The Curbsiders Internal Medicine Podcast – Episode #509

Fresh Hypertension Guidelines. West Philadelphia Doc Jordy Cohen Keeps Our Hypertension Management Fresh
Release Date: December 22, 2025
Guest: Dr. Jordana ("Jordi") Cohen, Nephrologist & Hypertension Specialist, University of Pennsylvania

Episode Overview

This action-packed episode welcomes back Dr. Jordana Cohen, a member of the AHA 2025 Blood Pressure Guideline writing committee, to break down the just-published fresh hypertension guidelines. The Curbsiders team (Drs. Matthew Watto and Paul Williams) and Dr. Cohen get into the weeds on blood pressure measurement, classification, diagnostic workup, treatment (including recent shifts in approach), the nuances of secondary hypertension, hypertension in special populations (pregnancy, the elderly), and much more. The lively discussion is loaded with practical pearls, memorable metaphors, and actionable teaching scripts for clinicians at every level.

Key Discussion Points & Insights

1. Why Hypertension Matters – Framing the Problem

• Cardiovascular & Cognitive Impact:
  • Hypertension is causally linked to cardiovascular disease, stroke, and, as new data show, dementia.

    “There’s decades of fantastic data showing causally that hypertension causes cardiovascular disease. We’ve got newer data too that hypertension causes dementia... No one wants to lose their brain.” – Dr. Cohen (06:16)

  • For every 20 mmHg higher systolic, the risk of a major cardiac event doubles.

[06:16–07:50]

• “Time in Target” Concept:
  • Not just about single BP value. Increasing time spent <120/80 is associated with better long-term outcomes.

    “The more, more often your blood pressure is less than 120 over long periods of time, the better you do in terms of cardiac risk.” – Dr. Cohen (07:14)

2. Accurate Blood Pressure Measurement – Eight Essential Elements

• Proper Measurement is Key:
  • Five-minute rest, legs/arms/back supported, empty bladder, avoid caffeine/exercise/food 30 min prior, validated device, measure over bare arm, avoid talking/positioning errors.

    “If we can’t do it that way, it’s really a random number generator…” – Dr. Cohen (09:21)

[09:21–13:56]

• Device Selection:

  • Only use validated, automated devices (find on validatebp.org).
  • Aneroid devices/manual cuffs: Out except for persistent arrhythmia (e.g., AFib). They otherwise become miscalibrated quickly.

    “In the office, we should be using automated devices… we really should be pushing away from using aneroid devices...” – Dr. Cohen (11:51)

• Home BP Monitoring (HBPM):

  • 1A recommendation: 2 readings AM + 2 readings PM for at least 3–7 days for diagnosis/management.
  • Involvement and education critical for patient reliability—always ask what device/method they’re using.

• Wearable Tech Not Ready:

  • Smartwatches & cuffless devices (even Apple Watch) are not validated for clinical hypertension diagnosis or management.

    “The data so far is quite, quite bad still that they’re not ready for use clinically... The sensitivity is 41%… so it’s worse than a coin flip.” – Dr. Cohen (13:56–17:45)

3. Prevalence and Initial Workup

• Prevalence:

  • 46% of US adults over age 40 have hypertension.

    “It’s 46% of US adults…” – Dr. Cohen (21:02)

• Initial Workup for Newly Diagnosed Hypertension:

  • Labs for all:
    • CBC
    • Basic Metabolic Panel (BMP)
    • Lipid panel
    • Hemoglobin A1c
    • TSH
    • Urinalysis and Urine protein-to-creatinine or albumin-to-creatinine ratio (new in 2025)

      “Not just diabetic patients! That’s what happens when you have three nephrologists on the guideline committee.” – Dr. Cohen (26:24)

  • Rationale:
    • Albuminuria/proteinuria: Early kidney involvement or secondary etiology (e.g., aldosteronism).
    • Other labs: Baseline for meds, secondary causes (e.g., polycythemia, thyroid).

• RENIN and ALDOSTERONE Testing:

  • Now recommended in all patients w/ BP ≥140/90 (stage 2). Not just for resistant hypertension.

    “It got buried... but there is a new TUBI recommendation to consider checking renin and aldo in anybody with a BP greater than or equal to 140/90…” – Dr. Cohen (29:18)

• Review Social/Medication History & Triggers:

  • Screen for: Alcohol, sleep apnea, NSAIDs, stimulants/ADHD meds, tizanidine, licorice, and over-the-counter/herbals.

4. Treatment Approach (2025)

• Immediate Treatment for Stage 2 (≥140/90):
  • Start fixed-dose combination therapy with two agents (unless contraindicated).

    “The guidelines now match everything I preached in our prior episode… you start right off the bat with a fixed dose combination that every single patient should get that ideally.” – Dr. Cohen (34:09)

[34:09–38:29]

• Fixed-Dose Combinations – Practical Pearls:

  • Improves adherence.
  • Olmesartan-based combos are Dr. Cohen’s #1 pick (covers HCTZ or amlodipine, and triple combos available); Valsartan 2nd line.
  • Losartan: Avoid unless no other option—less potent, variable metabolism.

    “Losartan’s really a challenge. …[With] Valsartan, even though it’s not as potent, you get so much bang for your buck in fixed-dose combo.” – Dr. Cohen (36:58)

• "Low and Slow" Titration Philosophy:

  • Especially in frail, elderly, or multi-drug intolerant patients: add low doses of more drugs rather than aggressively maximizing one agent.

    “The more you keep the drug at or below the median dose, the more bang you get for your buck… relative to adverse effects.” – Dr. Cohen (39:24)

• When to Check BP After Med Changes:

  • Wait ~2 weeks before rechecking and titrating, since effects are not immediate.

Notable Guidance for Stage 1 (130s/80s):

• Use the new PREVENT risk calculator (zip code/race-neutral) to assess 10-year ASCVD risk.
• If PREVENT risk ≥7.5%, DM, CKD, or known CAD: start meds at 130+.
• If lower risk: 3–6 months of lifestyle modification before reassessment.

5. Non-Pharmacologic & Lifestyle Modification Tips

• Dietary Potassium:

  • Food sources over supplements: potatoes (not fried), tomatoes, leafy greens, avocados.

    “I actually take the CKD list of high potassium foods that they wrongly tell patients to avoid, tear off the part… and I circle the high potassium foods and I’m like, these are the ones you should eat more of.” – Dr. Cohen (48:30)

• Salt Substitutes (Potassium Chloride):

  • Replace table salt 1:1 or 50:50 with potassium-based substitutes if culturally/practically feasible.
  • Caution in CKD or with certain drugs (ACE/ARBs, K-sparing diuretics).

• Processed Foods & Sodium:

  • Hidden sources: cheese, canned/jarred sauces. Most sodium comes from processed foods, not added salt.

• Lifestyle Modifications:

  • Abstain from alcohol (new in 2025: “really any alcohol is considered a teaching point to recommend to cut back.” – Dr. Cohen, 30:38).
  • Weight loss, increased activity, and revisiting social history for ongoing/lifestyle contributors.

6. Special Populations

Older Adults and Frail Patients

• BP Goal:

  • Less than 130 mmHg systolic for most elderly unless true intolerance.
  • “Asymptomatic orthostatic hypotension” is not an absolute contraindication anymore.

    “In patients with asymptomatic orthostatic hypotension, intensive blood pressure lowering didn’t really cause much harm at all and they did much better from a cardiovascular standpoint.” – Dr. Cohen (54:01)

• Isolated systolic hypertension (widened pulse pressure): still treat the systolic, adverse effects/fails seem related to frailty, not to low diastolic per se.

Hypertension in Pregnancy

• BP >140/90 before 20 weeks gestation = chronic hypertension.
• First-line in pregnancy:
  • Long-acting nifedipine, add labetalol as second, HCTZ as third line if needed.
  • Avoid ACE/ARB—unless significant albuminuria or kidney disease (stop as soon as pregnancy confirmed).
  • Home BP monitoring encouraged.
  • Aspirin prophylaxis: Baby aspirin (81mg) started in the second trimester for preeclampsia prevention in all hypertensive/high-risk pregnant patients.

7. Blood Pressure Crisis Terminology

• “Hypertensive Urgency” is Out:
  • Severe asymptomatic hypertension without end-organ damage = “chronic hypertension or chronic severe hypertension.”
  • Do NOT treat acutely with PRN IV/oral agents unless evidence of acute organ dysfunction.
  • Rapid lowering risks: ischemia, AKI, longer hospital stays.

    “If anyone is calling this hypertensive urgency… please, please, please shame them… That’s the key. Don’t treat it as something urgent. Don’t call it something urgent because that means you can potentially cause harm by trying to lower them too quickly.” – Dr. Cohen (64:49)

8. Other Hot Topics and Shifts in 2025 Guidelines

• Race-Based Treatment Algorithms Removed:

  • No more "ACE/ARB for non-Black, CCB/thiazide for Black" dichotomy.

    “That’s been removed from the guideline. That’s no longer part of it… the places that have achieved really great blood pressure control in black patients… have done these race-agnostic algorithms where you just get everybody to control fast regardless of whatever drug you use…” – Dr. Cohen (72:16)

• Renal Artery Stenosis:

  • Don’t routinely revascularize. Consider imaging/intervention only in true refractory HTN, unexplained rapid kidney function decline, unexplained albuminuria, or recurrent “flash” pulmonary edema, or in young women with FMD.

• GLP-1 Agonists:

  • BP benefits through weight loss, not direct antihypertensive effect.

Notable Quotes & Teaching Moments

• On the potential of smartwatch BP monitoring:

  “I would so much rather that Apple just sent people a notification saying, please go check in with your doctor every six months…” (16:11)

• On guideline changes:

  “The guidelines now match everything I preached in our prior episode.” (34:09)

• On home blood pressure monitoring:

  “Even the people that we think can’t [do home BP checks] usually surprise us.” (13:56)

• On potassium:

  “When you’re taking away one thing [salt], you add something back [potassium].” (48:30)

• On medical culture change:

  “If anyone is calling this hypertensive urgency in their outpatient note, in their inpatient note, please, please, please shame them. No longer considered acceptable practice.” (64:49)

Timestamps for Key Segments

• 06:16 – Why hypertension matters: disease risks & “time in target”
• 09:21 – Accurate BP measurement: technique, validated devices, home monitoring
• 13:56 – Wearables & blood pressure: why NOT to trust your Apple Watch (yet)
• 21:02 – Prevalence of HTN, transition to workup/labs
• 26:24 – Lab workup: what’s new (protein/albumin ratio; renin/aldo)
• 29:18 – Renin/aldosterone for stage 2, and nuances from the European guideline
• 34:09 – Treatment: fixed-dose combo as first-line for ≥140/90
• 39:24 – Low-and-slow vs. up-titrating: philosophy & evidence
• 44:24 – PREVENT risk calculator for stage 1 HTN
• 48:30 – Potassium, salt substitutes, and what foods to recommend
• 54:01 – BP goals in older/frail adults, “pulse pressure” concerns
• 59:05 – Hypertension in pregnancy: agents, home BP, aspirin
• 64:49 – The end of “hypertensive urgency” as a diagnosis
• 72:16 – Race-neutral prescribing & major guideline overhaul

High-Yield Take Home Points (from Dr. Cohen, [75:00])

• Never underestimate the importance of accurate BP measurement and a validated device—verify with patients what they’re actually using, especially with the rise of unproven wearables.
• HBPM is standard for diagnosis and management; involve and educate patients.
• Initiate fixed-dose combo therapy for Stage 2 HTN (≥140/90) unless clear contraindications.
• The urinalbumin-to-creatinine ratio and urinalysis should now be routine in new HTN workups.
• Consider renin/aldosterone for all with Stage 2 HTN (barriers to testing are removed; don’t overthink the need to stop antihypertensives).
• Potassium-rich foods are essential; pivot dietary advice to focus on these.
• Hypertensive urgency as a concept is obsolete; treat chronic severe HTN gently and with an eye toward long-term control, not rapid reduction.
• No more race-based initial therapy recommendations—just get people to goal, fast, with whatever classes are appropriate.
• For pregnancy or potential pregnancy, select agents appropriate to reproductive plans (nifedipine/labetalol/HCTZ).
• For the elderly and frail, goal remains <130 mmHg unless true intolerance.
• As a general philosophy: fast to goal, gentle with dose titration, specific with measurement, and broad with workup for secondary causes where suspicion remains.

Summary prepared for clinicians and trainees seeking a comprehensive, high-yield, and enjoyable update on the 2025 hypertension guidelines with practical implementation pearls by the field’s best.