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CLINICAL STATEMENTS AND GUIDELINES

September 16, 2025 Circulation. 2025;152:e114–e218. DOI: 10.1161/CIR.0000000000001356 e160

T2D is double that of age-matched adults without dia­ betes.13 Further, CVD risk in adults with both T2D and hypertension is more than double the risk for either con­ dition alone.14 Hypertension accelerates CKD, particu­ larly when moderate or severe albuminuria is present.

Recommendation-Specific Supportive Text

1 RCTs have shown that intensive BP goals are asso­

ciated with improved cardiovascular outcomes in the general population, and recently BPROAD confirmed the benefits of an intensive BP control regimen, spe­ cifically in patients with T2D.5 Of the 12 821 partici­ pants, improved cardiovascular outcomes were seen in patients ≥50 years with T2D and elevated SBP if they were assigned to an intensive BP target to lower SBP <120 mm Hg rather than a standard treatment strategy to lower SBP <140 mm Hg. Patients with diabetes were excluded from several major trials, including SPRINT.15 The ACCORD (Action to Control Cardiovascular Risk in Diabetes) trial enrolled patients with T2D at high risk for cardiovascular events but found that targeting an SBP of <120 mm Hg com­ pared with <140 mm Hg did not reduce the rate of a composite outcome of fatal and nonfatal MACE using a multifactorial design.1,16

2 There are few studies comparing DBP targets

in people with diabetes. Data from the HOT (Hypertension Optimal Treatment) trial, compar­ ing 3 DBP goals in patients with T2D, showed that DBP was reduced in each target group (target DBP ≤90 mm Hg, −20.3 mm Hg; target DBP ≤85 mm Hg, −22.3 mm Hg; target DBP ≤80 mm Hg, −24.3 mm Hg).6

3 Any of the recommended antihypertensive drug

classes (ACEi, ARB, CCB, and diuretics) are useful in the treatment of hypertension in diabetes.7–9,12

4 ACEi and ARB have greater efficacy in reducing uri­

nary albumin excretion among the drug classes. Therefore, an ACEi or ARB is recommended as part of treatment in patients with diabetes and CKD, defined by an eGFR <60 mL/min/1.73 m2, who also have moderate or severe albuminuria, defined as 30 mg albumin per g creatinine or greater.10,11 An ACEi or ARB is also appropriate for less severe CKD (stage 1 or 2 when moderate or severe albuminuria is present). No hypoglycemic agents are specifi­ cally indicated for BP lowering; however, among the new classes of hypoglycemic agents, sodium-glu­ cose cotransporter inhibitors (SGLT2i) and GLP-1 receptor agonists have been demonstrated to slow decline in kidney function whether or not diabetes is present and may have some beneficial effects on BP.17 For treatment of hypertension for people with CKD, including those with albuminuria (ie, ACR ≥30 mg/g or 24-hour urine albumin ≥30 mg), trial evidence to support benefits from ACEi or ARB specifically is strongest for those with moderate to severe albuminuria with or without diabetes.12 For people with CKD and high BP without albuminuria with or without diabetes, ACEi or ARB may be con­ sidered for CVD event reduction, although the risk for CKD progression may be lower and there is little evidence to support a unique advantage of these agents for kidney protection.18

5.3.2 Obesity and Metabolic Syndrome

Recommendations for Obesity and Metabolic Syndrome Referenced studies that support the recommendations are summarized in the Evidence Table. COR LOE Recommendations

2b B-R 1 In adults with hypertension who also have over­

weight or obesity with a BMI ≥27 kg/m2, incretin mimetics (eg, GLP-1 receptor agonists) when used for weight management may be effective as an adjunct to lower BP.1–4

2b B-R 2 In adults with hypertension who have obesity with

a BMI ≥35.0 kg/m2, bariatric surgery (when considered for weight loss) in combination with behavioral interventions and antihypertensive therapies may be effective at lowering BP.5,6

Synopsis

Obesity is a major modifiable risk factor for hyperten­ sion, with greater degrees of adiposity associated with higher BP levels. Obesity and hypertension often cooccur and with other obesity-related metabolic condi­ tions (eg, dysglycemia, dyslipidemia), and this cluster­ ing has traditionally been referred to as the metabolic syndrome, which is associated with increased risk of CVD.7 Metabolic syndrome, along with hypertension alone, is included in the AHA cardiovascular-kidneymetabolic (CKM) construct.8,9 CKM syndrome includes both individuals at risk for CVD due to the presence of metabolic risk factors and/or CKD, and individuals with existing CVD that is potentially related to or com­ plicates metabolic risk factors and/or CKD.8,9 Meta­ bolic syndrome has increased in recent years, with an estimated prevalence of 47% among US adults.10 Sex-specific risk factors for metabolic syndrome in­ clude gestational diabetes and hypertensive disorders of pregnancy (HDP). As obesity is a major cause of hypertension, strategies that target the underlying pathophysiology of excess or dysfunctional adiposity should be considered in hyperten­ sion management, including intensive lifestyle intervention (Section 5.1, “Lifestyle and Psychosocial Approaches”), pharmacotherapies,1–4,11 and bariatric surgery12,13 for weight loss. Among lifestyle interventions, the efficacy and safety of time-restricted eating as a strategy to improve metabolic health and lower BP remain unclear.14 While certain anti­ hypertensive therapies have been suggested to adversely

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