Introduction

Japan has established a well-structured national health system facilitating routine health screening and the prevention of lifestyle-related diseases. In addition, universal health coverage ensures broad access to antihypertensive medications at a low cost. Despite such favorable conditions, Japan ranks among the lowest among the high-income countries in terms of population-level blood pressure (BP) control [1]. To address this gap in real-world BP management, the Japanese Society of Hypertension released its Guidelines for the Management of Elevated Blood Pressure and Hypertension 2025 (JSH2025) on August 29, 2025 [2]. The new guidelines incorporate several novel approaches aimed at improving hypertension management in clinical practice. In line with its mission to summarize the best available evidence on all aspects of elevated BP and hypertension management, the JSH2025 Task Force Committee developed a comprehensive evidence-based guideline [2]. This paper provides an overview of the key components and innovations presented by JSH2025.

Development framework, methodology, and structure

JSH2025 is structured in two distinct formats: a “Clinical Question (CQ)”-based format and a textbook-style descriptive format. In the CQ-based section, 19 CQs were addressed through systematic reviews (SRs) and meta-analyses, which served as the basis for developing evidence-based recommendation statements. The SR teams systematically identified and reviewed the relevant studies, evaluated the quality of each article based on the outcomes and study design, and synthesized the findings into a comprehensive body of evidence. This evidence was critically appraised and integrated into the recommendation development process. Both the anticipated benefits and potential harms were considered, and the strength and direction of each recommendation were determined accordingly. A modified Delphi method consisting of three rounds of online voting was used to reach an expert consensus, and the level of agreement for each CQ was documented within the guidelines.

For 11 clinical topics in which the evidence was insufficient to support a formal SR, but which were still deemed important for everyday clinical practice, consensus-based responses were developed as “Questions (Qs)” and presented in the textbook-style sections. In addition, for other relevant topics not covered by CQs or Qs, narrative descriptions were created based on a comprehensive review of the existing medical literature. The draft guidelines underwent an internal review by the JSH2025 Task Force Committee, followed by an external review by affiliated academic societies and a public comment process [2]. The feedback from these reviews was incorporated into the final version of the manuscript.

The guidelines are organized into three distinct parts to provide guidance for their intended users and facilitate practical application (Table 1). Part 1 addresses the general population and communities, providing an epidemiological overview and outlining a population-based approach. Part 2 focuses on evidence-based standard treatment for patients with essential hypertension. The CQs were examined through systematic reviews and meta-analyses, with the results published in Hypertension Research (some articles currently in press). This section is intended for primary care physicians and other healthcare professionals involved in the management of hypertension. Part 3 addresses the management of hypertension in specific clinical conditions that typically require specialist care.

Table 1 Structure of JSH2025 guidelines
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Classification and diagnostic criteria

The classification of BP remains consistent with the 2019 guidelines (JSH2019) [3]. Hypertension is defined as an office BP of ≥140/90 mmHg, and elevated BP as a value of 130–139/80–89 mmHg (Table 2) [2]. However, the updated JSH2025 guidelines explicitly state that individuals with BP ≥ 130/80 mmHg should be considered for appropriate management [2].

Table 2 Classification of blood pressure in adults
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Emphasis on home blood pressure monitoring

JSH2025 continues to prioritize home BP monitoring (HBPM) as a central component of hypertension diagnosis and management. This approach is supported by recent systematic reviews demonstrating that HBPM yields a greater antihypertensive effect than management based on office BP [4, 5]. The diagnostic thresholds for home BP remain unchanged: hypertension is defined as a value of ≥135/85 mmHg and elevated BP as 125–134/75–84 mmHg.

Cardiovascular risk stratification

Consistent with JSH2019, JSH2025 continues to base the cardiovascular risk assessment the on data derived from Japanese populations. Category I includes individuals with no prognostic factors other than elevated BP (e.g., sex (woman), aged <65 years, without diabetes mellitus, dyslipidemia, smoking, atrial fibrillation, proteinuria-positive chronic kidney disease [CKD], or cardiovascular disease). Category II includes sex (man), aged ≥65 year, dyslipidemia and/or smoking, but without cardiovascular disease, atrial fibrillation, diabetes, or proteinuria-positive CKD. Category III includes individuals with a history of cardiovascular disease, atrial fibrillation, diabetes mellitus, proteinuria-positive CKD, or three or more Category II risk factors. Each risk category is further stratified into low, moderate, or high risk based on office BP levels (Table 3) [2].

Table 3 Stratification of the risk of cardiovascular diseases based on office blood pressure
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Treatment initiation and assessment

Initial clinical evaluation and management should include confirmation of sustained BP elevation, exclusion of secondary hypertension, assessment of cardiovascular risk and organ damage, education on lifestyle modification, and determination of pharmacological therapy. These steps can be performed sequentially or concurrently based on the clinical need. At the initial visit, a comprehensive hypertension management plan should be established (Fig. 1) [2].

Fig. 1
Fig. 1The alternative text for this image may have been generated using AI.
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Initial planning of hypertension management according to the blood pressure level. If a patient presents following a referral for BP elevation through routine or specific health checkup, confirm persistent elevation and proceed according to the flowchart. *1: Structured lifestyle modification involves shared decision-making to establish treatment goals (e.g., blood pressure targets) and implement comprehensive lifestyle-based management accordingly. *2: If hypertension has been previously diagnosed and lifestyle modification advised, pharmacologic therapy may be initiated at the first visit. BP blood pressure. Translated and adapted from ref. [2]

Blood pressure treatment targets

The systematic reviews and meta-analyses conducted for JSH2025 support a target office BP of <130/80 mmHg in adults with hypertension [6], prior stroke [7], diabetes mellitus [8], and individuals aged ≥75 years [9]. In patients with heart failure with preserved ejection fraction (HFpEF), targeting a systolic BP < 130 mmHg was associated with a significant reduction in hospitalizations compared to higher targets [10]. In those with CKD, this target showed a trend toward reduced all-cause mortality [11]. However, intensive systolic BP lowering, particularly to values < 120 mmHg, was associated with an increased risk of adverse events, including symptomatic hypotension and acute kidney injury [6]. Notably, no serious adverse events specific to older adults or those with comorbidities were reported, and findings were generally consistent across subgroups and studies [7,8,9,10,11].

Based on this body of evidence, JSH2025 recommends a treatment target of BP < 130/80 mmHg, irrespective of age or comorbid conditions (Table 4) [2]. Regarding the target level for home BP, a value of <125/75 mmHg is recommended in Japan, based on the findings of the HOMED-BP and HONEST studies [2]. Nonetheless, BP reduction should be approached cautiously, with careful monitoring for potential adverse effects, such as symptomatic or orthostatic hypotension, acute kidney injury, and electrolyte disturbances (e.g., hyperkalemia). For individuals with elevated BP (130–139/80–89 mmHg) who are at a low to moderate cardiovascular risk and without target organ damage or diabetes, intensified lifestyle modification may be considered as an initial approach, taking into account clinical context and cost-effectiveness [2].

Table 4 Target blood pressure levels
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Lifestyle interventions

Lifestyle modifications are essential both before and after the initiation of antihypertensive therapy. The core approach is consistent with the JSH2019 recommendations (Table 5) [2]. However, JSH2025 introduces new evidence supporting the utility of urinary sodium-to-potassium (Na/K) ratio measurements to encourage potassium intake, as well as the inclusion of resistance training as a strategy for BP management [2]. Reduction in sodium intake to <6 g/day is observed to effectively lower BP. Both individual-level and population-level interventions implemented in communities, workplaces, schools, and households have demonstrated significant benefits [12]. An increased consumption of potassium-rich foods, including vegetables, fruits, and low-fat dairy products, is also recommended. A systematic review reported that dietary counseling and clinical care incorporating Na/K ratio monitoring devices are effective in reducing both systolic BP and sodium intake [13]. The JSH Working Group has proposed a urinary Na/K ratio target of <2 as an optimal threshold for BP control [14]. Regular aerobic and resistance exercise have been shown to be equally effective in lowering BP, and both are strongly recommended [15]. In addition to dietary and exercise intervention, comprehensive lifestyle modifications include appropriate weight management, moderation of alcohol consumption, smoking cessation, stress reduction, adequate sleep, and the avoidance of cold exposure and constipation [2].

Table 5 Lifestyle modification strategies
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Antihypertensive drug therapy

The major antihypertensive agents with a proven efficacy in preventing cardiovascular events include long-acting dihydropyridine calcium channel blockers (CCBs), angiotensin receptor blockers (ARBs), angiotensin-converting enzyme (ACE) inhibitors, low-dose thiazide diuretics, and β-blockers (including αβ-blockers). These agents are classified as Group G1 drugs in the JSH2025 guidelines (Table 6) [2]. Each drug class has compelling indications, contraindications, and clinical considerations that should be carefully evaluated when selecting appropriate therapy.

Table 6 Classification of antihypertensive drug classes used in stepwise combination therapy
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Based on the JSH2025 systematic review and meta-analysis, the previous preferential recommendation for renin–angiotensin system inhibitors in patients with diabetes mellitus without proteinuria or microalbuminuria has been removed [16]. Among the Group G1 agents, CCBs, ARBs, and ACE inhibitors are generally well-tolerated and widely prescribed in clinical practice in Japan; thus, they are categorized as Group G1a in the treatment algorithm. In contrast, the use of low-dose thiazide diuretics (including thiazide-like agents) and β-blockers remains relatively limited despite their established efficacy in Japan; these are designated as Group G1b (Table 6) [2].

An early initiation of antihypertensive therapy is recommended to achieve target BP. If adequate BP control is not achieved, treatment should be escalated per the STEP strategy, while ensuring that patients understand the rationale for therapy intensification and that tolerability is continuously assessed to avoid adverse events. In the STEP strategy, STEP 1 involves initiating monotherapy using a Group G1 agent; however, for patients with Stage II or III hypertension, or high-risk Stage I hypertension, it may be appropriate to initiate treatment from STEP 2. In principal, STEP 2 involves the combination of two Group G1 agents, and Group G2 agents may also be used when clinically appropriate (Fig. 2, Table 6) [2]. If BP remains uncontrolled, treatment should be advanced to STEP 3, triple combination therapy with Group G1 and G2 agents. In cases of persistent uncontrolled hypertension, a comprehensive reassessment of medication adherence, lifestyle modifications, and treatment regimens is essential. Referral to a hypertension specialist should be considered when appropriate [2].

Fig. 2
Fig. 2The alternative text for this image may have been generated using AI.
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Stepwise antihypertensive therapy for hypertension: strategies for achieving target blood pressure. *1: For patients aged ≥75 years or with impaired renal function (CKD stage 4 or eGFR <30 mL/min/1.73 m²), treatment should generally be initiated at half the standard dose of monotherapy. *2: ARNI should not be used concomitantly with ACE inhibitors. A washout period of at least 36 h is required when switching from an ACE inhibitor to an ARNI. According to the product label, ARNI should not be used as the initial drug for antihypertensive therapy in principle. *3: Loop diuretics are preferred in patients with eGFR <30 mL/min/1.73 m². *4: ARNI and MR antagonists may be used as alternatives given their natriuretic effects. *5: Evaluate and address factors affecting lifestyle modifications and medication adherence, such as adverse effects or polypharmacy. ARB angiotensin II receptor blocker, ARNI angiotensin receptor–neprilysin inhibitor, ACE angiotensin-converting enzyme, BP blood pressure, CKD chronic kidney disease, eGFR estimated glomerular filtration rate, MR mineralocorticoid receptor. Translated and adapted from ref. [2]

Behavioral and digital health interventions

In addition to theoretical recommendations, JSH2025 synthesizes the best available evidence on behavior-based interventions—such as team-based approaches [17] and digital device-based strategies [13, 18, 19]—that support individuals and patients in improving BP control [2]. In recent years, digital technologies such as smartphone applications, short message services (SMS), and web-based platforms have been increasingly employed for BP management in adults. Systematic reviews and meta-analyses conducted for the development of JSH2025 evaluated the effectiveness of digital health interventions in BP control. The findings indicated that smartphone-based interventions significantly reduced the systolic BP for up to 3 months in normotensive individuals and up to 6 months in patients with hypertension [18]. Moreover, the integration of digital tools, such as smartphone apps and SMS into routine care in combination with in-person consultations, was associated with further reductions in BP levels [19]. In addition, digital devices capable of measuring the urinary Na/K ratio or urinary sodium concentration have shown benefit in lowering both systolic BP and dietary sodium intake by supporting self-monitoring, dietary counseling, and clinical management [13]. However, further evidence is warranted to establish the long-term effectiveness and sustainability of these digital interventions [2, 5, 13, 18, 19].

Hypertension in women: a life-course approach

A life-course approach is essential for the prevention and management of cardiovascular risk in women. JSH2025 offers specific recommendations for the management of hypertension across key life stages in women, including the preconception period, pregnancy, and menopause. Preconception care should be provided to all individuals of reproductive age, regardless of pregnancy intention, to support both physical health and reproductive well-being. Hypertensive disorders during pregnancy are classified as high-risk conditions and require appropriate clinical management. Although the optimal target for pre-pregnancy blood pressure remains uncertain [20], achieving an adequate control of hypertension and comorbid conditions prior to conception is strongly recommended. Similar management strategies are advised during the interconception period, with the goal of improving the maternal and perinatal outcomes in subsequent pregnancies [2].

Hypertension in older adults

With the increasing number of healthy older individuals and the growing body of evidence on hypertension management in the elderly, it is now considered inappropriate to categorize older adults solely based on chronological age. JSH2025 shifts from age-based to condition-based treatment recommendations, minimizing the references to the term “elderly” and instead focusing on individual characteristics associated with aging [2]. For patients with hypertension aged ≥75 years who are functionally robust and tolerate treatment well, a systolic BP target of <130 mmHg is recommended [9]. Particular attention is given to frailty, need for long-term care, and end-of-life considerations, where individualized treatment approaches are essential (Table 7) [2]. In cases of physical or cognitive decline, treatment should be carefully individualized to the patient’s condition. A systematic review and meta-analysis conducted for JSH2025 demonstrated that intensive BP reduction in elderly patients (≥75 years) was beneficial, regardless of their frailty status [9]. In individuals with functional impairment or dementia, BP management should be individualized with special attention to fall risk and medication adherence [2].

Table 7 Categories for blood pressure management based on health and functional status in older adults aged ≥75 yearsa
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Onco-hypertension

With the growing number of cancer survivors, the management of hypertension in this population—commonly referred to as “onco-hypertension”—has become an increasingly important clinical concern. Hypertension is a prevalent comorbidity among patients with cancer, often occurring alongside cardiovascular toxicities, which can significantly affect patient health and treatment outcomes. The JSH2025 guidelines explicitly address this issue by incorporating perspectives on onco-hypertension. The bidirectional relationship between cancer and hypertension is mediated by shared risk factors such as aging, obesity, smoking, and diabetes. In addition, cancer therapies—including anti-angiogenic agents, Bruton’s tyrosine kinase inhibitors, platinum-based chemotherapies, and radiation—can induce hypertension via endothelial dysfunction and renal toxicity. Effective BP control is essential to reduce the risk of cardiovascular events and to ensure the uninterrupted continuation of cancer treatment. Antihypertensive management in cancer patients should follow current recommendations for high-risk hypertension (Table 6, Fig. 2) [2], with careful consideration of frailty, nutritional status, and potential drug–drug interactions [2].

Public education: “10 Facts for Hypertension”

In response to the growing public narratives questioning the necessity and effectiveness of antihypertensive therapy, a supplementary section entitled “10 Facts About Hypertension” has been developed (Fig. 3). This section aims to provide scientifically accurate, evidence-based information to the general public [2]. It is specifically designed to enhance the public understanding of hypertension, its associated health risks, and the critical role of antihypertensive treatment in mitigating these risks—particularly in the Japanese population. By presenting well-established facts in a clear and accessible format, this section aims to counteract misinformation and promote informed decision-making regarding BP management. Ultimately, the objective is to empower individuals to take proactive steps toward managing their health by equipping them with the knowledge necessary to understand the importance of consistent and appropriate management of elevated BP and hypertension.

Fig. 3
Fig. 3The alternative text for this image may have been generated using AI.
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“10 Facts About Hypertension” sheet. Translated and adapted from ref. [2]

Conclusion

Despite these favorable healthcare resources, an estimated 4.5 million individuals in Japan remain untreated despite being aware of their condition, and ~12.5 million have poorly controlled hypertension despite receiving treatment [2]. Therefore, efforts to reduce the number of individuals with inadequately controlled BP are urgently required. The Japanese Society of Hypertension and its Guidelines Committee hope that the implementation of JSH2025 will lead to substantial improvements in hypertension management in Japan. Furthermore, the evidence and recommendations outlined in the guidelines are expected to make a meaningful contribution to the advancement of hypertension care globally.