Ask the Expert, Dr Aditya Mehra: What Is Hypertension?

Hypertension continues to be the most commonly encountered issue in medical practice. As a cardiologist, it is important for me to stay up-to-date with the latest guidelines, as well as cutting edge therapeutic modalities available to combat hypertension. Adequate control of hypertension is important to decrease the risk of cardiovascular events, such a stroke and heart attack, as well as risk of end organ damage such as kidney failure.

The 2025 American College of Cardiology/American Heart Association hypertension guidelines represent the most recent comprehensive update, emphasizing individualized blood pressure targets, optimized medication regimens, and expanded roles for device-based therapies. The guidelines recommend a target BP of less than 130/80 for most adults.

Key Treatment Recommendations

First-line pharmacotherapy continues to center on single-pill combination therapy to enhance adherence, typically including a renin-angiotensin system (RAS) inhibitor, calcium channel blocker (CCB), and thiazide or thiazide-like diuretic. For resistant hypertension (uncontrolled BP despite ≥3 medications including a diuretic), spironolactone (25-50 mg/day) is recommended as the preferred fourth-line agent, reducing 24-hour systolic BP by 6.6-8.7 mm Hg compared to placebo.

The American College of Physicians (ACP) and American Academy of Family Physicians (AAFP) recommend initiating treatment in adults aged 60 years or older when systolic blood pressure is persistently ≥150 mm Hg, with a target of <150 mm Hg. 

Treatment goals should be selected through periodic discussion of benefits and harms with the patient. The guidelines emphasize that while aggressive BP control below 140 mm Hg may provide additional benefit in select patients, the incremental benefit is small with inconsistent results across outcomes. Nonpharmacologic interventions—including weight loss, the DASH diet, and increased physical activity—should be considered as first-line therapy or used concurrently with medications, as they typically have fewer side effects.

Accurate BP measurement is essential before initiating or changing treatment, using multiple readings in clinical settings (2-3 readings separated by 1 minute in a seated, resting patient) or ambulatory/home monitoring.

Renal Denervation Therapy (RDN)

The 2025 ACC/AHA guidelines recommend RDN be reserved for adults with resistant hypertension who develop intolerable side effects to optimal antihypertensive regimens. The American Heart Association emphasizes that RDN is particularly appropriate for patients with resistant hypertension or multiple medication intolerances.

Renal denervation (RDN) received FDA approval in 2023 as an adjunctive treatment for hypertension, following multiple rigorous sham-controlled trials demonstrating modest but consistent BP-lowering efficacy. Both radiofrequency (Symplicity Spyral) and ultrasound (Paradise) catheter systems are approved and reduce 24-hour ambulatory systolic BP by approximately 3-5 mm Hg compared to sham procedures.

This procedure is being performed at a local hospitals in Monmouth and Ocean counties.

Patient selection requires multidisciplinary evaluation by teams with expertise in resistant hypertension and RDN. Before RDN consideration, clinicians must exclude pseudoresistance (white-coat hypertension, medication nonadherence), optimize medical therapy, screen for secondary causes (particularly primary aldosteronism), and confirm uncontrolled hypertension with out-of-office BP monitoring. 60-70% of patients experience a meaningful reduction (≥5 mm Hg) in ambulatory systolic BP, and individual response varies.

Long-term data show sustained efficacy and safety up to 10 years. However, RDN should not be considered curative or a replacement for antihypertensive medications, given modest BP reductions and absence of cardiovascular outcome trials.

Talk to your healthcare provider regarding the importance of hypertension recognition, and the latest in management options that are available today. 

Aditya Mehra, MD, FACC, FSCAI

Director-Heart & Vascular Center 

Ocean University Medical Center/Hackensack Meridian

CEO- Cardiology Associates Of Ocean County, Brick, NJ

Office-732-458-7575