources.

Scope for Future Research

To address the outlined limitations, further research and clinical trials are essential for developing more effective, equitable strategies in cardiovascular care. For aging populations with multiple comorbidities, the challenge of polypharmacy should be actively addressed with fixed-dose combinations, personalized pharmacogenomics, and other integrated care models. Further, the inconsistency among international guidelines may benefit from greater global collaboration, harmonization efforts, and context-sensitive adaptations that reflect diverse healthcare systems and populations. While organizations such as the WHO and other global health bodies are implementing measures to promote equity in healthcare, particularly in underserved regions, future directions could also explore scalable innovations, community-based interventions, and digital health tools that can overcome geographic and economic barriers. Finally, personalized management strategies are critical and should be adopted across all care settings to account for variability in disease presentation, patient context, and treatment response. Bridging gaps in adherence, access, and guideline coherence will be essential for advancing both equity and precision in cardiovascular care.

Study Limitations

As with any review, certain limitations should be considered when interpreting the findings. This work followed a narrative approach, which allowed for a broad exploration of recent updates in the clinical management of hypertension. However, because the focus was on summarizing rather than statistically comparing results, a meta-analysis was not conducted. Additionally, the studies included in the review varied widely in their designs and results, which made it challenging to compare results directly or draw firm conclusions across the studies. While every effort was made to highlight the strengths and relevance of each study, a formal risk of bias assessment was not applied; this limits the depth of critical appraisal. Although the search covered a 15-year period, only 26 studies met the inclusion criteria. This relatively small number reflects the narrow focus on high-quality research that directly addressed hypertension management with clear clinical outcomes. Finally, the potential for selection bias should be recognized, as studies reporting positive results are more likely to be published and included, whereas negative or inconclusive findings may be underrepresented. This publication bias may lead to an overestimation of the true effectiveness of the interventions.

Conclusion

Optimal care for hypertension requires a multifaceted approach integrating regular cardiovascular monitoring, lifestyle modification, pharmacologic therapy, and coordinated interdisciplinary collaboration. While lifestyle modification remains foundational, its success hinges on disease severity and individualized goals. Personalized approaches informed by genetic and electrophysiologic profiles are required to guide clinicians in providing individualized recommendations for patients. Novel agents like zilebesiran and riociguat, lorundrostat, and MANP hold significant promise for improved hypertension management while also enhancing adherence and long-term outcomes. Similarly, minimally invasive technologies, including renal denervation, baroreflex activation therapy, and real-time monitoring through wearable devices, provide advancements in redefining cardiovascular care, and emphasizing safety, efficiency, and personalization. Future direction must therefore prioritize equitable implementation, global guideline coherence, and innovation that bridges accessibility gaps. Collectively, these advances hold the potential to transform cardiovascular management for delivering more consistent, data-driven, and patient-specific care across diverse populations and clinical settings.

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Supplementary Material

Table S1: Search strategies used in the review.
Database	Date of Search	Coverage Period	Search Strategy (Exact Terms Used)
PubMed	June 30, 2025	Jan 2010 – Jun 2025	(“Hypertension”[MeSH] OR “high blood pressure”[Title/Abstract]) AND (“management”[Title/Abstract] OR “treatment”[Title/Abstract] OR “therapy”[Title/Abstract])
Scopus	June 30, 2025	Jan 2010 – Jun 2025	TITLE-ABS-KEY(hypertension OR “high blood pressure”) AND TITLE-ABS-KEY(management OR treatment OR therapy)
Cochrane Library	June 30, 2025	Jan 2010 – Jun 2025	(Hypertension OR “high blood pressure”):ti,ab,kw AND (management OR treatment OR therapy):ti,ab,kw
The literature search was conducted in PubMed, Scopus, and the Cochrane Library for articles published between 1st January 2010 and 30th June 2025. ti, title; ab, abstract; kw, keywords.

Cite this article as: Sanyaolu SE, Sowunmi AA, Kadejo PZ, Mabadeje RA, Sotannde AA and, Wilson DO. Updates on the Clinical Management of Hypertension: A Narrative Review. Premier Journal of Science 2025;14:100158

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