Ep #156: Hypertension Guidelines for NP Boards: What Matters for the Exam vs Practice

Welcome to the Real Deal Nurse Practitioner Club, the podcast for nurses who are ready to pass their boards and thrive in their careers as real deal nurse practitioners. I’m Anna and I’m the Director of Nursing Content at Blueprint Test Prep. Whether you’re deep in exam prep or stepping into practice, I’ve got you. It is time to become the confident, knowledgeable NP that you’re meant to be. Let’s dive in. 

Hey, hey everyone. Welcome back to another episode. In our two main January episodes this month, we are going to cover some clinical practice guidelines that you want to know if you are taking boards soon. Now, of course, you want to keep up with guidelines for practice as well, but we are going to focus really on the content that is tested on for boards.

Now, to start, in today’s episode, we’re tackling a big topic that shows up over all NP certification exams, right? And that is hypertension guidelines. Now, a quick caveat before we jump in. The ACC/AHA released brand new hypertension guidelines in 2025, and they include some pretty big changes. But we also know that exams are typically several years behind big guideline updates. So, the NP board exams are not testing on these new 2025 guidelines, to our knowledge, as of this recording in January 2026.

Now, when will they do that switchover, you ask? Unfortunately, I don’t have that exact answer, but it typically takes at least a year or two. So, if you’re testing in 2026, you can bet that they are testing on the older 2017 guidelines. If you’re testing beyond 2026, well, they may still have some old guidelines lingering through 2027, but we just don’t know that exact day.

However, we always keep our courses up to date. So, you can always follow along with us on social media, on the podcast here, and do your review course before taking boards right when you’re in your prep time, and you’ll be studying with confidence knowing that you have the most up-to-date material that is aligned with the exams. And either way, you still want to be familiar with the new guidelines as you enter practice.

So today, I’m going to briefly walk you through what’s new, what’s still the same, and what you actually need to know for your test. And of course, if you want a deeper dive into hypertension guidelines, including all the nuances, the exceptions, how to apply them to case-style questions, well, definitely check out our full SMNP review courses and question banks. But let’s get into this episode.

We’re going to start with a knowledge check. Do the blood pressure categories change in the new 2025 guidelines? No, the categories from the 2017 ACC/AHA guidelines stay exactly the same, and that’s what you’re seeing on boards. So remember, normal, less than 120 over less than 80. Elevated is that 120 to 129 over less than 80. Stage 1 is still the systolic 130 to 139 over diastolic 80 to 89, and Stage 2 would be anything 140 or greater and or 90 and greater diastolic.

So, if you’ve already memorized those, well, congrats. You are golden. And even better news, your basic treatment structure still holds. Stage 1, lifestyle changes first, consider medication if risk is high. Stage 2, well, medication for most patients. No surprises here, and all of this is still fair game for the certification exam.

So, now you’re probably asking, Anna, what did change in 2025 then? And really, the biggest shift is the move away from the ASCVD 10-year risk score for clinical decision-making. So historically, boards have tested that Stage 1 hypertension with that ASCVD risk score of 10% or greater, we’re going to start medication. And that logic is still what you should use on your exam if you are testing here in 2026.

But in real-world practice, the PREVENT calendar is now the recommended tool, and it’s a pretty big upgrade. And so here’s what makes it different. It works for adults ages 30 to 79, and it predicts total cardiovascular disease risk, not just focusing on MI and stroke. It incorporates the A1c, albuminuria, and even social determinants of health. And it gives both 10-year and 30-year risk estimates. And overall, it’s just a lot more comprehensive and individualized.

But again, if you are studying for boards right now, don’t switch over your exam brain just yet. Test questions are still based on that ASCVD cutoff. So, clinical practice, we’re using that PREVENT calculator. Board exams, remember the ASCVD risk score.

The 2025 guidelines also place a bigger emphasis on lifestyle changes. I’m talking earlier, more aggressively, and with more detail. So, here are the highlights. Sodium recommendations: Generally, they recommend less than 2300 milligrams a day, but they say the optimal recommendation is less than 1500 milligrams a day. 

And the new recommendation for alcohol is actually that total avoidance is considered ideal. And then there’s also some updates with timing. They say that if Stage 1 hasn’t improved over 3 to 6 months of lifestyle changes, consider medication sooner.

And what’s the rationale behind all of this, you ask? Well, earlier blood pressure control may help reduce long-term cognitive decline and dementia risk. Now, there’s also expanded guidance on pregnancy-related hypertension and a stronger push to screen for secondary causes, including primary aldosteronism.

And that leads me to another little pop quiz here. Why is routine albuminuria screening emphasized in patients with hypertension? And a little hint here, this is absolutely something you want to know for your boards. This is absolutely tested on.

Well, remember, albumin in the urine is an early sign of organ damage. So, if caught early, providers can start ACE inhibitors or ARBs to help protect the kidneys and the cardiovascular system.

Okay, let’s talk about treatment, because this is a big one, both for boards and for practice. For Stage 2 hypertension, the new guidelines now formally recommend starting with combination therapy, especially if the patient’s blood pressure is significantly above their goal. And can you guess why this is?

Well, two lower-dose medications generally work better. They have fewer side effects, and they actually improve adherence, especially with fixed-dose combinations like combined lisinopril and HCTZ. And ultimately, this matches what many clinicians are already doing. It’s just now officially supported in the guidelines.

But let’s put our exam hats back on. Boards are still going to test you on the main first-line classes. And what are those? ACE inhibitors, ARBs, thiazides, and calcium channel blockers. Boards are still going to test you on when to start meds, what to do for Stage 1 versus Stage 2. And even the very basics of combination therapy is testable for Stage 2 hypertension.

But let’s recap. Here’s what you really need to know if you’re prepping for your NP exam right now at the release of this recording. Blood pressure categories are unchanged. Make sure you know those ranges. ASCVD is still the risk tool used on the exam. And remember that little memory trick that we have in our courses for Stage 1 hypertension, we think hyperTENsion and 10% of the ASCVD risk score. 

And know those first-line meds. Remember, thiazides, ACEs, ARBs, calcium channel blockers. Stage 1 and Stage 2 treatment thresholds still reflect that 2017 guideline logic. And of course, lifestyle management and early intervention are always fair game on the exams.

But that new PREVENT calculator, not being tested yet. Good to know for the real world, but not on your exams. Combination therapy for Stage 2 can still show up as a general concept, but you’re not expected to know the nitty-gritties.

And if you want a full breakdown of highly testable guidelines and what to know for the exams, definitely check out our review courses at npreviews.com. We go way deeper than we can in a single podcast episode.

I know that hypertension guidelines, and especially just big guideline updates in general, can feel really overwhelming. But the good news is, for your certification exam, the core principles haven’t changed. Learn your blood pressure categories, know your first-line meds, understand how to manage it basically for Stage 1 and Stage 2. And then in real-world practice, start getting familiar with that new calculator and push for earlier lifestyle intervention and combination therapy.

Thanks for listening to another episode of the Real Deal Nurse Practitioner Club. If you want more information  about the different types of support that we offer to students and new nurse practitioners, you can visit npreviews, with an S, dot com. We’ll see you next week.