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CLINICAL STATEMENTS AND GUIDELINES

Circulation. 2025;152:e114–e218. DOI: 10.1161/CIR.0000000000001356 September 16, 2025 e161

impact metabolic health (eg, thiazide-type diuretics, BB), outcome data do not demonstrate overt harm. Regardless of the weight loss strategy, weight regain is common and may lead to rebound worsening of BP.11,12

Recommendation-Specific Supportive Text

1 In a systematic review and meta-analysis of 6 RCTs

of patients with excess weight and without diabetes, use of GLP-1 receptor agonists demonstrated signifi­ cant reduction in BP, which was a prespecified sec­ ondary endpoint in the phase 3 STEP (Once-Weekly Semaglutide in Adults With Overweight or Obesity) tri­ als.13 In patients with overweight or obesity and without diabetes, the STEP 8 (Research Study to Investigate How Well Semaglutide Works Compared to liraglu­ tide in People Living With Overweight or Obesity) trial demonstrated significant and similar reduction in SBP with semaglutide (−5.7 mm Hg [95% CI: −8.1 to −3.3 mm Hg]) and liraglutide (−2.9 mm Hg [95% CI: −5.3 to −0.5 mm Hg]); significantly greater reduction in DBP was achieved with semaglutide (−5.0 mm Hg [95% CI: −7.0 to −3.1 mm Hg]) compared with lira­ glutide (−0.5 mm Hg [95% CI: −2.3 to 1.3 mm Hg]).3 In a prespecified substudy of the SURMOUNT-1 (Study of Tirzepatide in Participants With Obesity or Overweight) trial, 600 participants completed ambu­ latory BP monitoring with placebo-adjusted SBP change at 36 weeks of −8.0 mm Hg (95% CI: −10.6 to −5.4 mm Hg) for tirzepatide 15 mg, with similar changes in BP for 5- and 10-mg doses and with 70% of the change in BP mediated by change in weight.5

2 Bariatric surgery has demonstrated improvement

in obesity-related risk factor levels, including BP. In a randomized single-center trial conducted in Brazil, 100 adults aged 18 to 65 years with a BMI 30.0 to 39.9 kg/m2 were randomized to Roux-en-Y gastric bypass combined with antihypertensive therapy or antihypertensive therapy alone. At 5-year follow-up, there was greater reduction in number of antihyper­ tensive medications, with 81% versus 14% achieving at least a 30% reduction in number of medications in the surgical compared with the medical therapy arm (primary endpoint: relative risk: 5.91 [95% CI: 2.58-13.52]). In addition, SBP was significantly lower in the surgical arm (124 mm Hg [95% CI:119-128 mm Hg]) compared with medical therapy alone (131 mm Hg [95% CI: 126-136 mm Hg]).6 Similar findings were observed for BP benefit in a prospective obser­ vational study of US adults aged 18 to 72 years with a BMI >35.0 kg/m2 in which 418 patients underwent Roux-en-Y gastric bypass and were compared with 738 patients who did not undergo surgery, demon­ strating a significantly lower incidence in hyperten­ sion at 12 years follow-up.15 In LABS-2 (Longitudinal Assessment of Bariatric Surgery-2), a prospective cohort study of adults aged ≥18 years from 10 hospi­ tals in 6 US cities who underwent Roux-en-Y gastric bypass, weight regain was frequent, with median rate of weight regain of 27% of the maximum weight loss at 5 years after reaching nadir weight.12

5.3.3 Chronic Coronary Disease

Synopsis

Adults with CCD and hypertension are at increased risk of death compared with adults with CCD who do not have hypertension.1 Reducing SBP to <130 mm Hg can lower cardiovascular risk and mortality in adults with CCD and hypertension.2–5 Although there are scarce data on the optimal treatment target for DBP, when SBP is <130 mm Hg, a DBP between 70 and 80 mm Hg is associated with reduced cardiovascular events without an increase in serious adverse events.5,6 ACEi, ARB, and BB have been shown to reduce CVD events and all-cause death in adults with CCD and hypertension.7 Conflicting evidence exists regarding the long-term use of BB therapy (>1 year) in adults with CCD (eg, post-MI or post–acute coronary syn­ drome [ACS]) and hypertension with preserved left ven­ tricular ejection fraction.5,8 If additional antihypertensive medications are needed to achieve BP control, CCB, thi­ azide-type diuretics, and/or MRA are recommended.2,9,10 For additional information on the management of CCD, see Section 4.2.7 (“BP Management”) in the “2023 AHA/ ACC/ACCP/ASPC/NLA/PCNA Guideline for the Man­ agement of Patients With Chronic Coronary Disease.”5

5.3.4 Prevention of HF in Adults With Hypertension

Recommendations for the Prevention of HF in Adults With Hypertension References that support the recommendations are summarized in the Evidence Table. COR LOE Recommendations

1 B-R 1 In adults with hypertension, treating SBP to

<130 mm Hg is recommended to lower the risk of developing HF.1–4

1 B-NR 2.	 In adults with hypertension, treating DBP to <80

mm Hg is recommended to lower the risk of developing HF.1–5

Synopsis

Antecedent hypertension is present in 71% of patients with HF,6 and the presence of hypertension in people <40 years of age is highly associated with the development of inci­ dent HF.7 There is a dose-dependent association between BP level and HF risk, and long-term treatment of systolic and diastolic hypertension has been shown to reduce this risk.6,8,9 Meta-analyses of clinical trials support BP control, rather than a specific medication class, to prevent HF.10,11

Recommendation-Specific Supportive Text

1 In adults with systolic hypertension (SBP ≥130 mm

Hg) and a high risk of CVD, a strong body of evidence supports treatment with antihypertensive medications

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