On July 25, 2025, the Japanese Society of Hypertension (JSH) released its new guidelines [1]. These updated guidelines are titled the “Guidelines for the management of elevated blood pressure and hypertension 2025” reflecting the inclusion not only of patients with hypertension but also those with elevated blood pressure levels even who do not meet the diagnostic criteria for hypertension. The aim is to provide detailed recommendations for managing these individuals as well.

In Japan, national health systems have established a well-structured framework for health screening and prevention of life related diseases. Additionally, due to universal health coverage, effective antihypertensive medications are widely available at low cost. Despite these favorable conditions, Japan ranks among the lowest among high-income countries in terms of blood pressure control at the population level [2]. To address this gap, several novel approaches have been incorporated into the new guidelines:

  1. 1.

    Three-Part Structure: The guidelines are organized into three distinct parts to clarify their targets and facilitate practical user:

  • Part 1 focuses on the general population and communities, providing an epidemiological overview and outlining a population-approach.

  • Part 2 centers on evidence-based standard treatment for patients with essential hypertension. Clinical questions were addressed through systematic reviews and meta-analyses, with results published in Hypertension Research (some in press). The intended users are primary care physicians and healthcare providers working alongside them.

  • Part 3 discusses the management of hypertension in specific clinical conditions that typically require specialist care.

  1. 2.

    Emphasis on Behavioral Interventions: In addition to theoretical recommendations, the guidelines compile as much evidence as possible regarding behavior-based interventions that can help individuals and patients achieve optimal blood pressure levels, including team-based approaches [3].

  2. 3.

    Blood Pressure Classification: The classification of blood pressure remains unchanged from the 2019 guidelines (JSH2019). Hypertension is defined as ≥140/90 mmHg, and high-normal blood pressure as 130–139/80–89 mmHg. However, it is now clearly stated that individuals with blood pressure ≥130/80 mmHg should be properly managed. This principle is connected to the “Asakatsu Blood Pressure Campaign” [4].

  3. 4.

    Home Blood Pressure Monitoring: The policy of prioritizing home blood pressure measurements continues from JSH2019. A new systematic review further supports its validity [5].

  4. 5.

    Target Blood Pressure Goal: A uniform target blood pressure of <130/80 mmHg is recommended, regardless of age, sex, or comorbidities. The previously used intermediate goal of 140/90 mmHg has been removed. This strong recommendation is based on systematic reviews and meta-analyses for clinical questions related to whether lowering BP below 130/80 mmHg is beneficial in the following groups:

  • General adult hypertensive patients [6]

  • Patients with a history of stroke [7]

  • Patients with heart failure with preserved ejection fraction [8]

  • Patients with chronic kidney disease (CKD) [9]

  • Patients with diabetes [10]

  • Older patients (aged ≥75 years) with hypertension [11]

The benefits of low target blood pressure goal outweighed the risks in all groups. At the same time, potential adverse effects specific to each condition are clearly noted, with guidance for primary care physicians.

  1. 6.

    Lifestyle Modifications: The fundamental approach remains unchanged from JSH2019. However, evidence is introduced supporting the use of urinary sodium-to-potassium ratio measurements to encourage increased potassium intake.

  2. 7.

    Pharmacological Treatment: First-line antihypertensive drugs (Group 1 medications) remain the same: long-acting dihydropyridine calcium channel blockers (CCBs), angiotensin II receptor blockers (ARBs), angiotensin-converting enzyme inhibitors (ACEIs), β-blockers, and diuretics. If blood pressure remains uncontrolled, early dose escalation or combination therapy is emphasized. Group 1 medications are preferred also for second-line therapy as well, though Goup 2 medications such as angiotensin receptor neprilysin inhibitor (ARNI) and mineralocorticoid receptor antagonist (MRA) may be used based on clinical context. The guidelines also stress the importance of appropriate use of diuretics and β-blockers, which are underutilized in Japan, for effective blood pressure control and disease management.

  3. 8.

    Renin-Angiotensin System Inhibitors: Based on recent systematic reviews, the preferential recommendation for renin-angiotensin system inhibitors in diabetes without proteinuria or microalbuminuria has been removed [12].

  4. 9.

    Hypertension in Women: In addition to addressing hypertensive disorders during pregnancy and menopause, the new guidelines include recommendations for antihypertensive treatment in the context of preconception care.

  5. 10.

    Elderly Patients: With an increasing number of healthy older adults, the guidelines shift from age-based to condition-based treatment recommendations. Special attention is given to frailty, the need for nursing care, and end-of-life situations, where individualized approaches are essential.

  6. 11.

    Onco-Hypertension: As cancer survivorship increases due to advances in oncology, the guidelines include a section on the management of hypertension in cancer survivors, incorporating perspectives from “onco-hypertension”.

  7. 12.

    Public Education – “10 Facts for Hypertension”: To counteract narratives that question the necessity of antihypertensive treatment, a supplementary section titled “10 Facts for Hypertension” has been created to inform and engage the general public with scientifically accurate information.

The Japanese Society of Hypertension and its committee on the guideline hope that the implementation of these guidelines will significantly improve the management of hypertension in Japan. They also hope that the evidence compiled herein will be of value on a global scale.