Reading Between the Guidelines: Perioperative Implications of the 2025 American Heart Association/American College of Cardiology Hypertension Update.

The 2025 American Heart Association/American College of Cardiology Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults introduces important updates to the classification, risk assessment, and treatment of hypertension. Notable changes include adoption of the Predicting Risk of Cardiovascular Disease EVENTs risk calculator, revised criteria for initiating pharmacotherapy, and a shift toward lower treated blood pressure targets. Yet these updates have limited direct application to the perioperative setting. Recommendations for surgical patients remain largely unchanged from prior iterations, with continued dependency on expert opinion and low-certainty evidence. Anesthesiologists are left to reconcile evolving outpatient management paradigms with conflicting perioperative data, including recent trials demonstrating no benefit from preoperative blood pressure optimization in noncardiac surgery. This narrative review examines the key updates from the 2025 Hypertension Guideline and their implications for perioperative care, identifies persistent knowledge gaps, and advocates for a multidisciplinary, individualized approach in which anesthesiologists assume active leadership in integrating evidence-based care across the surgical continuum.