Hypertension care has clearly shifted from an era of having evidence to an era of delivering evidence. The persistent reality that control rates remain suboptimal despite expanded diagnostic and therapeutic options reflects not a lack of knowledge or medications, but an “implementation gap” across the care continuum—screening, diagnosis, treatment intensification, and sustained support. The concept of “implementation hypertension” succinctly captures this challenge and has been positioned as a central unmet need in an era when multiple guidelines coexist [1]. To address this, the Japanese Society of Hypertension (JSH) has articulated a strategy that advances research and social implementation in parallel, built on three pillars: digital hypertension, implementation hypertension, and internationalization [2]. In addition, a core metric for measuring implementation—achievement of <130/80 mmHg (with further stratification by home BP < 125/75 mmHg)—has been proposed, emphasizing that implementation must be designed to improve the achievement rate itself [3].

What matters most in discussing the post–JSH 2025 outlook is not to reiterate the “correctness” of recommendations, but to design pathways that reliably deliver those recommendations into routine practice and society. The international significance of JSH 2025 and the challenges after its release have been summarized in a Hypertension Research editorial [4]. Building on this, JSH has proposed and promoted an implementation model that expands blood pressure (BP) measurement from a clinic-based act to a daily public behavior, through the declaration and actions of “Asakatsu BP” (Morning BP Action), focusing societal implementation on morning home BP < 130/80 mmHg [5].

The key point is not mere awareness-raising, but the deliberate design of an implementation chain that increases opportunities for measurement (access), ensures measurement quality (accuracy), and reliably links measurement data to treatment intensification [1]. In particular, the clinical and population-level application of kiosk BP measurement has been clearly proposed as an entry point for individuals who do not own home BP devices, those who struggle to sustain self-measurement, and those who are untreated or not yet engaged in care [6]. Figure 1 summarizes the updated management framework for overcoming implementation hypertension.

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Update management of implementation hypertension. AI artificial intelligence, PB blood pressure, PHR personal health record, Na/K sodium/potassium ratio, SAS sleep apnea syndrome, ARNi angiotensin receptor–neprilysin inhibitor, MRA mineralocorticoid receptor antagonist, SGLT2i sodium–glucose cotransporter 2 inhibitor, ASi aldosterone synthase inhibitor, siRNA small interfering RNA, NPRA natriuretic peptide receptor agonist, GLP-1/GIP RA glucagon-like peptide-1/glucose-dependent insulinotropic polypeptide receptor agonist, NT-proBNP N-terminal pro–B-type natriuretic peptide, UACR urinary albumin-to-creatinine ratio, PWV pulse wave velocity, CAVI cardio-ankle vascular index, RDN renal denervation

Reframing “care not achieved” as implementation science

Implementation hypertension represents a structural shortfall—not because therapeutic strategies are ineffective, but because effective strategies are not executed and/or not sustained [1]. Accordingly, future performance indicators should move beyond the merits of individual drug selection toward the execution of the care chain: (1) detection (screening), (2) diagnosis (use of out-of-office BP), (3) treatment initiation, (4) timeliness of intensification, (5) adherence and persistence, and (6) multidisciplinary and community linkage [1, 3].

“Home BP–centered” plus “morning-focused”: maximizing risk reduction with minimal behavior

A home BP–centered approach accelerates identification of white-coat and masked hypertension and masked uncontrolled hypertension, and supports earlier decisions on treatment intensification. A home BP–centered strategy has been systematized as an Asian consensus [7]. Moreover, translating the risk of morning hypertension into a national movement and designing measurement pathways (home, workplace, and kiosks) has been explicitly articulated as a declaration [5, 6].

Nighttime and sleep BP: toward full-scale 24-hour management

Nighttime BP has high prognostic value, and clinicians must address “the night” by integrating related conditions such as sleep apnea syndrome/obstructive sleep apnea (SAS/OSA), nocturnal hypoxia, insomnia, and nocturia. A framework has been presented that integrates nocturia and sleep BP (sleep BP excluding the influence of physical activity), aiming to detect pathological nocturnal hypertension while avoiding overestimation of nocturnal BP elevation [8]. In addition, daytime activity–BP responsiveness (actisensitivity) has been reported to relate to nocturnal dipping patterns and the morning surge, reinforcing the importance of understanding 24-hour BP in an integrated manner with behavior and sleep [9]. Furthermore, nocturnal hypertension has been shown to be prognostically relevant even in those of very advanced age, positioning it as a priority issue in aging societies [10]. To treat nocturnal BP as a therapeutic target, implementation of a clinical pathway that includes the division of roles among home monitoring, wearables, and ABPM—and linkage to sleep medicine—is essential [8, 10].

Seasonal variation and the living environment: “environmental hypertension” as a message from Japan to the world

In Japan, winter is characterized by amplified risk in the early morning due to indoor–outdoor temperature gradients, housing-related BP elevation, and heat-shock–related hazards. The “Morning BP Action in Winter” initiative has been proposed with its scientific rationale and public health significance [11]. Additionally, a perspective has been presented that reframes winter environmental factors as “life-environment disease” hypertension and positions Japan’s experience for international dissemination [12, 13].

Digital hypertension: connecting measurement, analytics, and intervention as a continuous “line”

Digital technology integrates novel measurement (including wearables), large-scale time-series analytics, feedback, and behavior change support (digital therapeutics), transforming hypertension management from episodic clinic “points” to continuous life “lines.” A review has summarized the overall landscape and implementation issues of digital hypertension [14]. Another perspective has proposed linking digital hypertension to anticipation medicine [15]. From the standpoint of implementation hypertension, digital tools are valuable not because they are “convenient,” but because they address core gaps: sustaining measurement, reducing delays in treatment intensification (therapeutic inertia), and supporting persistence of lifestyle change [1, 14]. As a concrete example, a systematic review and meta-analysis have synthesized the BP-lowering effects of smartphone app–based interventions [16]. Furthermore, the B-INDEX study identified determinants of BP-lowering effects of hypertension digital therapeutics (DTx), helping to operationalize “which design to deliver to which patient” and thereby advancing precision implementation [17].

In addition, the concept of Time-Space Network Hypertension has been proposed as a data-science framework integrating time axes (24 h, seasons) and space axes (living environment, community), potentially evolving digital hypertension into an integrated model; supplementary materials have also been published [18, 19]. A review focusing on medical devices and implementation has clarified key issues such as clinical workflow integration, standardization, and access disparities [20]. Finally, an integrated ecological framework for Digital-Social Hypertension Implementation has been proposed to comprehensively encompass digital innovation and societal implementation [21].

Hypertension-related conditions: stage B heart failure and stratification of kidney–metabolic risk

Hypertension lies upstream of heart failure, and frameworks to detect subclinical myocardial injury (Stage B) early may reshape the boundary between primary and secondary prevention. A Hypertension Research paper stratifying Stage B using home BP and cardiac biomarkers provides a concrete picture of clinical implementation [22]. In CKD risk strata (KDIGO risk categories), cardiovascular events have been shown to relate not only to office BP but also to home BP control, supporting the importance of linking kidney-risk stratification with home BP in implementation [23]. Moreover, even among individuals with left ventricular hypertrophy (LVH), home BP control status relates to prognosis, highlighting the value of integrating organ-damage stratification with home BP [24].

Resistant hypertension: implementing pharmacologic optimization plus device-based therapy (renal denervation)

Resistant hypertension often becomes the “final barrier” of implementation hypertension. Home BP or Ambulatory BP–confirmed resistant hypertension has been shown to carry an extremely high risk, underscoring the need for strict phenotyping and intensive intervention [25, 26]. For renal denervation (RDN), an ARDeC consensus has been published that reflects Asian characteristics (including the high prevalence of nocturnal and morning hypertension) and the potential for improving 24-h BP, organizing an implementation framework that includes patient selection, evaluation, and follow-up [27].

New drug therapies: connecting expanding options to the implementation chain

New drug therapies (e.g., RNA-interference–based mechanisms, aldosterone-pathway modulation, natriuretic peptide system approaches) provide options that may target mechanisms beyond what existing agents can achieve [28]. However, the key remains the ability to implement “who, when, and how intensively,” and to evaluate these therapies together with implementation challenges, including therapeutic inertia, adherence, and access disparities [1, 28].

Looking ahead, the role of Hypertension Research should extend beyond presenting evidence. It should help elevate implementation science to an international standard by measuring the implementation gap, designing pragmatic intervention pathways, and advancing blood pressure control in synchrony with society [2].