What are the latest American Heart Association (AHA) guidelines for managing cardiovascular conditions?

Latest AHA Guidelines for Cardiovascular Disease Management

Blood Pressure Management

The 2017 ACC/AHA guideline defines hypertension as blood pressure ≥130/80 mmHg and recommends treating to a target of <130/80 mmHg for most adults. 1

Key Blood Pressure Thresholds and Targets

• Hypertension is now defined as BP ≥130/80 mmHg, representing a significant change from the previous 140/90 mmHg threshold 1
• Target BP should be <130/80 mmHg for most adults, with encouragement to achieve systolic BP <120 mmHg when tolerated 1, 2
• For adults at increased cardiovascular risk (age >75 years, established vascular disease, chronic kidney disease, or Framingham Risk Score >15%), target systolic BP <130/80 mmHg 1
• For patients with heart failure with reduced ejection fraction (HFrEF) and hypertension, prescribe guideline-directed medical therapy titrated to achieve systolic BP <130 mmHg 1
• For patients with heart failure with preserved ejection fraction (HFpEF) and persistent hypertension after volume management, target systolic BP <130 mmHg 1

Diagnostic Approach

• Out-of-office BP measurements (home BP monitoring or ambulatory BP monitoring) should be used to confirm the diagnosis of hypertension and monitor treatment success 1
• BP measurements should be obtained twice at each visit and averaged 1
• This approach helps identify white-coat hypertension and masked hypertension, improving diagnostic accuracy 1

Treatment Initiation Strategy

For adults NOT on antihypertensive medication: 1

• Initiate treatment if BP ≥140/90 mmHg regardless of cardiovascular risk
• Initiate treatment if BP 130-139/80-89 mmHg AND high cardiovascular disease risk (defined as 10-year ASCVD risk ≥10%, diabetes, chronic kidney disease, or age ≥65 years)
• Begin with lifestyle modifications for all patients, adding pharmacotherapy based on the above criteria

For adults ALREADY on antihypertensive medication: 1

• Intensify treatment if BP remains ≥130/80 mmHg
• Adjust medications to achieve target BP while monitoring for adverse effects

Pharmacological Treatment

Initial drug selection: 1

• For non-black patients: Start with ACE inhibitor, ARB, calcium channel blocker, or thiazide-type diuretic
• For black patients (including those with diabetes): Start with calcium channel blocker or thiazide-type diuretic
• For patients with chronic kidney disease: Use ACE inhibitor or ARB as initial or add-on therapy to improve kidney outcomes 3

For resistant hypertension (BP uncontrolled on 3 medications including a diuretic): 1

• Add a mineralocorticoid receptor antagonist (spironolactone or eplerenone)
• Consider adding agents with different mechanisms of action
• Use loop diuretics in patients with chronic kidney disease
• Refer to a hypertension specialist if BP remains uncontrolled

Adherence Strategies

Critical implementation factors: 1

• Use once-daily dosing and combination pills to improve adherence (up to 25% of patients don't fill initial prescriptions, and only 1 in 5 achieves sufficient adherence)
• Implement team-based care approaches with nurses, pharmacists, and community health workers
• Utilize electronic health records and patient registries to identify uncontrolled hypertension
• Consider telehealth strategies as adjuncts to BP-lowering interventions

Cardiovascular Risk Assessment

For adults 40-79 years without established CVD, use the Pooled Cohort Equations to estimate 10-year ASCVD risk as the foundation for prevention decisions. 1, 4

Risk Calculation Components

The risk calculator includes: 4

• Age, sex, and race
• Total cholesterol and HDL cholesterol
• Systolic blood pressure and BP treatment status
• Diabetes status
• Smoking status

Risk-Based Treatment Decisions

For borderline risk (5% to <7.5% 10-year ASCVD risk) or intermediate risk (≥7.5% to <20%): 1

• Use additional risk-enhancing factors to guide preventive interventions (family history of premature ASCVD, chronic kidney disease, metabolic syndrome, inflammatory conditions, premature menopause, preeclampsia)
• Consider measuring coronary artery calcium score if treatment decisions remain uncertain (particularly useful for intermediate-risk patients)

For adults 20-39 years or those 40-59 years with <7.5% 10-year risk: 1

• Consider estimating lifetime or 30-year ASCVD risk to motivate lifestyle changes

Cholesterol Management

Use fixed-intensity statin therapy based on four major benefit groups. 4

Statin Benefit Groups

Group 1: Individuals with clinical ASCVD 4

• High-intensity statin therapy recommended
• Target LDL-C <55 mg/dL with >50% reduction from baseline for secondary prevention 5

Group 2: Individuals with LDL-C ≥190 mg/dL 4

• High-intensity statin therapy recommended regardless of ASCVD risk

Group 3: Individuals with diabetes aged 40-75 years with LDL-C 70-189 mg/dL 4

• Moderate- to high-intensity statin therapy recommended regardless of baseline LDL-C

Group 4: Individuals without diabetes aged 40-75 years with estimated 10-year ASCVD risk ≥7.5% 4

• Moderate- to high-intensity statin therapy recommended

Advanced Lipid Management

For patients with established ASCVD not at goal with statin therapy: 5

• Add ezetimibe as second-line therapy
• Add PCSK9 inhibitors if LDL-C remains ≥55 mg/dL despite statin plus ezetimibe

Lifestyle Modifications

All patients should receive comprehensive lifestyle counseling as the foundation of cardiovascular prevention. 1, 4

Dietary Recommendations

Adopt a heart-healthy dietary pattern: 1, 4, 5

• Emphasize fruits, vegetables, whole grains, low-fat dairy products, fish, legumes, poultry, and lean meat
• Limit foods high in saturated fats, cholesterol, and trans fats
• Mediterranean diet rich in legumes, fiber, nuts, fruits, and vegetables is specifically recommended 5
• Reduce sodium intake to support BP control

Physical Activity

Exercise recommendations: 4, 5

• Adults: Regular moderate-to-vigorous physical activity most days of the week
• Children and adolescents: At least 60 minutes of moderate-to-vigorous physical activity daily
• For peripheral artery disease: Structured exercise programs to increase pain-free and maximal walking distance 5
• Low- to moderate-intensity aerobic exercise (or high-intensity if tolerated) improves cardiovascular outcomes 5

Tobacco Cessation

Complete cessation of all tobacco products is mandatory for all individuals. 4, 5

• Smoking cessation reduces risk of adverse events, MI, death, and limb ischemia in patients with peripheral artery disease 5

Weight Management

Achieve and maintain normal body mass index through caloric restriction and increased physical activity. 5

Diabetes Management in Cardiovascular Prevention

For patients with type 2 diabetes and established cardiovascular disease, use SGLT2 inhibitors with proven CV benefit to reduce major adverse cardiovascular events and heart failure hospitalization. 5

Glucose-Lowering Medications with CV Benefits

SGLT2 inhibitors: 5

• Recommended for all patients with type 2 diabetes and established CVD
• Reduce heart failure hospitalization by 27-39% across multiple trials
• Dapagliflozin reduces composite of worsening heart failure or cardiovascular death by 26%
• Should be used in asymptomatic patients with diabetes at risk for heart failure

GLP-1 receptor agonists: 5

• Recommended as alternative or additional therapy for CV risk reduction
• Use agents with proven cardiovascular benefit

Glycemic Targets

Target near-normal fasting plasma glucose and HbA1c <7% with individualization based on age and hypoglycemia risk 4

Special Populations

Women

Women with adverse pregnancy outcomes (preeclampsia, gestational hypertension, gestational diabetes) have increased future CVD risk. 4

• Screen for cardiovascular risk factors within 3 months postpartum
• Apply same risk assessment and treatment approaches using sex-specific risk equations

Older Adults (≥80 years)

For adults ≥85 years with symptomatic orthostatic hypotension, moderate-to-severe frailty, or limited life expectancy, consider more lenient BP targets around 140/90 mmHg. 1

• Balance benefits of BP lowering against risks of adverse effects in this vulnerable population

Implementation and Monitoring

Use a shared decision-making model between clinician and patient for all preventive interventions. 1, 4

Key Implementation Strategies

• Discuss potential benefits versus adverse effects of all interventions 4
• Conduct regular monitoring and reassessment of risk and treatment effectiveness 4
• Implement team-based care approaches with multidisciplinary involvement 1
• Utilize electronic health records and patient registries to track outcomes and quality metrics 1