What are the key recommendations in the American Heart Association (AHA) guidelines for cardiovascular care in 2025?

AHA 2025 Guidelines: Key Cardiovascular Care Recommendations

The American Heart Association's most recent 2023-2024 focused updates prioritize advanced cardiovascular life support protocols, with emphasis on vasopressor management, extracorporeal CPR, post-cardiac arrest care, and equity in resuscitation outcomes. 1

Advanced Cardiovascular Life Support (ACLS) Updates

Vasopressor Management in Cardiac Arrest

The 2023 AHA focused update provides clear algorithmic guidance for epinephrine administration during cardiac arrest:

• Epinephrine 1 mg IV/IO every 3-5 minutes is the standard vasopressor for all cardiac arrest rhythms 1
• For non-shockable rhythms (PEA/asystole): administer epinephrine as soon as feasible after recognizing the rhythm 1
• For shockable rhythms (VF/pVT): administer epinephrine after initial defibrillation attempts have failed 1

High-dose epinephrine (>1 mg doses) should not be used routinely, as it provides no survival benefit and may worsen outcomes 1

Alternative vasopressor strategies have limited evidence:

• Vasopressin alone or combined with methylprednisolone may be considered but offers no advantage over standard epinephrine 1
• These alternatives should not replace epinephrine as first-line therapy 1

Post-Cardiac Arrest Care Priorities

The 2023 update introduces new recommendations for:

• Extracorporeal CPR (ECPR) for selected patients with refractory cardiac arrest 1
• Early coronary angiography and percutaneous coronary intervention when indicated 1
• Targeted temperature management protocols 1
• Seizure prophylaxis and management strategies 1

Equity and Inclusion in Resuscitation

The 2023 guidelines formally introduce diversity, equity, and inclusion considerations into resuscitation protocols, recognizing disparities in cardiac arrest outcomes across different populations 1

Blood Pressure Management (2024 ESC Alignment)

While not specifically AHA 2025, the most recent cardiovascular guidelines emphasize aggressive blood pressure control:

Target systolic BP of 120-129 mmHg for adults receiving BP-lowering medications, provided treatment is well-tolerated 1

Key caveats for BP targets:

• More lenient targets for patients ≥85 years 1
• Individualized approach for those with symptomatic orthostatic hypotension 1
• Modified targets for moderate-to-severe frailty or limited life expectancy 1

Out-of-office BP measurement is essential to confirm targets and detect white-coat or masked hypertension 1

Cardiovascular Disease Prevention

Lipid Management

For patients with atherosclerotic cardiovascular disease, target LDL-C <55 mg/dL (1.4 mmol/L) with >50% reduction from baseline 1

Treatment algorithm:

1. Initiate high-intensity statin therapy 1
2. Add ezetimibe if target not achieved on maximally tolerated statin 1
3. Add PCSK9 inhibitor if target still not met 1
4. For statin-intolerant patients: ezetimibe + bempedoic acid ± PCSK9 inhibitor 1

Diabetes and Cardiovascular Protection

SGLT2 inhibitors with proven CV benefit are recommended for all patients with type 2 diabetes and established cardiovascular disease to reduce MACE and heart failure hospitalization 1

GLP-1 receptor agonists with proven CV benefit are recommended as alternative or additional therapy for CV risk reduction 1

Finerenone is recommended for patients with type 2 diabetes and diabetic kidney disease to prevent progression to symptomatic heart failure 1

Heart Failure Prevention and Treatment

SGLT2 inhibitors reduce heart failure hospitalization by 27-39% across multiple trials and should be used in asymptomatic patients with diabetes at risk for heart failure 1

For established heart failure with reduced ejection fraction:

• Dapagliflozin reduces the composite of worsening heart failure or cardiovascular death by 26% (HR 0.74) 1
• This benefit applies regardless of diabetes status 1

Peripheral Artery Disease (PAD) Management

Longitudinal Care Structure

Patients with PAD require multispecialty coordinated care with periodic vascular evaluation by experienced clinicians 1

Surveillance components:

• Aggressive cardiovascular risk factor management can yield 6.3 MACE-free years gained 1
• Functional status assessment using validated tools (VascuQOL-6, PADQOL, PAQ) 1
• Depression screening with Patient Health Questionnaire-9, as depression amplifies adverse outcomes 1

Medical Therapy for PAD

All patients with PAD should receive statin therapy targeting LDL-C <55 mg/dL 1 Antiplatelet therapy is essential for MACE prevention 1 Structured exercise programs increase pain-free and maximal walking distance 1

Lifestyle Interventions Across All Guidelines

Smoking cessation of any kind is mandatory to reduce risk of adverse events, MI, death, and limb ischemia 1

Mediterranean diet rich in legumes, fiber, nuts, fruits, and vegetables is recommended for CV disease prevention 1

Low- to moderate-intensity aerobic exercise (or high-intensity if tolerated) improves walking distance and cardiovascular outcomes 1

Alcohol intake should be minimized 1 Weight loss to achieve normal BMI is recommended 1

Critical Implementation Points

These 2023-2024 recommendations supersede all previous AHA advanced life support guidelines from 2020 1

All other 2020 AHA basic and advanced cardiovascular life support algorithms remain official recommendations where not specifically updated 1

Guidelines prioritize fatal and non-fatal CVD outcomes over surrogate endpoints like BP lowering alone 1