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CLINICAL STATEMENTS AND GUIDELINES

September 16, 2025 Circulation. 2025;152:e114–e218. DOI: 10.1161/CIR.0000000000001356 e162

and more-intensive rather than less-intensive inter­ vention (Section 5.2.7, “BP Goal for Patients With Hypertension”). In SPRINT, a more intensive interven­ tion that targeted an SBP <120 mm Hg significantly reduced the incidence of HF, a component of the primary outcome (HR: 0.62; 95% CI: 0.45-0.84).12 Meta-analyses of clinical trials have identified a simi­ lar beneficial effect of more-intensive SBP reduction on the incidence of HF,2–4 but the body of information from studies confined to trials that randomly assigned participants to different SBP targets is more limited and less compelling.1 In addition, the available trials were efficacy studies in which BP measurements were more consistent with guideline recommenda­ tions than is common in clinical practice, resulting in lower absolute values for SBP. For both of these rea­ sons, the SBP target recommended (<130 mm Hg) is higher than that used in SPRINT. 2.	 In adults with diastolic hypertension (DBP ≥80 mm

Hg) and a high risk of CVD, a strong body of evidence supports treatment with antihypertensive medications (Section 5.2.2, “BP Treatment Threshold and the Use of CVD Risk Estimation to Guide Drug Treatment of Hypertension”). Meta-analyses of clinical trials have identified a similar beneficial effect of DBP reduction on the incidence of HF,2–4 but the body of information from studies confined to trials that randomly assigned participants to different DBP targets is more limited and less compelling.1,5

5.3.4.1 HF With Reduced Ejection Fraction

Synopsis

Hypertension is the most common medical comorbid­ ity in patients with HF, and its prevalence among pa­ tients with heart failure with reduced ejection fraction (HFrEF), defined as left ventricular ejection fraction ≤40%, continues to rise.1 Hypertension is known to be a major risk factor for HFrEF directly through altera­ tions in cardiac structure and function in response to chronic pressure overload and indirectly through its associations with ischemic heart disease.2 In patients with HFrEF and hypertension, uptitration of HF GDMT to the maximally tolerated dose is recommended for hypertension control (Table 18). Clinical trials assess­ ing the impact of BP reduction on outcomes in patients with HFrEF and hypertension are limited, and the op­ timal BP goal is unknown; however, a goal SBP <130 mm Hg should at least be attained in patients with hy­ pertension and HFrEF. Diuretics should be added as needed for volume overload. Dihydropyridine CCB may be used to treat hypertension in patients with elevated BP despite the optimization of GDMT. Nondihydropyri­ dine CCB may be harmful in patients with HFrEF due to their negative inotropic effects and are not recom­ mended for hypertension management.3,4 For informa­ tion on the management of HFrEF in adults, see the “2022 AHA/ACC/HFSA Guideline for the Manage­ ment of Heart Failure.”5

5.3.4.2 HF With Preserved Ejection Fraction

Synopsis

Hypertension is a major risk factor for developing heart failure with preserved ejection fraction (HFpEF) and an important target for HF management to reduce hospital­ ization, CVD events, and mortality.1 Appropriate use of di­ uretics is crucial to the success of other antihypertensive medications in the presence of HFpEF and should be used for signs and/or symptoms of volume overload.1,2 RAASi are indicated for management of HFpEF to at­ tain an SBP of <130 mm Hg, especially with an MRA or ARNi, or ARB when ARNi is not feasible.1–3 BB are not recommended for hypertension management with HFpEF given negative chronotropic effects and should be restricted to specific comorbid conditions (eg, ar­ rhythmia, ACS).1,2 SGLT2i are used frequently for HFpEF treatment (with and without diabetes), unless contrain­ dicated, to reduce the risk of hospitalization and cardio­ vascular mortality.1,4–6 SGLT2i may lower BP; therefore, adjustment in other antihypertensive medications may be indicated if signs or symptoms of hypotension are pres­ ent.2,3,5 For more information on the management of and guidelines for HFpEF in adults, see the “2022 AHA/ ACC/HFSA Guideline for the Management of Heart Failure,” and the “2023 ACC Expert Consensus Decision Pathway on Management of Heart Failure With Preserved Ejection Fraction.”1,2

5.3.5 Atrial Fibrillation

Synopsis

Hypertension has the highest attributable risk for the de­ velopment of AF.1,2 It is present in >80% of patients with AF and is the most common comorbid condition, regard­ less of age.1,2 Both AF and hypertension increase in fre­ quency with age,3,4 and because of the close relationship between BP and AF, hypertension remains a key compo­ nent in several AF and CVD risk prediction scores.1,5 BP control in individuals with hypertension reduces the risk for incident AF,3,5 especially in patients with HF.6 In adults with AF and hypertension, optimal BP control reduces rates of MACE, including stroke.7 Lifestyle modifications that result in lower BP may decrease the recurrence of AF.1 Small studies and secondary analyses of RCTs re­ ported lower incident AF with ACEi or ARB,1 and 2 metaanalyses suggest reduction in recurrent AF with ACEi or ARB,8 although more definitive evidence is needed. RCTs and observational studies suggest that MRAs reduce AF burden.1,9 Control of hypertension is a key component of AF management,8 although optimal treatment targets for the management of hypertension in AF remain unclear. Therefore, it is reasonable to apply general hypertension guidelines to adults with AF,8 which would include attain­

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