As 2025 draws to a close, there have been a number of important changes in the management of cardiovascular health.  When reviewing the work of the American College of Cardiology (ACC), American Heart Association (AHA), American Society of Preventive Cardiology (ASPC), National Lipid Association (NLA), and the American College of Clinical Endocrinology (ACCE), one of the most impactful works is the update to the high blood pressure guidelines.

High Blood Pressure Management Revamped

The theme of the new guidelines is improving the understanding of an individual’s risk of heart disease and then using that risk stratification to institute earlier and potentially more aggressive efforts to improve blood pressure to limit long term consequences such as heart failure, kidney failure, and dementia.  The American Heart Association PREVENT calculator, released 2023, has a number of improvements over the previous Pooled Cohort Equations (PCEs) from 2013.  PREVENT applies to 30-79 yo and provides 10- and 30-year chances of atherosclerotic cardiovascular disease (ASCVD) and heart failure, while the PCEs applied to 40-79 yo and provided only 10-year chance of ASCVD.  PREVENT also adds consideration of kidney and metabolic disease, as well as incorporation zip code as a social determinant of health.

Table 1. Blood Pressure Categories

• Incorporated into the new guidelines are suggestions of monitoring for end-organ damage, such as universal screening of urine albumin-to-creatinine ratio testing for patients being treated for high blood pressure.

• There are also suggestions to incorporate more data from out-of-office blood pressure measurement, recognizing the importance of white coat hypertension and masked hypertension.  ValidateBP.org gives examples of blood pressure machines for home use.

• Utilize a universal systolic blood pressure target <130 mmHg, favoring <120 mmHg for high-risk patients, with greater emphasis on limiting cognitive decline and dementia.  Treatment should be initiated early, after only 3-6 months of lifestyle changes.

• Reduce dietary sodium to <2,300 mg/day, with an eventual ideal goal of <1,500 mg/day.

• There is growing understanding of the need for addressing diets low in potassium, as the low potassium increases sodium retention. The target range for dietary intake is 3,500-5,000 mg/day, though excess potassium can be harmful or even fatal.

Table 2. Potassium-Rich Items

American Society of Preventive Cardiology Highlights

A variety of issues were presented in the latest updates from the American Society of Preventive Cardiology (ASPC), found here.

Understanding Women’s Cardiovascular Health

While the AHA PREVENT calculator shows improved performance at predicting risk compared to the prior PCEs, the improvement was inferior in women compared to men (https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2824692), suggesting a need for improved understanding of risk in women.  Perhaps some of that gap in prediction relates to a number of added risk factors shown below, with a woman having 3 or more of these providing comparable predictive value to having an abnormal coronary calcium score ≥100.  Risk is also increased with systemic inflammation, autoimmune disorders, and breast cancer. Of note, the inclusion of menopausal hormone therapy in Table 3 is nuanced and warrants its own blog post discussion. Briefly, greatest risk is attributed to oral formulation, administration more than 10 years after menopause, and when patient age is over 60 years old. Lastly, "risk" is important to understand, as there can be "absolute risk" and "relative risk", so this will need to be another blog post, otherwise this long post would become unbearable.

Table 3. Risk Enhancers of CV Risk in Women. Three or more conveys similar risk to CAC ≥100.

Download the official Evexeya Health form used to assess these cardiovascular disease risk factors in women. Even if you don't have an Evexeya Health physician, you can fill out this form and take it to your own physician to ensure they have the information.

Other Topics

• The ASPC document stresses the importance of universal screening of LDL-C, hsCRP, and Lp(a) for both primary and secondary prevention, though it does touch on the variable nature of Lp(a) testing as being an issue of which to be aware.

• The ASPC indicated an important focus for heart failure is on prevention, particularly targeting hypertension, diabetes, obesity, and dyslipidemia.  In addition, they addressed the importance of identifying those with early, asymptomatic left ventricular dysfunction with a goal of limiting progression.

• The use of a polygenic risk score, such as GPSMult (https://pubmed.ncbi.nlm.nih.gov/37414900/) was described as providing useful clinical information with similar predictive value as coronary artery calcium scoring.  However, the ASPC pointed out that the commercially available scores are not included in the guidelines and are not advocated by the guidelines, in part due to the lack of transparency around the scores and the need for formal evaluation in clinical trials.

Updated Acute Coronary Syndrome (ACS) Guidelines

Cholesterol Management

The ACS guidelines have been updated to further solidify important ideas, such as the importance of driving LDL to <70 mg/dL, potentially to <55 in high-risk populations.

Antiplatelet Agents

The use of dual antiplatelet therapy is recommended for at least 12 months unless at a high risk of bleeding.  Ticagrelor and prasugrel are favored over clopidogrel after ACS.  With higher risk of gastrointestinal bleeding, proton pump inhibitors can be considered.  With higher general risk of bleeding, it is reasonable to discontinue aspirin and utilize ticagrelor monotherapy ≥1 month after PCI.  With long-term anticoagulation, consideration of stopping aspirin 1-4 weeks after PCI and favor clopidogrel with anticoagulation.

General

• Radial PCI is increasingly favored over femoral access to limit complications. 

• Intracoronary imaging is increasingly being considered to improve intervention quality.

• Cardiac rehabilitation is strongly recommended given its impact on mortality, reduced MI recurrence risk, and limiting readmissions.

Remaining Points

When comparing the recent works from the National Lipid Association (NLA) and the American Association of Clinical Endocrinology (AACE), the NLA position leans to more aggressive lowering of LDL-C, stressing a “Lower LDL-C for longer is Better” and touching on how an LDL-C of 10-40 mg/dL is increasingly being recognized as safe and beneficial.  In counterpoint, the AACE strives for an LDL-C <70 mg/dL, suggesting the data supporting a role of LDL-C<55 mg/dL originates from a single study and that subsequent work has failed to demonstrate a meaningful benefit of pushing aggressively below 55 mg/dL.

The AACE also urges a degree of caution when treating hyperlipidemia in those without ASCVD, recommending against the use of PCSK9 mAb or bempedoic acid due to unproven benefit and/or caution of harm, such as gout, cholelithiasis, and tendon rupture with bempedoic acid.  Lastly, EPA-alone (icosapent ethyl) is recommended for triglycerides 150-500 mg/dL, but argues against using EPA-alone for triglycerides >500 mg/dL.  The AACE also recommends against the use of both niacin and combination EPA/DHA.