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CLINICAL STATEMENTS AND GUIDELINES September 16, 2025 Circulation. 2025;152:e114–e218. DOI: 10.1161/CIR.0000000000001356 e140 may cure hypertension in some adults with nonatheroscle rotic renal artery stenosis.4,6 Recommendation-Specific Supportive Text 1 Atherosclerotic disease in the renal arteries rep resents systemic disease and indicates higher risk for both kidney failure and cardiovascular morbidity and mortality. No RCT to date has demonstrated a clear clinical advantage of renal artery revasculariza tion (with either angioplasty or stenting) over medical therapy among individuals with hypertension.1–3 By meta-analysis, renal angioplasty with stenting results in a small reduction in DBP and antihypertensive medication requirement.2 On the basis of the CORAL (Cardiovascular Outcomes in Renal Atherosclerotic Lesions) trial, the recommended medical approach encompasses optimal management of hypertension with an antihypertensive regimen that includes a renin-angiotensin system (RAS) blocker, in addition to reduction of low-density lipoprotein cholesterol with a high-intensity statin, smoking cessation, HgbA1c reduction in patients with diabetes, and antiplatelet therapy.9 2 Revascularization can be favorable for select indi viduals with uncontrolled hypertension accompa nied by progressively worsening kidney function and/or acute HF who were not represented in RCTs.1–3 3 Revascularization may be considered for those with nonatherosclerotic renal artery disease (eg, fibromus cular dysplasia, Takayasu arteritis in select cases) and hypertension and may be curative.6 Fibromuscular dysplasia is most common in women (90%) and may present at a younger age (mean age 53 years) with almost equal frequency in the renal and carotid circu lations.5 Percutaneous transluminal angioplasty alone without stenting can improve BP control and even normalize BP, especially in patients with recent onset of hypertension or resistant hypertension.4,6 3.2.3.3 Obstructive Sleep Apnea Recommendations for OSA Referenced studies that support the recommendations are summarized in the Evidence Table. COR LOE Recommendations 2a B-R 1 In adults with hypertension and OSA who are overweight or obese, weight loss interventions when combined with continuous positive airway pressure (CPAP) treatment can be effective in reducing SBP.1 2a B-R 2 In adults with resistant hypertension and moderate-to-severe OSA, CPAP treatment can be useful in reducing BP.2,3 Synopsis OSA is a chronic condition characterized by recurring up per airway obstruction during sleep, resulting in hypoxia and disrupted sleep.4 Diagnostic criteria and screening methods for OSA can be found in Table 10 and Section 3.2.3 (“Secondary Forms of Hypertension”). Moderateto-severe OSA is associated with an increased risk of hypertension, CVD events, and mortality.5,6 Antihyperten sive medications can treat hypertension in adults with OSA.7 Weight loss in conjunction with CPAP therapy can reduce BP levels in adults with OSA who are over weight or obese.1 Additionally, some studies have shown that CPAP can reduce BP levels in adults with OSA and resistant hypertension.2,3 Although CPAP is an effective therapy for OSA,8 data do not support the use of CPAP for the prevention of CVD events or mortality in adults with moderate-to-severe OSA.9 The role of sleep sur gery, including newer device therapy such as hypoglossal nerve stimulation, has been investigated in the treatment of OSA, but the benefit for BP has not been observed in large RCTs to date.10,11 Recommendation-Specific Supportive Text 1 Lifestyle interventions are recommended for all individuals with high BP (Section 5.1, “Lifestyle and Psychosocial Approaches”), including adults with OSA and hypertension. Obesity is a risk factor for OSA.1 A meta-analysis examining the impact of weight loss interventions on BP in adults with OSA demonstrated small effects on SBP (−1.86 mm Hg; 95% CI: −3.57 to −0.15 mm Hg) and DBP (−2.07 mm Hg; 95% CI: −3.79 to −0.35 mm Hg).12 However, weight loss interventions when combined with CPAP therapy have been shown to lower SBP by 8 mm Hg in adults with moderate-to-severe OSA.1 Recent data from SURMOUNT OSA (Tirzepatide for the Treatment of OSA)13 demonstrated that tirzepatide versus placebo was associated with a reduction in BP at 48 weeks, a prespecified key secondary end point, among adults with moderate-to-severe OSA and obesity. For adults not on CPAP therapy, the estimated treatment difference for SBP was −7.6 mm Hg (95% CI: −10.5 to −4.8 mm Hg) and for DBP was −2.8 mm Hg (95% CI: −5.0 to −0.6 mm Hg), whereas for adults on CPAP therapy the esti mated treatment difference for SBP was −3.7 mm Hg (95% CI: −6.8 to −0.7 mm Hg) and for DBP was −1.1 mm Hg (95% CI: −3.2 to 1.0 mm Hg). 2. OSA is a secondary cause of hypertension (Section 3.2.3, “Secondary Forms of Hypertension”) and is associated with nocturnal hypertension and resis tant hypertension.14,15 Several RCTs have demon strated that short-term treatment with CPAP can reduce high office BP and ambulatory BP by 2 to 5 mm Hg,3 including among individuals with resis tant hypertension.2 However, these BP outcomes vary based on factors such as patient adherence to CPAP therapy, OSA severity, and presence of daytime sleepiness among study participants. Data Downloaded from http://ahajournals.org by on October 7, 2026