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CLINICAL STATEMENTS AND GUIDELINES

Circulation. 2025;152:e114–e218. DOI: 10.1161/CIR.0000000000001356 September 16, 2025 e163

ing a goal BP of <130/80 mm Hg. For detailed discus­ sion of AF management, see Section 5.2.8 and Table 3 in the “2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation.”1

5.3.6 Valvular Heart Disease

Synopsis

There are no recommendations based on sufficient­ ly strong evidence for the management of adults with hypertension and valvular heart disease other than for aortic stenosis or chronic aortic regurgitation.1 Uncon­ trolled hypertension among individuals with moderate to severe aortic stenosis and/or aortic regurgitation is as­ sociated with worsening symptoms, HFrEF, and death.2–5 Data support the use of antihypertensive medications to control BP in adults with aortic stenosis and/or chronic aortic regurgitation and hypertension. Among adults with severe aortic stenosis who have undergone transcath­ eter aortic valve implantation, the use of ACEi or ARB to achieve BP control is associated with reduced mortality.6 However, there are no data from RCTs that examined op­ timal BP targets for adults with hypertension and chronic aortic regurgitation. Chronic aortic regurgitation is often accompanied by a wide pulse pressure, and medications that lower heart rate may paradoxically increase SBP.7,8 The use of ACEi and ARB in adults with chronic mod­ erate to severe aortic regurgitation and hypertension is associated with reductions in cardiovascular events and lower all-cause mortality.9 For additional information on the management of aortic stenosis and chronic aortic re­ gurgitation and mitral regurgitation, including indications for appropriate consultation or referral to a primary or comprehensive Heart Valve Center, see Sections 3, 4.3, and 2.6 in the “2020 ACC/AHA Guideline for the Man­ agement of Patients With Valvular Heart Disease.”1 5.3.7 Aortic Disease

Synopsis

Hypertension is a major risk factor for AD, including thoracic aortic aneurysm,1 abdominal aortic aneurysm,2,3 and aortic dissection,4 resulting in AD-related mortal­ ity.5,6 The risk for abdominal aortic aneurysm rupture increases by 30% for each 10 mm Hg elevation in BP levels.6–8 Intensive BP management and optimal BP control (<130/80 mm Hg) are important for cardiovas­ cular risk reduction in patients with hypertension and AD, although patients may be asymptomatic.9 BB are recommended, although limited data exist on the op­ timal choice of antihypertensive medication and have generally been extrapolated from acute aortic syn­ drome management, such as for aortic dissection.9 Fu­ ture studies should focus on optimal antihypertensive medication therapy for patients with hypertension and AD. For information on the management of hyperten­ sion in AD in adults, see Sections 6.4.1, 7.3, and 9.4.1 in the “2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease.”9

5.3.8 Hypertension Treatment in Patients With CKD

Recommendations for Hypertension Treatment in Patients With CKD References that support recommendations are summarized in the Evidence Table. COR LOE Recommendations

1 A 1 For adults with hypertension and CKD as

identified by eGFR <60 mL/min/1.73 m2 or albu­ minuria ≥30 mg albumin/g creatinine, treatment should target an SBP goal of <130 mm Hg to decrease all-cause mortality.1–3

1 B-R 2 For adults with hypertension and CKD as

identified by eGFR <60 mL/min/1.73 m2 with albuminuria of ≥30 mg/g, RAASi (either with ACEi or ARB but not both) is recommended to decrease CVD and delay progression of kidney disease.4,5

Table 18.  GDMT for Patients With Hypertension and HFrEF Drug Class Notes on Use BB In patients with HFrEF, even if asymptomatic, use 1 of the 3 BBs proven to reduce mortality and hospitalizations (bisoprolol, carvedilol, metoprolol succinate). MRA In patients with symptomatic HFrEF, spironolactone or eplerenone is recommended to reduce morbidity and mortality if eGFR is >30 mL/min/1.73 m2 and potassium is <5.0 mEq/L. RAASi with ACEi or ARB or ARNi In patients with HFrEF and NYHA functional class II to III symptoms, ARNi is recommended to reduce morbidity and mortality.

When the use of ARNi is not feasible, ACEi or ARB is recommended to reduce morbidity and mortality.

SGLT2i SGLT2i are recommended in patients with symptomatic HFrEF to reduce hospitalization and cardiovascular mortality irrespective of the presence of type 2 diabetes. Additional GDMT to be added as indicated Hydralazine and isosorbide dinitrate For patients self-identified as Black with NYHA functional class III to IV HFrEF who are receiving optimal medical therapy, the com­ bination of hydralazine and isosorbide dinitrate is recommended to improve symptoms and reduce morbidity and mortality.

In patients with current or previous symptomatic HFrEF who cannot be given first-line agents, such as ARNi, ACEi, or ARB, because of drug intolerance or renal insufficiency, a combination of hydralazine and isosorbide dinitrate might be considered to reduce morbidity and mortality.

Modified with permission from Heidenreich et al.5 Copyright 2022 American Heart Association, Inc., and American College of Cardiology Foundation. ACEi indicates angiotensin-converting enzyme inhibitors; ARB, angiotensin receptor blockers; ARNi, angiotensin receptor-neprilysin inhibitors; BB, beta blocker; eGFR, estimated glomerular filtration rate; GDMT, guideline-directed medical therapy; HFrEF, heart failure with reduced ejection fraction; MRA, mineralocorticoid receptor antagonist; NYHA, New York Heart Association; RAASi, renin-angiotensin-aldosterone system inhibitors; and SGLT2i, sodium-glucose cotransporter inhibitors. Downloaded from http://ahajournals.org by on October 7, 2026