Manesh Patel, MD

Updating the Hypertension Treatment Landscape With Manesh Patel, MD

On August 14, 2025, the American Heart Association (AHA) and American College of Cardiology (ACC) released a revised set of clinical guidelines for the management of 

 among adults. Based on decisions from the ACC/AHA Joint Committee on Clinical Practice Guidelines, the “2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults” replaces the existing 2017 guidelines.

Investigators undertook a comprehensive examination of all recent research and developments in hypertension from December 2023 to June 2024, picking out key studies, reviews, and other evidence. These were collated and combined into the 2025 guidelines, which aim to provide clinicians with a “living” document for the treatment of hypertension.

“I think the guidelines highlight important features for people with difficult-to-manage or difficult-to-control blood pressure,” Manesh Patel, MD, chief of the divisions of cardiology and clinical pharmacology at the Duke University School of Medicine, said in an interview with 

. “The first is that somewhere around 47% – almost half – of Americans have high blood pressure. So when you have such a large number of people with high blood pressure, you obviously have a significant number of people who require more than one medication who might still be hypertensive.”

Patel noted several important takeaways from the updated guidelines, including an increased emphasis on lifestyle changes, the creation of the PREVENT calculator, and more aggressive treatment for stage 2 hypertension after the lowering of the threshold for stage 1 hypertension.

“For patients with stage 2 hypertension, greater than 140/90, they now prefer the use of at least two first-line antihypertensive medications of different classes, sometimes in a single pill or a fixed dose,” Patel told 

. “The guidelines also emphasize lifestyle changes; reducing sodium intake, limiting alcohol consumption, eating a heart-healthy diet, maintaining a healthy weight, physical activity, and managing stress.”

Patel also discussed the increasing focus on GLP-1 receptor agonists, noting the need for further research before incorporating them into the treatment cascade.

“Obviously, we await more studies with GLP-1 receptor agonists, as they will probably play a role in two places that the guidelines mentioned,” Patel said. “One is weight loss, and the second is, of course, an important potential therapeutic effect on cardiovascular events and also kidney events.”

Looking forward, Patel expressed his excitement for several upcoming treatments and trials in the hypertension sphere, pointing out aprocitentan and aldosterone antagonists, such as spironolactone.

“Because it’s such a large problem, we need more arrows in our quiver,” Patel said. “So, more therapeutics are really great. I’m excited about longer-acting therapeutics, because they’ll likely give us a better chance for adherence and potentially a larger outcome of benefit for our patients.”

Ultimately, Patel left patients with advice to consistently and continuously monitor blood pressure levels, staying on top of their numbers to stay involved in their treatment.

“For patients, I think the biggest thing you could say is something we’ve been saying: check it, change it, know your numbers,” Patel suggested. “The greatest prevention we can have is knowledge about what we have, and that might make it much easier to prevent the complications of it.”

Editor's Note: Patel reports disclosures with Bayer Pharmaceuticals, Janssen Pharmaceuticals, and Novartis.

Jones DW, Ferdinand KC, Taler SJ, et al. 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Hypertension. Published online August 14, 2025. 

Jones, D, Ferdinand, K, Taler, S. et al. 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. JACC. null2025, 0 (0). 

https://doi.org/10.1016/j.jacc.2025.05.007

Videos

Patel addresses the updated AHA/ACC hypertension guidelines, explaining important features and highlighting the potential of newer therapies.

Dr. Taub describes effective strategies in overcoming access barriers to novel lipid lowering therapies.

Overcoming Access Barriers to Novel Non Statin Therapies

The experts discuss barriers to initiate newer, more intensive lipid-lowering therapies after cardiovascular events and strategies to enhance access. A key challenge is overcoming inertia and reluctance to intensify therapy quickly. Even when attempts are made to accelerate treatment, new therapies are frequently denied by insurers.

For example, with the advent of PCSK9 inhibitor immunotherapy, the outstanding 60% LDL reductions seen in trials did not readily translate to clinical practice due to strict insurance approval criteria. However, eligibility criteria have eased over time, enhancing real-world access. Still, uniform approval standards are needed to facilitate broad access to novel therapies after events.

Strategies like shared decision-making boards between medical societies, clinicians, and payers can align guidelines with insurer expectations. One example is a one-page prior authorization checklist outlining required information like recent LDL levels, documentation of maximally tolerated statin therapy, and other key phrases payers look for. Incorporating such “buzzwords” into the medical record can accelerate approvals by addressing common reasons for denials.

In summary, overcoming clinical inertia as well as administrative burdens imposed by payers is critical to optimizing lipid management after cardiovascular events. A shared vision between stakeholders, clear documentation requirements, and streamlined approval processes for novel therapies can enhance real-world access and uptake.

Summary was AI-generated and edited for clarity. 

Dr Taub describes effective strategies in overcoming access barriers to novel lipid lowering therapies.

This has been a great program. I’ve learned a lot. We covered lots of ground about antithrombotic therapy, coronary artery disease [CAD], and peripheral artery disease [PAD] in general. Let me turn to our distinguished panel for some closing thoughts. I’ll start with you, Manesh. Any final points [that] you want to make for the audience?

Deepak, it’s been fun and exciting. It’s fun to talk to people about evidence for the things we see. We’ve learned over the last decade is that vascular disease unfortunately is still the leading cause of cardiovascular mobility issues and mortality. As we have more options, which is a good thing, we have to get the right dose for the right patient at the right time. Some of that is understanding the risk and the risk benefits that we’ve talked about. Concerning patients with polyvascular disease, patients with broad thrombotic risk, it’s important to understand how you can make them have better outcomes. We’ve talked about that today. Hopefully it’s something that people will take home.

 I agree. It’s been a wonderful panel. I’m thrilled to be part of this. My take-home message would be to focus on identifying these polyvascular patients. Because they’re such high-risk patients, it’s important not to be focused on the coronary artery disease. But if patients have coronary artery disease and vascular disease in another territory, then that’s the pinnacle of our risk. Diabetes on top of that is going to be at that highest cardiovascular risk, so we need to talk with our patients about the fact that they’re at a higher risk and how that guides our recommendations for changing medications. Oftentimes patients can be resistant, understandably, to wanting to add another medication. But part of patient-centered decision-making is educating them that this is why that goes a long way.

We need to educate the medical community about those risks that identify polyvascular disease, diabetes is a real risk amplifier. Great points. Eric, any closing thoughts?

 This was a fantastic discussion. For everyone watching this, it’s important for us to not be fearful of making a change in our practice. We’ve been set in our ways for a long time, but we’ve had these accumulating data. It’s time for us to be open-minded about making changes that benefit our patients. We’ve heard today that there are many agents that can optimize long-term cardiovascular and limb-related risk outcomes and improve the care for our patients, so it was a great discussion.

Absolutely agree and Sahil, any final thoughts?

 That’s really important. What Eric just said is that we’ve been in this mode of using dual-antiplatelet therapy for extended amounts of time with very little evidence, particularly in the PAD population, which is the predominant part of my practice. It’s great that we have strong evidence to support the use of dual-pathway inhibition. We need to get the message out to our referring doctors and our patients that this is the way forward to optimize the risk.

Terrific. Marc, you’ll get the final word.

 It’s been an honor to be part of this panel. We’ve learned that we have a gap in terms of the evidence and how we treat our patients. Part of that is that we have a lot of patients to see. We’re all very busy clinicians. Everyone wants to do their best. But understanding who the highest-risk patient is and what the best evidence is needs to be at the top of your mind as you see your clinic patients, and polyvascular disease resonates. I learned that term from you, Deepak, many years ago. It has been shown in every study to be such a potent marker of risk and beneficial for some of these strategies and other things like diabetes. We need to take that into the clinic and start treating our patients better.

I couldn’t agree more. Hopefully the audience found this exchange of ideas informative, interesting, and educational. Hopefully these are things you can take this into your practices. As I mentioned, I learned a lot. A final point I’ll make is that when you’re thinking about coronary artery disease, think about the whole patient. For that patient you’re seeing for 1 specific condition, that might be the issue in the office for that day. But they may have other risk factors. They may have plaque in other arterial territories. We talked a lot in this session about polyvascular disease, but keep in mind that CAD, PAD, and cerebrovascular disease can coexist. Even though the patient might be seeing you for angina in that office visit or hospital encounter, think about all those associated risks. If you identify those associated risks, you realize that it’s a very high-risk patient, the sort of patient for whom we want to do everything possible to reduce their risk, including intense lifestyle modification. Beyond that, in many cases pharmacotherapy, polypharmacy with wisdom and caution, and in some cases procedural care are all complementary approaches, not competitive approaches.

Thanks to all of you on our panel and to our audience for this rich and informative discussion. If you enjoyed the content, please subscribe to our e-newsletters to receive upcoming 

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A panel of expert cardiologists share their concluding thoughts on management of polyvascular disease in clinical practice.  

Concluding Thoughts

Let’s move on to the final segment to see what our panel thinks are the latest and greatest things coming down the pike to treat high-risk patients and particularly patients with CAD [coronary artery disease] who are at high risk, patients with PAD [peripheral artery disease], patients with polyvascular disease. Manesh, I’ll start with you and work my way down the table. What are the big unmet needs, and what things—in terms of drugs, procedures, or lifestyle approaches—will target those unmet risks?

 That’s a great question. It’s something that we struggle with as we try to think about how we can eradicate atherosclerosis, especially as we think about the burden on our population and the health equity issues inherent that have been laid bare over the last several years with COVID-19 and other things. If I go back to my thinking about where we are with atherothrombosis, there are a few big opportunities. I said it was inflammatory atherothrombosis, so understanding that first part is important. There are strategies coming, but the biggest unmet need is on both the implementation side and the discovery side. On the implementation side, we have proved therapies that aren’t getting used.

The reason we’re having this conversation is we just talked about some therapies that might reduce mortality in cardiovascular disease. I’ll use the A-Fib [atrial fibrillation] example: 12 years ago, we presented the first DOAC [direct oral anticoagulant] data. This was the first year that more than 50% of people worldwide will get a DOAC. The amount of time it takes from something being proven to getting to our patients—I’ll call it the last mile—is probably where we should spend a lot of time.

What are the areas in the first mile? Concerning areas for discovery that are the biggest, we need to do screening studies. We’re at the point with CT scans and some other things that, instead of saying there’s an ASCVD [atherosclerotic cardiovascular disease] risk, we should be saying, “You have the disease. Here’s how much your plaque burden in the legs and the heart is, and here’s how I’m going to get you motivated.” Behavioral change starts with getting the person to have an emotional response—not a rational response, but an emotional response—to that issue.

A variety of things, whether it’s LP(a) [lipoprotein(a)] or other things, are going to change how we think of the biology of the plaque. Maybe the biggest discovery I see coming is how we think about diabetes. You’ve worked on this with others. There are agents that not only change your cardiovascular events but also reduce your weight and help you with diabetes. If you think about the global burden of those issues, those are the big areas.

Those are all good ones. Amy, you’re next. What’s coming down the pike?

 I agree wholeheartedly. Screening is critical. We know from the decisions about aspirin for primary prevention and shrinking the population, who gets treated with aspirin for primary prevention based on USPTSF [US Preventive Services Task Force] recommendation changes, you’re using a coronary calcium scan. It can help risk-stratify. To your point, we’re identifying patients who have atherosclerosis. We need to be doing the same thing in patients at increased cardiovascular risk and looking for PAD as well.

Marc brought up the PCSK9 inhibitors and more aggressive lipid lowering. It’s been too long of not treating our highest-risk patients aggressively enough if we have these tools at our disposal. We’re not talking with patients about why we need to use these. You brought up the importance of diet despite everything else we’re layering on: trying to address food deserts, access to healthy food, all of the social determinants of health. As a community, as we’re emerging from COVID-19 and start to be together again in communities, it’s going to be critical to find safe ways to have patients exercise and be active, such as walking trails.

The last thought is regarding the microvascular disease. One of my other hats is with women’s heart health, and microvascular disease has certainly been part of how we view women’s presentation with chronic symptoms or an acute coronary syndrome. We’re at the beginning of understanding microvascular disease with PAD. My final thought is we have this imprint in our minds of the heart, brain, leg connection—the 3 legs of the stool—if we’re going to treat patients’ cardiovascular risk aggressively.

You’ve made many different and good points. We’ll do a lot more as a community about microvascular disease. It will be primarily medical therapy based, but that’s going to be an area that’s ripe for further discovery. Marc, what’s exciting to you in terms of unmet needs, risks, and ways to address them?

 Thank you, Deepak. Those are great comments. We’ve had a lot of trouble being successful in implementing lifestyle change with our patients. You have 15 minutes with the patient. It’s hard enough to prescribe drugs, but lifestyle change is really hard to do when it’s every 6 months in the clinic. There are new digital therapeutics out there that are helping people with cognitive behavioral therapy and other ways that have shown improvements. You can have patients lower their own hemoglobin A1C [glycated hemoglobin] and other things through lifestyle change. That’s an exciting avenue to interact with our patients in the digital domain. That plays into what Manesh said about implementation science. We need to invest the same resources and study how to move the needle as we do in the refined experiments that show efficacy and safety of the drugs. I look forward to more implementation science.

In the therapeutic domain a lot of things have been said. With LP(a), there’s a real relationship with peripheral artery disease and some very bad events. There may be an exciting avenue for tailored therapy in those patients who have an elevated LP(a). Finally, we’re further decoupling ischemic risk and bleeding risk with our antithrombotics and broadening the utilization of antithrombotic therapies, in terms of those perceived as high bleeding risk or who are at high bleeding risk, to offer more avenues. When you look at patient selection things, it’s always hard to say, “What if you’re at a high bleeding risk?” If you use antiplatelet monotherapy, then that thrombotic risk that Manesh talked about remains unaddressed, so finding new therapies is important.

Those are all promising areas for the future. What do you think, Sahil? What do you put on your top 10 list?

 As a coronary and peripheral interventionalist, I think the most vexing thing is that we’ve known for a long time that the critical inpatient is the highest-risk patient that I ever treat, whether it’s a stent or any other intervention. For the last 4 decades, we’ve gotten better at revascularization, but we haven’t altered the mortality curve. It’s because of a lack of understanding that the systemic things that Eric alluded to are the problem: the patient’s diet, mind, and stroke. Even though we’re taking care of their legs, we need to take care of the whole patient. With low-dose rivaroxaban, we may have an arrow in the quiver, and we just need to use more to bend that curve. That’s what I hope for. That’s what we’ve been waiting for all this time.

There are other areas, though. It seems as if every other day there’s an article about SGLT2 inhibitors becoming a panacea for every cardiovascular ailment we see. The application of that is specifically looking in these high-risk populations, trying to see which arrows in the quiver are going to bend that mortality curve. That’s where the field is moving. Yes, we’ll be innovating new technologies for the specific treatments, but we’re just fixing potholes; we’re not fixing the highway. Until we get that infrastructure fixed, we’re not going to bend that mortality curve.

Both are important. You don’t want potholes on your drive to work, either. The potholes matter too, but the highway matters a lot as well. I totally agree. It’s always tougher going at the end of the panel because everyone has already said the good things already.

 I’m checking off everything I can’t say.

That’s why I’m giving you a couple of seconds. What’s on your list of things that are up and coming?

 We start the conversation with polyvascular disease. We haven’t spent a lot of time on polypharmacy. Concerning all the things we’ve discussed; the therapies don’t work if the patients don’t take them. We’ve seen this in hypertension. More than 50% of people don’t have hypertension under control. If you go from 2 hypertension agents to 3, you double your risk of nonadherence. We have some amazing therapies available, but we need to get our patients to take them. We’ve saw some great evidence last year on polypills—the renewal of the polypill. Maybe we should be tailoring some of our therapy, so that list of 10 medical regimens that our patients carry around in their pillboxes are 1, 2, or 3.

We’re also going to see more device-based treatments for other conditions, like hypertension. We’re talking about renal denervation as an option to limit the pill burden and use another mechanism of reducing a cardiovascular risk factor that has great long-term risks. Bringing it back to the patient, we can do a great job creating these therapies, but they don’t work if the patient doesn’t take them. We need to do a little better job of getting an adherent regimen that a patient can follow long term. Marc, that ties in to your comment on implementation science and bringing it from the clinic to the home.

Cardiologists share unmet needs and emerging approaches to management of patients with polyvascular disease.

Manesh Patel, MD

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