Humans

Importance: Hypertension, defined as office systolic blood pressure (SBP) 130 mm Hg or greater and/or diastolic blood pressure 80 mm Hg or greater, affects 43.9% of women and 49.5% of men in the US. Approximately 19.7% of patients treated for hypertension have apparent resistant hypertension (blood pressure ≥130/80 mm Hg) despite using 3 or more antihypertensive medications, preferably a renin-angiotensin system blocker, a calcium channel blocker, and a thiazide-type diuretic, at maximally tolerated doses.

Observations: Approximately 10% of patients treated for hypertension have true resistant hypertension confirmed with home or 24-hour ambulatory blood pressure monitoring to exclude white-coat hypertension (approximately 37.5% of apparent resistant hypertension) and after excluding medication nonadherence (approximately 50%) and secondary hypertension such as primary aldosteronism (approximately 5%-25%). Conditions associated with resistant hypertension include obesity, diabetes, chronic kidney disease, and sleep apnea. Resistant hypertension is associated with increased risk of cardiovascular death vs controlled blood pressure at 5 years to 10 years (absolute risk increase, 10.3% [95% CI, 8.7%-12.1%]). Lifestyle modifications for resistant hypertension include a low-sodium diet (<1500 mg/d), reducing or avoiding alcohol, 150 min/wk or more of aerobic exercise, and weight loss. Illicit drugs (eg, cocaine) and medications that increase blood pressure (eg, nonsteroid anti-inflammatory drugs, serotonin-norepinephrine reuptake inhibitors) should be avoided. Sleep apnea should be treated when diagnosis is confirmed. Pharmacologic optimization includes use of combination tablets of antihypertensives; intensifying diuretic therapy by using chlorthalidone; and sequential addition of antihypertensive medications using evidence-based algorithms. In a meta-analysis of 20 studies (9 randomized clinical trials [RCTs] and 11 observational studies [331 participants]), use of antihypertensive therapies that combine 2 to 3 medications into a single formulation reduced SBP by -3.99 mm Hg (95% CI, -7.92 to -0.07) vs equivalent doses given separately. For patients with apparent or true resistant hypertension who have an estimated glomerular filtration rate of 45 mL/min/1.73 m2 or greater and a serum potassium level of 4.5 mmol/L or less, adding spironolactone (25-50 mg/d) compared with placebo lowers office SBP by -13.3 mm Hg (95% CI, -17.89 to -8.72 [4 RCTs]) and 24-hour ambulatory SBP by -8.46 mm Hg (95% CI, -12.54 to -4.38 [2 RCTs]) in a network meta-analysis of 24 RCTs (3485 patients with resistant hypertension). A meta-analysis of 10 RCTs (2478 participants) reported that compared with a sham procedure, catheter-based renal denervation, which disrupts the sympathetic nerves in the renal artery walls, decreased 24-hour ambulatory SBP by -4.4 mm Hg (95% CI, -6.1 to -2.7) and office SBP by -6.6 mm Hg (95% CI, -9.7 to -3.6).

Conclusions and relevance: True resistant hypertension affects 10% of patients treated for hypertension and is diagnosed after excluding white-coat hypertension, medication nonadherence, and secondary hypertension such as primary aldosteronism. First-line treatment includes lifestyle modifications, diuretic therapy with chlorthalidone, and combination tablets of antihypertensives. Spironolactone and renal denervation decrease blood pressure in patients with true resistant hypertension.

Importance Accurate assessment of intravascular volume facilitates management decisions about fluid management in patients with volume overload.

Objective To identify the most accurate clinical examination, radiographic, and laboratory findings for assessing volume overload in nonintubated patients.

Data Sources and Study Selection MEDLINE was searched (1946 to January 6, 2026) to identify peer-reviewed English-language studies about the diagnostic accuracy of the clinical examination of spontaneously breathing patients with intravascular volume overload.

Data Extraction and Synthesis Three authors independently extracted data for each finding and calculated sensitivity, specificity, and likelihood ratios (LRs). A 2-level mixed logistic regression model was used to pool estimates.

Results Forty studies, involving 11 490 adult patients, were included, with a prevalence of volume overload of 35% to 69%. Thirty-three of those studies evaluated patients with dyspnea. Prevalence of volume overload was more likely when the physical examination revealed jugular venous distention with the highest point of pulsation more than 3 cm in a vertical line above the sternal angle (LR, 4.1 [95% CI, 2.9-5.6]; specificity, 92%), lower extremity edema (LR, 2.2 [95% CI, 1.5-3.1]; specificity, 80%), or crackles on auscultation (LR, 2.7 [95% CI, 1.7-4.5]; specificity, 81%). Vascular congestion on chest radiography increased the likelihood of intravascular volume overload (LR, 5.9 [95% CI, 2.9-12.0]; specificity, 91%). Point-of-care ultrasonography that identified bilateral pulmonary B-lines suggested volume overload (LR, 4.0 [95% CI, 2.6-6.1]; specificity, 77%), and absence of pulmonary B-lines made volume overload unlikely (LR, 0.09 [95% CI, 0.04-0.23]; sensitivity, 93%). Inferior vena cava collapsibility index of less than 50% increased the likelihood of volume overload (LR, 3.9 [95% CI, 2.5-6.1]; specificity, 79%), and a collapsibility index of at least 50% made it less likely (LR, 0.22 [95% CI, 0.11-0.45]; sensitivity, 82%). Point-of-care ultrasonographic measurement of jugular venous pressure (JVP; >8 cm) also increased the likelihood of volume overload (LR, 2.8 [95% CI, 2.2-3.5]; specificity, 71%), although JVP of 8 cm or less identified patients less likely to have volume overload (LR, 0.26 [95% CI, 0.20-0.33]; sensitivity, 81%). A plasma brain-type natriuretic peptide (BNP) level of 100 ng/mL or higher was the single best test to identify those most likely to have volume overload (LR, 6.9 [95% CI, 2.4-20.4]; specificity, 87%), and a normal value made it less likely (LR, 0.14 [95% CI, 0.08-0.24]; sensitivity, 87%).

Conclusions and Relevance A BNP level of 100 ng/mL or higher and presence of vascular congestion on chest radiography may be the most useful tests to identify patients with volume overload. Absence of pulmonary B-lines using point-of-care ultrasonography or BNP levels of less than 100 ng/mL may be most useful to exclude volume overload.

Aim: The "2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Dyslipidemia" retires and replaces the "2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol."

Methods: A comprehensive literature search was conducted from October 2024 to December 2024 to identify clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

Structure: The focus of this clinical practice guideline is to address the evaluation, management, and monitoring of individuals with dyslipidemias, including high blood cholesterol, hypertriglyceridemia, and elevated lipoprotein(a).

Keywords: ACC/AHA clinical practice guideline; HDL; LDL; anticholesteremic agents; atherosclerosis; atherosclerotic disease; cardiovascular disease; cardiovascular diseases; cholesterol; drug interactions; dyslipidemia(s); hydroxymethylglutaryl-CoA reductase inhibitors; hypercholesterolemia; hyperlipid(a)emia/s; hyperlipoproteinemia type II; hypertriglyceridemia; hypolipidemic agents; lipids; lipoprotein(a); primary prevention; risk adjustment; risk assessment; risk factors; simvastatin; statin(s); triglycerides.

The risk of recurrent ischemic stroke can be reduced by managing modifiable risk factors and instituting a regimen of mechanism-specific secondary stroke prevention. Strategies for secondary prevention should be instituted as early as possible. Poststroke monitoring of risk metrics, lifestyle behaviors, and medication recommendations is of key importance.