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CLINICAL STATEMENTS AND GUIDELINES

September 16, 2025 Circulation. 2025;152:e114–e218. DOI: 10.1161/CIR.0000000000001356 e202

4 Bull S, Loudon M, Francis JM, et al. A prospective, double-blind, randomized

controlled trial of the angiotensin-converting enzyme inhibitor Ramipril In Aor­ tic Stenosis (RIAS trial). Eur Heart J Cardiovasc Imaging. 2015;16:834–841. 5.	 Yang LT, Pellikka PA, Enriquez-Sarano M, et al. Diastolic blood pressure and heart rate are independently associated with mortality in chronic aortic re­ gurgitation. J Am Coll Cardiol. 2020;75:29–39. 6.	 Ochiai T, Saito S, Yamanaka F, et al. Renin-angiotensin system blockade therapy after transcatheter aortic valve implantation. Heart. 2018;104:644–651. 7.	 Otto CM. Heartbeat: beta-blockers for aortic regurgitation. Heart. 2016;102:165–167. 8.	 Aronow WS. Hypertension, aortic stenosis, and aortic regurgitation. Ann Transl Med. 2018;6:43. 9.	 Elder DH, Wei L, Szwejkowski BR, et al. The impact of renin-angiotensin-

aldosterone system blockade on heart failure outcomes and mortality in patients identified to have aortic regurgitation: a large population cohort study. J Am Coll Cardiol. 2011;58:2084–2091.

5.3.7 Aortic Disease

1 Rooprai J, Boodhwani M, Beauchesne L, et al. Central hypertension in pa­

tients with thoracic aortic aneurysms: prevalence and association with an­ eurysm size and growth. Am J Hypertens. 2022;35:79–86. 2.	 Altobelli E, Rapacchietta L, Profeta VF, et al. Risk factors for abdominal aor­ tic aneurysm in population-based studies: a systematic review and metaanalysis. Int J Environ Res Public Health. 2018;15:2805. 3.	 Kobeissi E, Hibino M, Pan H, et al. Blood pressure, hypertension and the risk of abdominal aortic aneurysms: a systematic review and meta-analysis of cohort studies. Eur J Epidemiol. 2019;34:547–555. 4.	 Hibino M, Otaki Y, Kobeissi E, et al. Blood pressure, hypertension, and the risk of aortic dissection incidence and mortality: results from the J-SCH Study, the UK Biobank Study, and a meta-analysis of cohort studies. Circula­ tion. 2022;145:633–644. 5.	 Otaki Y, Watanabe T, Konta T, et al. Effect of hypertension on aortic artery disease-related mortality; 3.8-year nationwide community-based prospec­ tive cohort study. Circ J. 2018;82:2776–2782. 6.	 Howard DP, Banerjee A, Fairhead JF, et al. Age-specific incidence, risk fac­ tors and outcome of acute abdominal aortic aneurysms in a defined popula­ tion. Br J Surg. 2015;102:907–915. 7.	 Jaeger BC, Bress AP, Bundy JD, et al. Longer-term all-cause and cardiovas­ cular mortality with intensive blood pressure control: a secondary analysis of a randomized clinical trial. JAMA Cardiol. 2022;7:1138–1146. 8.	 Sweeting MJ, Thompson SG, Brown LC, et al. Meta-analysis of individual patient data to examine factors affecting growth and rupture of small ab­ dominal aortic aneurysms. Br J Surg. 2012;99:655–665. 9.	 Isselbacher EM, Preventza O, Black JH 3rd, et al. 2022 ACC/AHA guideline

for the diagnosis and management of aortic disease: a report of the Ameri­ can Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation. 2022;146:e334–e482.

5.3.8 Hypertension Treatment in Patients With CKD

1.	 Wright JT Jr, Williamson JD, Whelton PK, et al. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 2015;373:2103– 2116. 2.	 Aggarwal R, Petrie B, Bala W, et al. Mortality outcomes with intensive blood pressure targets in chronic kidney disease patients. Hypertension. 2019;73:1275–1282. 3.	 Malhotra R, Nguyen HA, Benavente O, et al. Association between more intensive vs less intensive blood pressure lowering and risk of mortality in chronic kidney disease stages 3 to 5: a systematic review and metaanalysis. JAMA Intern Med. 2017;177:1498–1505. 4.	 Xie X, Liu Y, Perkovic V, et al. Renin-angiotensin system inhibitors and kidney and cardiovascular outcomes in patients with CKD: a bayesian network metaanalysis of randomized clinical trials. Am J Kidney Dis. 2016;67:728–741. 5.	 Wu HY, Huang JW, Lin HJ, et al. Comparative effectiveness of reninangiotensin system blockers and other antihypertensive drugs in patients with diabetes: systematic review and bayesian network meta-analysis. BMJ. 2013;347:f6008. 6.	 Plantinga LC, Miller ER 3rd, Stevens LA, et al. Blood pressure control among persons without and with chronic kidney disease: US trends and risk factors 1999-2006. Hypertension. 2009;54:47–56. 7.	 Bangalore S, Toklu B, Gianos E, et al. Optimal systolic blood pressure target after SPRINT: insights from a network meta-analysis of randomized trials. Am J Med. 2017;130:707–719.e708. 8.	 Molnar MZ, Kalantar-Zadeh K, Lott EH, et al. Angiotensin-converting en­

zyme inhibitor, angiotensin receptor blocker use, and mortality in patients with chronic kidney disease. J Am Coll Cardiol. 2014;63:650–658. 9 Wright J, Jackson T., Bakris G, Greene T, et al. Effect of blood pressure

lowering and antihypertensive drug class on progression of hypertensive kidney disease: results from the AASK trial. JAMA. 2002;288:2421–2431. 10.	 Brenner BM, Cooper ME, de Zeeuw D, et al. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med. 2001;345:861–869. 11.	 Lewis EJ, Hunsicker LG, Clarke WR, et al. Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. N Engl J Med. 2001;345:851–860. 12.	 Yusuf S, Teo KK, Pogue J, et al. Telmisartan, ramipril, or both in patients at high risk for vascular events. N Engl J Med. 2008;358:1547–1559. 13.	 Holtkamp FA, de Zeeuw D, Thomas MC, et al. An acute fall in estimated glomerular filtration rate during treatment with losartan predicts a slower decrease in long-term renal function. Kidney Int. 2011;80:282–287. 14.	 Clase CM, Barzilay J, Gao P, et al. Acute change in glomerular filtration rate with inhibition of the renin-angiotensin system does not predict subsequent renal and cardiovascular outcomes. Kidney Int. 2017;91:683–690. 15.	 McCallum W, Tighiouart H, Ku E, et al. Acute declines in estimated glo­ merular filtration rate on enalapril and mortality and cardiovascular out­ comes in patients with heart failure with reduced ejection fraction. Kidney Int. 2019;96:1185–1194. 16.	 Bhandari S, Mehta S, Khwaja A, et al. Renin-angiotensin system inhibition in advanced chronic kidney disease. N Engl J Med. 2022;387:2021–2032. 17.	 Fried LF, Emanuele N, Zhang JH, et al. Combined angiotensin inhibition for the treatment of diabetic nephropathy. N Engl J Med. 2013;369:1892– 1903. 18.	 Mann JF, Schmieder RE, McQueen M, et al. Renal outcomes with telmis­

artan, ramipril, or both, in people at high vascular risk (the ONTARGET study): a multicentre, randomised, double-blind, controlled trial. Lancet. 2008;372:547–553.

5.3.8.1 Hypertension After Kidney Transplantation

1 Kasiske BL, Anjum S, Shah R, et al. Hypertension after kidney transplanta­

tion. Am J Kidney Dis. 2004;43:1071–1081. 2.	 Malhotra R, Katz R, Weiner DE, et al. Blood pressure, chronic kidney disease progression, and kidney allograft failure in kidney transplant recipients: a sec­ ondary analysis of the FAVORIT trial. Am J Hypertens. 2019;32:816–823. 3.	 Chatzikyrkou C, Schmieder RE, Schiffer M. Update on treatment of hyper­ tension after renal transplantation. Curr Hypertens Rep. 2021;23:25. 4.	 Eleftheriadis G, Naik MG, Osmanodja B, et al. Office or home versus 24hour blood pressure measurement in stable kidney transplant recipients. Nephrol Dial Transplant 2024;28:gfae076. 5.	 Tutone VK, Mark PB, Stewart GA, et al. Hypertension, antihypertensive agents and outcomes following renal transplantation. Clin Transplant. 2005;19:181–192. 6.	 Natale P, Palmer SC, Jaure A, et al. Blood pressure lowering for kidney transplant recipients: systematic review with network meta-analysis. J Hy­ pertens. 2024;42:848–855. 7.	 Mortensen LA, Jespersen B, Helligsoe ASL, et al. Effect of spironolac­

tone on kidney function in kidney transplant recipients (the SPIREN tri­ al): a randomized placebo-controlled clinical trial. Clin J Am Soc Nephrol. 2024;19:755–766.

5.3.9 Cerebrovascular Disease

1 Martin SS, Aday AW, Almarzooq ZI, et al. 2024 heart disease and stroke

statistics: a report of US and global data from the American Heart Associa­ tion. Circulation. 2024;149:e347-e913.

5.3.9.1 Acute Intracerebral Hemorrhage

1 Anderson CS, Heeley E, Huang Y, et al. Rapid blood-pressure lowering in pa­

tients with acute intracerebral hemorrhage. N Engl J Med. 2013;368:2355– 2365. 2.	 Ma L, Hu X, Song L, et al. The third Intensive Care Bundle with Blood Pres­ sure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT3): an international, stepped wedge cluster randomised controlled trial. Lancet. 2023;402:27–40. 3.	 Moullaali TJ, Wang X, Martin RH, et al. Blood pressure control and clinical outcomes in acute intracerebral haemorrhage: a preplanned pooled analysis of individual participant data. Lancet Neurol. 2019;18:857–864. 4.	 Manning L, Hirakawa Y, Arima H, et al. Blood pressure variability and out­ come after acute intracerebral haemorrhage: a post-hoc analysis of INTER­ ACT2, a randomised controlled trial. Lancet Neurol. 2014;13:364–373. 5.	 Arima H, Heeley E, Delcourt C, et al. Optimal achieved blood pressure in

acute intracerebral hemorrhage: INTERACT2. Neurology. 2015;84:464– 471.

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