Cardiovascular diseases are among the complex health conditions that require accurate diagnosis, timely intervention, and extensive experience. Particularly in high-risk conditions such as advanced age, multivessel disease, heart valve diseases, aortic diseases, heart failure, and previous cardiac surgeries, it is of great importance that the treatment process be managed by an experienced team, supported by strong technological infrastructure, and guided by a multidisciplinary approach.

Ankara Bilkent City Hospital Cardiovascular Surgery Clinic provides comprehensive healthcare services for a wide range of cardiovascular diseases through its modern healthcare infrastructure, advanced diagnostic and treatment facilities, experienced surgical staff, and multidisciplinary working model.

At our clinic, not only the patient’s existing disease but also their age, general health condition, accompanying diseases, functional capacity of the heart, and long-term quality-of-life goals are evaluated together. An individualized treatment plan is developed for each patient in accordance with scientific evidence, clinical experience, and individual needs.

Advanced Cardiac Surgery at One of Europe’s Largest Healthcare Campuses

Ankara Bilkent City Hospital is one of the largest integrated healthcare centers in Türkiye and Europe, with its high bed capacity, comprehensive healthcare services, advanced technological infrastructure, and structure that brings together numerous medical specialties within the same campus.

With approximately 4,050 beds, 958 intensive care beds, 131 operating rooms, and extensive multidisciplinary healthcare infrastructure, Ankara Bilkent City Hospital enables advanced diagnostic, therapeutic, surgical, and intensive care services to be provided in a coordinated manner within the same healthcare campus.

With an enclosed area of approximately 1.3 million square meters, Ankara Bilkent City Hospital is one of the largest healthcare campuses built in a single phase in Europe and one of the world’s leading integrated healthcare infrastructure projects.

Approximately 7 million outpatient examinations are performed at the hospital annually, while an average of 30,000 patients receive outpatient healthcare services daily. This high-volume healthcare ecosystem, where approximately 200,000 surgical procedures are performed annually, enables various clinical disciplines to provide coordinated and uninterrupted services under the same roof.

This large scale represents not only physical capacity but also a comprehensive healthcare ecosystem that brings together high patient volume, extensive clinical experience, a strong healthcare workforce, and advanced medical services.

The Legacy of Türkiye Yüksek İhtisas Hospital and the Strength of Bilkent City Hospital

Ankara Bilkent City Hospital Cardiovascular Surgery Clinic combines the clinical, academic, and educational legacy of Türkiye Yüksek İhtisas Hospital, one of Türkiye’s most established institutions in cardiovascular healthcare, with today’s modern healthcare infrastructure.

The extensive experience in advanced cardiac surgery developed over many years at Türkiye Yüksek İhtisas Hospital has established a strong clinical culture in the management of high-risk patients, advanced heart failure, mechanical circulatory support systems, heart transplantation, complex aortic surgery, and multidisciplinary cardiovascular care.

This long-established experience has been combined with the extensive patient capacity, advanced technological infrastructure, and integrated healthcare system of Ankara Bilkent City Hospital, which brings together different medical specialties.

Today, our clinic serves as a strong cardiovascular referral center that carries the knowledge and experience inherited from the past into the future through high surgical volume, modern operating room infrastructure, and multidisciplinary care facilities.

A 500-Bed Cardiovascular Hospital

The Thoracic and Cardiovascular Hospital within Ankara Bilkent City Hospital is a comprehensive center where the diagnosis, treatment, surgery, and intensive care processes of cardiovascular diseases are managed holistically.

With a capacity of approximately 500 beds, Yüksek İhtisas Cardiovascular Hospital enables close cooperation among related medical specialties such as cardiology, cardiovascular surgery, pulmonology, and thoracic surgery.

Thanks to this structure, patients can undergo comprehensive evaluation within the same healthcare campus, from diagnosis to advanced imaging, from interventional procedures to surgical treatment, and from intensive care services to rehabilitation and long-term follow-up.

Particularly in patients with complex and high-risk cardiac conditions, the rapid and coordinated collaboration of different medical specialties contributes to a more comprehensive evaluation of treatment decisions and the holistic planning of patient care.

High Surgical Volume and Advanced Surgical Capacity in Cardiovascular Surgery

Ankara Bilkent City Hospital Yüksek İhtisas Cardiovascular Surgery Clinic is a high-volume cardiac surgery center performing approximately 3,000 open-heart surgeries annually.

This surgical volume encompasses a broad patient population, including coronary artery surgery, heart valve surgery, complex aortic surgery, repeat cardiac operations, advanced heart failure surgery, mechanical circulatory support systems, heart transplantation, and high-risk cardiovascular interventions.

High surgical volume allows experienced surgical teams to regularly encounter different and complex clinical conditions and contributes to the development of strong institutional experience in preoperative evaluation, surgical planning, intensive care management, and postoperative follow-up.

Surgical procedures performed at our clinic are carried out in accordance with patient safety principles, current scientific evidence, multidisciplinary decision-making processes, and a commitment to continuous quality improvement.

Despite our high-risk and complex patient population, our surgical outcomes are regularly evaluated and monitored with the aim of achieving mortality and morbidity outcomes consistent with internationally accepted quality indicators and those of high-volume cardiac surgery centers.

Success is evaluated not only by the number of operations performed but also by appropriate patient selection, suitable surgical strategies, prevention of complications, effective intensive care management, patient safety, and long-term clinical outcomes.

12 Operating Rooms and Hybrid Surgical Infrastructure

Our Cardiovascular Surgery Clinic has extensive and advanced surgical infrastructure, including 12 modern operating rooms dedicated exclusively to cardiac surgery.

These operating rooms accommodate a wide range of surgical procedures, from routine cardiac surgical interventions to advanced and high-risk operations.

Our main areas of surgical practice include:

• Coronary artery bypass surgery
• Multivessel coronary bypass operations
• Mitral, aortic, and tricuspid valve surgery
• Heart valve repair and replacement
• Complex operations involving multiple heart valves
• Aortic root surgery
• Ascending aorta and aortic arch surgery
• Acute aortic dissection surgery
• Complex aortic aneurysm operations
• Repeat cardiac surgery in patients who have previously undergone heart operations
• Advanced heart failure surgery
• Left ventricular assist device procedures
• Mechanical circulatory support systems
• Heart transplantation
• Surgical treatment of cardiac tumors
• Pulmonary endarterectomy and surgery for chronic thromboembolic pulmonary hypertension
• Emergency and high-risk cardiac surgical interventions

The hybrid operating room at our clinic combines advanced imaging and surgical technologies within the same environment, allowing surgical and interventional techniques to be applied together in suitable patients.

Hybrid surgical infrastructure provides an important advantage, particularly for patients with complex aortic diseases, advanced vascular diseases, and conditions in which both open surgery and endovascular or interventional approaches are considered together.

This structure contributes to the planning of different treatment methods within the same process according to the patient’s clinical needs and enables the more effective implementation of multidisciplinary treatment options.

Advanced Intensive Care and Postoperative Care

Successful outcomes in cardiac surgery are not limited to the technical completion of the operation.

Postoperative intensive care management encompasses numerous critical processes, including support of cardiac function, respiratory therapy, preservation of kidney function, bleeding control, prevention of infections, neurological monitoring, and early rehabilitation.

The extensive intensive care infrastructure and multidisciplinary healthcare services of Ankara Bilkent City Hospital enable comprehensive postoperative monitoring, particularly for high-risk and complex cardiac surgery patients.

At our Cardiovascular Surgery Clinic, surgeons, cardiovascular anesthesiologists, intensive care teams, cardiologists, perfusionists, nurses, and other healthcare professionals work in coordination.

This team-based approach is of great importance in improving patient safety, identifying complications early, managing treatment processes rapidly, and ensuring that patients safely progress into the recovery phase.

High Surgical Volume, Strong Infrastructure, and Measurable Quality

The strength of Ankara Bilkent City Hospital Yüksek İhtisas Cardiovascular Surgery Clinic does not arise solely from the number of operations performed.

The fundamental strengths of our clinic are shaped by:

• The long-established clinical legacy inherited from Türkiye Yüksek İhtisas Hospital
• Approximately 3,000 open-heart surgeries annually
• High surgical volume and an experienced surgical team
• 12 modern cardiac surgery operating rooms
• Hybrid operating room infrastructure
• An approximately 500-bed Cardiovascular Hospital
• The extensive 4,050-bed healthcare infrastructure of Ankara Bilkent City Hospital
• 958 intensive care beds
• 131 operating rooms
• Advanced cardiac imaging and interventional treatment facilities
• Close cooperation between cardiology and cardiovascular surgery
• Experience in advanced heart failure, LVAD, and heart transplantation
• Multidisciplinary management of complex and high-risk patients
• Continuous quality improvement and regular evaluation of clinical outcomes

Experience from the Past, Today’s Technology, and the Future of Cardiac Surgery

Ankara Bilkent City Hospital Cardiovascular Surgery Clinic brings together the long-established clinical legacy of Türkiye Yüksek İhtisas Hospital, the modern infrastructure of one of Europe’s largest healthcare campuses, and extensive experience in high-volume cardiac surgery under the same roof.

At our clinic, where thousands of open-heart surgeries are performed every year, a scientific approach, advanced technology, experienced teamwork, and patient-centered care are integrated into a holistic treatment model.

Our goal is not only to provide advanced surgical services to every patient but also to ensure a safe, scientific, personalized, and sustainable treatment process, from accurate diagnosis to long-term follow-up.

A long-established legacy. Extensive surgical experience. Advanced technology. Cardiac surgery in accordance with international standards.

“Our clinic, which performs approximately 3,000 open-heart surgeries annually, combines its high surgical volume with mortality and morbidity outcomes consistent with internationally accepted quality indicators, multidisciplinary care, and a commitment to continuous quality improvement.”

Comprehensive Cardiovascular Surgery Services

At our Cardiovascular Surgery Clinic, we provide services to a broad patient population, ranging from simple and routine surgical interventions to advanced and high-risk operations.

Our main areas of surgical practice include:

• Coronary artery bypass surgery
• Surgical treatment of multivessel coronary artery disease
• Surgical treatment of heart valve diseases
• Aortic valve repair and replacement
• Mitral valve repair and replacement
• Tricuspid valve surgery
• Complex operations involving multiple heart valves
• Surgical treatment of aortic aneurysms
• Aortic root, ascending aorta, and aortic arch surgery
• Treatment of life-threatening emergency aortic diseases such as acute aortic dissection
• Repeat cardiac surgery in patients who have previously undergone heart operations
• Pulmonary endarterectomy (CTEPH surgery)
• Surgical treatment of cardiac tumors
• Surgical treatment of advanced heart failure
• Mechanical circulatory support systems
• Left ventricular assist device (LVAD) procedures
• Heart transplantation and advanced heart failure treatments
• Surgical treatment of carotid artery diseases
• Emergency cardiovascular surgical interventions

Each patient’s treatment plan is developed by taking into account the anatomical characteristics of the disease and the patient’s clinical needs. In patients requiring surgical treatment, the potential benefits, risks, and alternatives of the proposed procedure are discussed in detail with the patient and their family.

Complex and High-Risk Cardiac Surgery

One of the important areas of practice at our clinic is complex cardiac surgery, which requires advanced expertise and extensive experience.

Patients with diseases involving multiple heart valves, advanced coronary artery disease, large aortic aneurysms, acute aortic dissections, advanced heart failure, previous cardiac surgeries, and multiple organ diseases undergo a detailed and multidisciplinary evaluation process.

In these patients, surgical decisions are based not only on imaging findings but also on a combined evaluation of the heart’s pumping function, lung function, kidney function, neurological status, infection risk, and the patient’s overall clinical condition.

The aim is not only to perform a successful operation but also to protect patient safety, reduce the risk of complications, and support long-term quality of life.

Advanced Heart Failure, Mechanical Circulatory Support, and Heart Transplantation

Advanced heart failure is a complex clinical condition that cannot be controlled by medication alone and may seriously affect patients’ quality of life.

When heart failure reaches an advanced stage, patients are evaluated with the participation of cardiology, cardiovascular surgery, intensive care, anesthesiology, imaging, infectious diseases, and other relevant medical specialties.

In suitable patients, advanced treatment options are considered, including:

• Advanced heart failure treatments
• Temporary mechanical circulatory support systems
• Long-term left ventricular assist devices
• Preparation for heart transplantation
• Heart transplantation
• Long-term follow-up after heart transplantation

The treatment of patients who receive mechanical circulatory support devices or undergo heart transplantation is not limited to surgery. During the postoperative period, device management, anticoagulant therapy, infection control, rehabilitation, and regular clinical follow-up are continued through a holistic approach.

Multidisciplinary Treatment Approach

Successful treatment of cardiovascular diseases depends not only on surgical experience but also on the coordinated work of different medical specialties.

At our clinic, patients are evaluated together, when necessary, by specialists in:

• Cardiovascular surgery
• Cardiology
• Anesthesiology and reanimation
• Intensive care
• Radiology
• Nuclear medicine
• Pulmonology
• Nephrology
• Neurology
• Infectious diseases
• Endocrinology
• Physical therapy and rehabilitation
• Nutrition and dietetics

This multidisciplinary approach contributes to more accurate treatment decisions, holistic planning of the treatment process, and improved patient safety, particularly in complex and high-risk patients.

Modern Technology and Advanced Surgical Infrastructure

Success in cardiac surgery depends on the combined effectiveness of surgical experience, technological infrastructure, and efficient team coordination.

The advanced imaging systems, modern operating rooms, comprehensive intensive care facilities, and multidisciplinary healthcare services available at Ankara Bilkent City Hospital enable patients’ diagnostic, treatment, and follow-up processes to be managed holistically within the same healthcare campus.

Before surgery, the patient’s cardiac and vascular anatomy is evaluated in detail. During surgery, advanced anesthesia and monitoring methods are used. Following surgery, patients are closely monitored by experienced intensive care teams.

This approach aims to support patient safety and quality of care at every stage of the treatment process.

Patient-Centered and Personalized Treatment

Every cardiac patient’s clinical condition is different. Two patients with the same diagnosis may differ in age, cardiac function, vascular anatomy, accompanying diseases, and treatment needs.

Therefore, the treatment approach at our clinic is based on individualized assessment rather than a standardized practice.

The treatment process aims to include:

• Detailed evaluation of the disease
• Planning of necessary diagnostic examinations
• Comparison of surgical and interventional treatment options
• Assessment of treatment risks
• Determination of the appropriate surgical method for the patient
• Planning of postoperative care
• Continuation of long-term clinical follow-up

It is of great importance that patients and their families understand the treatment process correctly, actively participate in decision-making, and receive clear answers to all their questions.

Postoperative Follow-Up and Rehabilitation

In cardiac surgery, treatment does not end when the operation is completed. A successful recovery process requires effective intensive care management, early mobilization, appropriate medication, infection control, nutritional support, and regular follow-up.

Our patients’ postoperative care processes are planned according to their clinical needs. Following discharge, coordinated follow-up with cardiology and other relevant specialties is provided when necessary.

The aim is to help patients safely return to their daily lives, maintain their heart health, and support their long-term quality of life.

Scientific Education and Academic Approach

Our Cardiovascular Surgery Clinic is not only a center providing patient treatment but also an academic working environment that contributes to scientific production, specialty training, clinical research, and professional development.

Through scientific meetings, clinical training programs, national and international collaborations, the aim is to transfer current knowledge and technologies into clinical practice.

In today’s continuously evolving field of medicine, combining clinical experience with current scientific evidence is a fundamental approach to sustainably improving the quality of patient care.

Comprehensive Evaluation for International Patients

For patients applying from outside Türkiye, a preliminary evaluation of existing medical documents and imaging results may be performed.

Depending on the patient’s clinical condition, a comprehensive approach is provided in the following areas:

• Evaluation of medical reports
• Review of imaging results
• Identification of necessary additional examinations
• Evaluation of treatment options
• Determination of the need for surgical intervention
• Planning of the diagnostic and treatment process in Türkiye
• Development of postoperative follow-up recommendations

The aim is to ensure that the treatment process for international patients is carried out in a planned, transparent, and coordinated manner as much as possible.

Trust, Experience, and Science in Cardiac Surgery

Cardiac surgery is not a field that requires only technical skills. Choosing the right treatment at the right time, evaluating the patient’s individual characteristics, anticipating potential risks, and effectively managing the postoperative process are also integral parts of treatment.

At Ankara Bilkent City Hospital Yüksek İhtisas Cardiovascular Surgery Clinic, a scientific approach, experienced teamwork, advanced technology, and patient-centered care come together.

Our goal is to provide every patient with safe, comprehensive, and personalized treatment based on current scientific evidence; not only to treat the disease but also to contribute to our patients’ quality of life and future.

Quick Clinician Summary — 5 Critical Changes

• LDL targets are back:
  • <55 mg/dL (very high risk)
  • <70 mg/dL (high risk)
  • <100 mg/dL (primary prevention)
• Lp(a) is now a routine measurement recommendation — at least once in a lifetime for everyone.
• PREVENT-ASCVD risk calculator has replaced the old PCE.
• Combination therapy (statin + ezetimibe) is moved to an earlier stage.
• Initiate treatment in young adults if LDL >= 160 mg/dL.
• Reduce lifetime exposure to atherogenic lipoproteins.
• Initiate screening and treatment at younger ages.
• Therefore, lifestyle interventions must begin very early.

Introduction: A Comprehensive Update Replacing the 2018 Guideline 

The ACC (American College of Cardiology) and AHA (American Heart Association) published the new ‘Guideline on the Management of Dyslipidemia’ in 2026. Replacing the 2018 cholesterol guideline, this document approaches dyslipidemia assessment, treatment, and monitoring within a holistic framework.

The scope of the guideline is not limited solely to LDL cholesterol; triglycerides, Lp(a), and other lipid disorders are also detailed. The most important message for clinical practice is this: early screening, aggressive targets, and combination therapy are now built on a stronger evidence base.

1. Core Philosophy: ‘Lower LDL Earlier, for Longer’

The foundational approach of the new guideline is built on three principles:

1. Reduce lifetime exposure to atherogenic lipoproteins
2. Initiate screening and treatment at younger ages
3. Lower LDL to more aggressive targets and maintain that target

Therefore, lifestyle interventions must now begin very early, long before cardiovascular disease appears. Atherosclerosis is not treated once established; it is only slowed down or halted. Prevention is key.

2. New Model in Risk Assessment: PREVENT-ASCVD

The guideline abandons the old Pooled Cohort Equations (PCE) risk calculator in favor of the PREVENT-ASCVD risk calculator. This change is highly significant in practice:

• PREVENT takes diabetes, chronic kidney disease (CKD), and cardiovascular biomarkers into account.
• It offers a more valuable estimation across broader patient populations.
• When used alongside the CAC (Coronary Artery Calcium) score, it can facilitate decision-making in borderline cases.

Practical Note: You can access the PREVENT-ASCVD calculator via the official ACC website. Consider using the CAC score as a supportive tool for borderline risk patients.

3. LDL Targets Brought Back — The Biggest Difference from 2018

The 2018 guideline adopted an approach emphasizing percentage reduction. The 2026 guideline has clearly redefined absolute target LDL levels. This means major practical convenience for clinicians.

Secondary Prevention (Patients with an ASCVD Diagnosis)

Primary Prevention (Patients without an ASCVD Diagnosis)

What Does This Mean in Practice? If you previously set a target of 70 mg/dL for your patients with an ASCVD diagnosis, you may need to revise this plan to 55 mg/dL. The addition of ezetimibe has now been made an earlier step.

4. Lipoprotein(a) Measurement is Now a Routine Recommendation

One of the most striking innovations of the ACC/AHA 2026 is that Lp(a) screening has become a universal recommendation.

Why is it Important?

• Lp(a) is an inherited cardiovascular risk factor that does not respond to statin therapy.
• >= 50 mg/dL (approx. 125 nmol/L) -> Independently increases ASCVD risk.
• >= 100 mg/dL -> Risk increases approximately 2-fold.
• If high Lp(a) is present, a more aggressive LDL lowering strategy is recommended.

Recommendation: Lp(a) measurement at least once in a lifetime for every individual is now a Class I recommendation level. ESC 2025 also considers an Lp(a) level >50 mg/dL as a marker that refines risk stratification.

Clinical Point: Consider ordering an Lp(a) measurement from the very first visit for patients with a family history of premature cardiovascular disease, those unable to reach their LDL target despite statins, or those with an unexplained high-risk profile.

5. Early Treatment in Young Adults

The guideline defines new thresholds for young adults for early cardiovascular intervention:

The goal can be summarized in one sentence: Intervene before atherosclerosis begins.

6. Treatment Steps: Lifestyle and Medication

6.1 Lifestyle Interventions (Always the First Step)

• Mediterranean diet (the strongest evidence-based nutritional model)
• Weight control — abdominal obesity increases the risk multiplier
• Regular physical activity (at least 150 min of moderate intensity per week)
• Smoking cessation — increases HDL, reduces inflammation

6.2 Medical Therapy Algorithm

What Does This Mean in Practice? 

Combination therapy is no longer repositioned as a ‘last resort’, but rather ‘add early if the target is not met’. Especially in very high-risk patients, if the target is not reached at the first check-up, ezetimibe should be added without delay.

7. Triglyceride Management

Statins continue to be the primary therapy in triglyceride management. However, threshold values for severe elevations have been clarified:

8. Special Patient Groups

In the patient groups below, the risk should be considered high independent of the LDL level, and lipid-lowering therapy should be considered in primary prevention:

9. Practical Algorithm for the Outpatient Clinic

Aligned with the official messages of ACC/AHA 2026 and the aggressive target approach of the ESC, this algorithm can be used in routine dyslipidemia outpatient visits:

Step 1 — Basic Panel for Every Patient

• Full lipid panel (fasting or non-fasting measurement)
• Liver functions (ALT/AST)
• Creatinine / eGFR
• HbA1c or glucose status
• TSH (when necessary — hypothyroidism can be a cause of dyslipidemia)
• Lp(a) — at least once in a lifetime ACC/AHA 2026 explicitly recommends that Lp(a) be measured at least once. ESC 2025 also accepts an Lp(a) level >50 mg/dL as a marker refining risk stratification.

Step 2 — Determine the Risk

• Calculate the 10-year risk with the PREVENT-ASCVD calculator
• Refine the risk with a CAC score in borderline cases
• Familial Hyperlipidemia? Family history? Lp(a)? -> Incorporate risk multipliers

Step 3 — Determine the Target

Step 4 — Stepwise Treatment

• Lifestyle is always foundational
• Start with a statin -> add ezetimibe early if you don’t reach the target
• If reduction is insufficient, evaluate a PCSK9 inhibitor or inclisiran

10. Overall Assessment: America Approaches Europe

The ACC/AHA 2026 lipid guideline has brought the American cardiology approach significantly closer to the ESC (European Society of Cardiology) standards. The practical differences between the two guidelines have diminished:

Frequently Asked Questions (FAQ)

How is the ACC/AHA 2026 cholesterol guideline different from 2018? 

The 2026 guideline abandoned the 2018 guideline’s emphasis on percentage reduction and defined clear LDL targets (<55 mg/dL for very high risk, <70 mg/dL for high risk). In addition, it made Lp(a) measurement routine and replaced the old PCE with the PREVENT-ASCVD risk calculator.

What should your LDL cholesterol target be? 

Depending on your risk group: <55 mg/dL if there is very high risk or an ASCVD diagnosis; <70 mg/dL if high risk; <100 mg/dL if low-intermediate risk in primary prevention. These targets are determined according to the ACC/AHA 2026 guideline.

Why should Lp(a) be measured? 

Lp(a) is an inherited cardiovascular risk factor that does not respond to statins. Levels >= 50 mg/dL increase ASCVD risk, while levels >= 100 mg/dL increase the risk approximately 2-fold. The ACC/AHA 2026 recommends measuring Lp(a) at least once in a lifetime for everyone.

When are PCSK9 inhibitors used? 

When the LDL target cannot be reached despite a combination of a high-intensity statin and ezetimibe, PCSK9 inhibitors (evolocumab, alirocumab) come into play. Early use should be considered especially in very high-risk patients and those with familial hypercholesterolemia.

How is the PREVENT-ASCVD risk calculator used? 

PREVENT-ASCVD is available for free on the official ACC website. When age, gender, systolic BP, total cholesterol, HDL, diabetes, and CKD status are entered, the 10-year cardiovascular risk is calculated. It is recommended to refine the outcome with a CAC score for borderline risk patients.

References

1. ACC/AHA 2026 Guideline on the Management of Dyslipidemia. American College of Cardiology / American Heart Association. 2026.
2. ESC/EAS 2025 Guidelines for the Management of Dyslipidaemias. European Heart Journal. 2025.
3. Jones DW, Ferdinand KC, Taler SJ et al. Circulation 2025;152:e114-e218 — 2025 Hypertension Guideline.
4. Grundy SM et al. 2018 ACC/AHA Cholesterol Guideline. Circulation. 2019;139:e1082-e1143.

This article is for informational purposes only and does not replace medical advice. Always consult a physician for a definitive diagnosis and treatment.

⚠️ Important Note:
This document is a public information tool. Always consult your physician for personal health decisions. The guideline is prepared to support the shared decision-making process between the physician and the patient.

A. Why is this Guideline Important?

Globally, cardiovascular diseases (heart and blood vessel diseases) remain the leading cause of death. High cholesterol is one of the most important and modifiable causes of this risk. The American College of Cardiology (ACC) and the American Heart Association (AHA) evaluated the latest scientific evidence and published the new cholesterol management guideline in 2026.

Why was the guideline updated?

• New drugs have gained clinical evidence since the 2018 guideline (bempedoic acid, PCSK9 inhibitors)
• More accurate risk calculation methods have been developed (PREVENT equations)
• The importance of new biomarkers such as Lipoprotein(a) and ApoB has been proven
• LDL target values were removed in 2018 — they have returned in 2026
• Very strong new evidence has emerged regarding the importance of early treatment
• The protective effect of bempedoic acid has been demonstrated in patients who cannot take statins

B. Basic Concepts: Cholesterol and Blood Fats

B.1 What is Cholesterol? 

Cholesterol is a fat that our body needs to build cell membranes, produce hormones, and aid in digestion. It is produced by the liver and is also absorbed from the animal-based foods we eat. The problem starts when too much of it accumulates in the blood.

B.2 Atherosclerosis: The Process of Clogged Arteries 

LDL cholesterol sticks to the inner wall of blood vessels and forms plaque over time. This process begins in childhood and progresses silently for decades. When the plaque grows, it either narrows the artery or ruptures, causing sudden blockage (heart attack, stroke).

❤️ Important Fact: The effect of LDL cholesterol on atherosclerosis is cumulative and time-dependent. High LDL starting at an early age causes much more damage than the same level starting in middle age. Therefore, the 2026 guideline particularly emphasizes early treatment.

C. 10 Major Innovations of the 2026 Guideline

This guideline contains radical changes compared to 2018. Here are the 10 most important innovations:

INNOVATION 1: LDL Target Values Have Returned 

In the 2018 guideline, the LDL target was removed, and only a ‘percentage reduction’ was recommended. The 2026 guideline recommends both percentage reduction and absolute target values together.

INNOVATION 2: New Risk Calculation — PREVENT Equations 

The new ‘PREVENT Equations’ are now used instead of the old ‘Pooled Cohort Equations’. This new system can calculate both 10-year and 30-year risk.

CPR Model — Risk Assessment in Three Steps:

• C — Calculate: Calculate the 10-year risk using PREVENT-ASCVD equations
• P — Personalize: Consider risk enhancers (see table)
• R — Reclassify: Clarify the risk with a CAC score if necessary

INNOVATION 3: Lp(a) Measurement is Now Recommended for Everyone 

The 2026 guideline states as a Class 1 (highest) recommendation that all adults should have their Lp(a) [Lipoprotein(a)] measured at least once in their lifetime.

Why is Lp(a) Important?

• Lp(a) levels are primarily genetically determined and do not change
• Lifestyle changes have very little effect on Lp(a)
• A single measurement is usually sufficient

🧬 Genetic Risk: High Lp(a) is passed down to children. If you or your first-degree relatives have high Lp(a), it is recommended that all first-degree family members (parents, siblings, children) get tested.

INNOVATION 4: ApoB Test — To Find Hidden Risk 

The new guideline states that after LDL and non-HDL targets are reached, the ApoB test is useful for additional risk assessment. It is especially valuable in the following situations:

• People with elevated triglycerides (> 200 mg/dL)
• In patients with diabetes
• Those who continue to have risk concerns despite having achieved low LDL (< 70 mg/dL)

🔬 Why is ApoB Important? Standard cholesterol measurements can sometimes hide the risk. Even if LDL appears ‘normal’, ApoB can be high. ApoB counts all the harmful lipoprotein particles circulating in the blood and more accurately reflects the true danger.

INNOVATION 5: Coronary Artery Calcium (CAC) Score — A Determinant in Treatment Decisions 

In some individuals, it may be uncertain whether to start medication. In these cases, the coronary artery calcium (CAC) score helps clarify the decision by measuring plaque accumulation in the heart arteries.

*Exceptions: In those with familial hypercholesterolemia, LDL≥190, diabetes and over age 40, active smoking, or a family history of premature heart disease, even a CAC=0 is not enough to delay treatment.

INNOVATION 6: Early Treatment — Starting in Youth is Critical 

The 2026 guideline presents strong evidence that bringing cholesterol management to earlier ages is life-saving.

• Preventing dyslipidemia with a healthy diet and exercise in childhood is the core strategy
• Early medication for children with genetic (familial) hypercholesterolemia
• Early initiation of medication in young adults if LDL ≥ 160 mg/dL or if there is a family history of premature heart disease
• Early and prolonged elevation of LDL causes much more damage than a short-term elevation

👶 Why is it so important to start early? The damage LDL does to the vessel wall accumulates over time. Someone living with high LDL from their 20s to their 60s is not in the same situation as someone whose high LDL started at age 40. Early prevention = less damage.

INNOVATION 7: Cholesterol Treatment in Diabetes, Chronic Kidney Disease, and HIV 

For people aged 40-75 with diabetes, chronic kidney disease (stages 3-4), or HIV infection, cholesterol-lowering medication is recommended regardless of their LDL level.

INNOVATION 8: Ezetimibe Prerequisite for PCSK9 Inhibitors Removed 

In the 2018 guideline, it was mandatory to use ezetimibe before switching to PCSK9 inhibitors (evolocumab, alirocumab). The 2026 guideline has removed this requirement. New Approach:

• Drug selection after statin therapy is now based on ‘how much LDL needs to be lowered?’ and ‘patient preference’
• The choice between ezetimibe, bempedoic acid, or a PCSK9 inhibitor is left to the clinician and the patient
• Long-term safety data for PCSK9 inhibitors has strengthened; the cost has also decreased

💊 Bempedoic Acid: A New Option for Those Who Cannot Take Statins 

Bempedoic acid is a new hope for people who cannot take statins due to muscle pain. In the CLEAR Outcomes trial, it lowered LDL by 20% and significantly reduced the risk of heart attacks. Because it is not activated in muscle tissue, it does not cause statin-like side effects.

INNOVATION 9: A Clear ‘No’ to Dietary Supplements 

The 2026 guideline explicitly opposes the use of dietary supplements to lower cholesterol or triglycerides. This is a Class 3 recommendation level — meaning ‘do not do it, it may cause harm or has no benefit’.

• Garlic capsules, red yeast rice, fish oil pills (not prescription high-dose omega-3), plant sterols, etc.
• The efficacy of these products in lowering LDL or triglycerides was found to be inconsistent and limited in clinical trials
• Using dietary supplements can lead to risk by delaying real treatment

⚠️ Beware of cholesterol supplements sold in pharmacies or online! 

Supplements claiming to ‘lower cholesterol’ lack sufficient scientific evidence. They cannot replace real treatment. Do not use them without talking to your physician.

INNOVATION 10: Female-Specific Risk Factors Are Now Official 

The 2026 guideline recommends that female-specific reproductive health history be included in the cardiovascular risk assessment. 

Risk-Enhancing Women’s Health Factors:

• Premature menopause (before age 45)
• Hypertension during pregnancy (preeclampsia, gestational hypertension)
• Gestational diabetes
• Premature birth (before 37 weeks)
• Recurrent pregnancy loss
• Early menarche (before age 10)

In the presence of these factors, a woman’s risk of heart disease may be evaluated higher than it otherwise would be, and cholesterol-lowering treatment may be considered earlier.

D. Lifestyle — The Foundation of Treatment

Alongside any drug treatment, or even if medication is not required, lifestyle changes form the foundation of cholesterol management. The 2026 guideline states that lifestyle alone can reduce cardiovascular risk by approximately 50%.

D.1 Heart-Healthy Diet

D.2 Physical Activity AHA Recommendation — How Much Per Week?

• Moderate-intensity aerobic activity: At least 150 minutes per week (30 min a day, 5 days)
• Or: Vigorous-intensity aerobic activity: 75 minutes per week
• Muscle strengthening: 2 days a week
• Walk for 5 minutes every hour to reduce the harms of prolonged sitting

Effect of Exercise on Cholesterol:

• Lowers LDL by 5-10%
• Increases HDL
• Significantly lowers triglycerides
• Contributes to weight loss — weight loss lowers LDL even further

D.3 Other Lifestyle Recommendations

E. Drug Treatments — Current Options

The choice of cholesterol-lowering medication is individualized by the physician, taking into account the person’s risk level, other diseases, tolerability, and preferences. Current options are summarized below.

💊 If You Are Experiencing Statin Side Effects: If you cannot use statins due to muscle pain or liver problems, alternatives like bempedoic acid are now available. Talk to your physician; look for an alternative instead of stopping treatment. Stopping medication can increase your risk.

F. High Triglycerides — A Separate Problem

While high triglycerides (TG) are an independent cardiovascular risk factor, very high levels (≥ 1000 mg/dL) also increase the risk of pancreas inflammation (pancreatitis).

Main Causes That Raise Triglycerides:

• Alcohol consumption
• Sugary drinks, refined carbohydrates, white flour
• Obesity and uncontrolled diabetes
• Hypothyroidism, kidney disease
• Some medications (beta-blockers, estrogen, glucocorticoids, some antipsychotics)
• Genetic disorders

G. Cholesterol in Children and Young Adults

The 2026 guideline now starts cholesterol management from childhood. Early diagnosis and treatment are life-saving in children with familial hypercholesterolemia.

When to Screen for Cholesterol in Children?

• Children aged 2 and older should have lipid measurement if there is obesity, diabetes, or a family history of premature cardiovascular disease
• Universal screening is recommended for all children aged 9-11
• Re-evaluation between ages 17-21
• Test at the earliest possible age if there is high LDL or familial hypercholesterolemia in the family

👨‍👩‍👧 If There is a Family History of High Cholesterol: If one of the parents has LDL > 190 mg/dL or a history of an early heart attack/stent/bypass, take your children to a physician and have their lipid profile measured, including Lp(a). Early treatment of familial hypercholesterolemia makes a massive difference.

H. Which Tests Should Be Done? — Checklist

⏱️ When to Retest After Starting Medication? A new lipid measurement is required 4-12 weeks after starting medication or changing the dose. Then, a check-up every 6-12 months. Once values are stable, 1 measurement per year is sufficient.

I. Frequently Asked Questions

Do I have to take cholesterol medications for life? 

In the vast majority of conditions such as familial hypercholesterolemia or established heart disease, yes. However, if LDL can be sufficiently lowered through lifestyle changes, the dose may be reduced or the medication stopped in some people. This decision must be made with your physician. When medication is stopped, LDL rises again.

Are statins harmful? Do they ruin the liver and muscles? 

Statins have been safely used by millions of people for decades. Serious liver damage is extremely rare. Muscle pain can occur in about 1 in 10-15 people, but it is usually mild and is resolved by adjusting the dose or changing the medication. Severe myopathy indicating muscle damage occurs in less than one in a thousand. Stopping statins poses a much greater risk than these rare side effects.

Are there always symptoms when cholesterol is high? 

No. The vast majority of high cholesterol is completely asymptomatic (causes no symptoms). A person can live with high LDL for years, while the progressing atherosclerosis in their arteries grows unnoticed, manifesting suddenly with a heart attack or stroke. This is why regular screening is vitally important.

What can I do if my Lp(a) is high? 

It is not yet possible to significantly lower Lp(a) with lifestyle or current medications. However, in the presence of high Lp(a), it is recommended to control other risk factors (LDL, blood pressure, smoking, diabetes) much more aggressively. New drugs specifically targeting Lp(a) (olpasiran, muvalaplin) are currently in the final stages of clinical trials.

Do natural supplements like omega-3 and garlic work? 

The 2026 guideline is very clear on this: Dietary supplements do not lower LDL or triglycerides to a clinically meaningful level and do not appear to prevent cardiovascular disease. Prescription high-dose omega-3 (icosapent ethyl) is in a separate category and is different. It should not be confused with fish oil capsules sold in pharmacies.

What should I ask my physician?

• Question 1: What are my LDL, HDL, triglyceride, and non-HDL values, and what should my target be?
• Question 2: Have I ever had my Lp(a) measured in my life? Should I?
• Question 3: What is my cardiovascular risk category? (low/borderline/intermediate/high)
• Question 4: Do I need a coronary calcium score?
• Question 5: Are my current medications sufficient? Are changes needed?
• Question 6: There is a cholesterol problem in my family. Do my children need to be tested?

J. Quick Reference: Summary of the 2026 Guideline

10 MAJOR INNOVATIONS — BRIEF SUMMARY

1. LDL target values have returned: Very high risk < 55, high risk < 70 mg/dL
2. More accurate risk calculation with PREVENT equations: CPR model (Calculate-Personalize-Reclassify)
3. Lp(a): Measurement is recommended for all adults at least once in their lifetime
4. ApoB: Useful for additional risk detection, especially in diabetes and high triglycerides
5. CAC score: A deciding tool in treatment uncertainties — men ≥40, women ≥45
6. Early treatment is critical: High LDL starting in youth leads to more damage
7. Diabetes, CKD, HIV: Medication treatment regardless of LDL level between ages 40-75
8. Ezetimibe prerequisite for PCSK9 inhibitors removed: Bempedoic acid is a new option
9. Dietary supplements are not recommended for cholesterol: Class 3 (harm or no benefit)
10. Female-specific risk factors have become official: preeclampsia, gestational diabetes, premature menopause

📚 Source 

Blumenthal RS, Morris PB, Gaudino M, et al. 2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Dyslipidemia: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2026;153. DOI: 10.1161/CIR.0000000000001423

This document has been prepared for public information purposes. Consult your physician for individual medical decisions.

1. Article Format and Type

This article is an interactive clinical decision format belonging to NEJM’s ‘Clinical Decisions’ series. This format is presented in a structure where two experts defend different positions assigned by the editors based on a real patient case, after which readers can express their opinions. The format does not prescribe a clear ‘correct answer’; the goal is to improve the decision-making processes of clinicians and reveal the distribution of opinions within the medical community.

Features of the Format

• Realistic, context-rich clinical case presentation
• Two experts defend assigned positions (debate format)
• Community opinion is formed via a reader poll
• Editorial independence is maintained; no single option is declared ‘correct’

2. Clinical Case Summary

A 75-year-old male patient presents for routine follow-up. His physical activity is limited due to chronic joint pain; this situation is of critical importance regarding both his cardiovascular risk profile and medication tolerability.

2.1. Patient’s Baseline Characteristics

3. Clinical Decision Options

Two experts have been assigned by the editors to advocate for different treatment targets. Below are the core arguments of both positions presented comparatively.

3.1. Option 1: SBP < 120 mmHg Target 

Advocate: Paul K. Whelton, M.B., M.D. (Tulane University, Public Health)

• Large-scale meta-analysis: A <120 target reduces major CVD events by 18% and all-cause mortality by 13% compared to a <140 mmHg target.
• Associated with better cognitive function and a 15% lower risk of dementia (He 2025, Nature Medicine).
• Similar CVD protection was achieved in patients with orthostatic hypotension (Juraschek 2023, JAMA).
• Single-pill combination regimens (dual/triple) increase treatment adherence and provide targeted BP reduction.
• Isometric resistance exercises (wall sits, yoga) can lower SBP by >8 mmHg without putting a load on the joints.
• NSAID use only increases SBP by <5 mmHg; it remains at a manageable level.

3.2. Option 2: SBP < 140 mmHg Target 

Advocate: Clinton B. Wright, M.D. (NINDS / NIH, Bethesda)

• The patient’s current BP value is within the target range of many national and international guidelines; <120 mmHg is only recommended in Canadian and Australian guidelines.
• The SPRINT trial was stopped early, and the number of participants at this patient’s BP level is insufficient for a definitive comparison.
• Although the diagnostic threshold for orthostatic hypotension (20 mmHg) is not met, the possibility of autonomic dysfunction exists; further diagnostic evaluation is required.
• BP variability and hypotensive episodes are associated with cognitive decline, which could increase with intensive treatment (Zhang 2025, Hypertension).
• Patients with neurogenic orthostatic hypotension have been underrepresented in existing studies.
• Diagnostic steps such as ambulatory BP monitoring and the Valsalva maneuver should be completed first.

4. Core Evidence Base

5. Alignment with Guidelines

Important Guideline Note: The 2025 AHA/ACC guideline recommends a <130/80 mmHg target for all older adults with a 10-year ASCVD risk >10%. This value forms a middle ground between the two options discussed in the article and is not directly compared due to the constraints of the editorial format.

6. Orthostatic Hypotension: Critical Diagnostic Evaluation

The most nuanced debate of the article shapes around orthostatic hypotension. The patient remains below the technical diagnostic threshold (>20 mmHg drop), but clinical findings suggest autonomic dysfunction.

6.1. Diagnostic Algorithm (Wright’s Suggestion)

• 10 minutes supine position → standing up → 3 minutes BP and heart rate measurement
• Valsalva maneuver: slow BP recovery, no compensatory tachycardia in neurogenic failure
• 24-hour ambulatory BP monitoring: investigation of nocturnal BP and ‘non-dipping’ pattern
• Symptom inquiry: heat intolerance, postprandial dizziness, neck pain (‘coat hanger’ pattern), olfactory impairment
• Rhythm monitoring for cardiac arrhythmias (e.g., atrial fibrillation)

6.2. Comparison of Both Experts’ Evaluations

7. Scientific Evaluation of the Article

7.1. Strengths

• Published in a high-impact, peer-reviewed journal; the Clinical Decisions series is one of NEJM’s most respected formats.
• Both experts base their arguments on current, high-evidence-level literature (RCTs, meta-analyses, 2025 guidelines).
• The clinical case is realistic and context-rich: multiple comorbidities, polypharmacy, elderly patient profile.
• Editorial independence is preserved; no position is explicitly declared ‘correct’.
• The reader participation mechanism reveals the true distribution of opinions within the clinical community.

7.2. Limitations and Methodological Notes

• The debate format forces experts to defend an assigned position; this may not fully reflect genuine clinical judgment.
• The SPRINT trial lacked sufficient statistical power in the subgroup close to this patient’s baseline BP value.
• A third option (e.g., <130 mmHg) was not presented; whereas the current AHA/ACC guideline dictates this.
• Patients with neurogenic orthostatic hypotension were excluded from most studies; there is no specific evidence for this population.
• Both experts cite some of their own studies or those of close colleagues (potential conflict of interest with limited impact).

8. Overall Evaluation and Conclusion

This article successfully summarizes the real clinical tension between intensive blood pressure control and safe treatment balance in hypertension management. The arguments of both experts are consistent with the literature and proceed through a dilemma frequently encountered in clinical practice.

Whelton’s position argues that population-level cardiovascular benefit outweighs individual safety concerns. Wright, on the other hand, emphasizes that this patient’s atypical autonomic profile may fall outside standard treatment protocols and requires a more comprehensive diagnostic evaluation. Both arguments are scientifically defensible.

Editor’s Note:

• Clinical Conclusion: The <130/80 mmHg target recommended by the 2025 AHA/ACC guideline forms a practical middle ground between both options. An individualized approach for this patient should include a combination of a careful BP titration plan, ambulatory monitoring, and exercise rehabilitation.
• Evidence Gap: Prospective RCTs investigating optimized BP targets for older hypertensive patients with neurogenic orthostatic hypotension are needed.

9. References

1. Whelton PK, O’Connell S, Mills K, He J. Evolution in the targets for blood pressure control. Curr Opin Nephrol Hypertens 2026;35:141-9.
2. Wright JT Jr, Whelton PK, Johnson KC, et al. SPRINT revisited: updated results and implications. Hypertension 2021;78:1701-10.
3. He J, Zhao C, Zhong S, et al. Blood pressure reduction and all-cause dementia in people with uncontrolled hypertension: an open-label, blinded-endpoint, cluster-randomized trial. Nat Med 2025;31:2054-61.
4. Juraschek SP, Hu JR, Cluett JL, et al. Orthostatic hypotension, hypertension treatment, and cardiovascular disease: an individual participant meta-analysis. JAMA 2023;330:1459-71.
5. Edwards JJ, Deenmamode AHP, Griffiths M, et al. Exercise training and resting blood pressure: a large-scale pairwise and network meta-analysis of randomised controlled trials. Br J Sports Med 2023;57:1317-26.
6. Jones DW, Ferdinand KC, Taler SJ, et al. 2025 AHA/ACC guideline for the prevention, detection, evaluation and management of high blood pressure in adults. Hypertension 2025 (Epub ahead of print).
7. Wright JT Jr, Williamson JD, Whelton PK, et al. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med 2015;373:2103-16.
8. Duval GT, Raud E, Gohier H, Dramé M, Tabue-Teguo M, Annweiler C. Orthostatic hypotension and cognitive impairment: systematic review and meta-analysis of longitudinal studies. Maturitas 2024;185:107866.
9. Zhang W, Redline S, Viswanathan A, et al. Hypotensive episodes on 24-hour ambulatory blood pressure and cognitive function: insights from the SPRINT study. Hypertension 2025;82:627-37.

2025 AHA / ACC / AANP / AAPA / ABC / ACCP / ACPM / AGS / AMA / ASPC / NMA / PCNA / SGIM

TABLE OF CONTENTS

1. Guideline Overview and Novelties

2. Blood Pressure Classification

3. Diagnostic Evaluation

   • In-Office Measurement — Out-of-Office Monitoring (ABPM/HBPM)

   • White Coat / Masked Hypertension

   • Secondary Hypertension Screening

4. Drug Initiation Threshold & CVD Risk Assessment

5. Lifestyle Modifications

6. Pharmacological Treatment

   • First-Line Agents and Combination Therapy

   • BP Goals

   • Medication Adherence Strategies

7. Special Populations

   • Diabetes | CKD | Heart Failure | Stroke | Pregnancy | Elderly

8. Resistant Hypertension

9. Hypertensive Emergency and Severe Hypertension

10. Team-Based Care and Follow-Up

1. Guideline Overview and Novelties

The 2025 AHA/ACC Hypertension Guideline is an updated clinical practice document that replaces the 2017 guideline, based on a comprehensive literature review from December 2023 to June 2024. The guideline is designed for all clinicians managing hypertension in primary care and specialty settings.

Top Take-Home Messages of the 2025 Guideline

• High blood pressure is the most common and modifiable risk factor for cardiovascular diseases. The general BP goal for all adults is <130/80 mmHg.
• Clinicians should collaborate with community leaders and health systems to screen all adults in their communities.
• Multidisciplinary team-based care is effective in evaluating access to medications and overcoming individual barriers.
• BP classification: Normal <120/80, Elevated 120-129/<80, Stage 1 HTN 130-139/80-89, Stage 2 HTN ≥140/≥90 mmHg.
• Lifestyle modifications (DASH diet, sodium restriction, weight loss, exercise, alcohol reduction) are strongly recommended for all adults.
• Pharmacological treatment is recommended for all adults with an average BP of ≥140/90 mmHg, and selected adults with a BP of ≥130/80 mmHg along with CVD, diabetes, CKD, or a PREVENT score of ≥7.5%.
• Single-pill combination therapy (SPC) should be preferred in Stage 2 HTN.
• Home BP monitoring + integration with a multidisciplinary team is an important tool that improves BP control.
• Severe hypertension (>180/120, no target organ damage) should be managed by initiating oral medication in an outpatient setting.
• When SBP ≥160 / DBP ≥110 mmHg is confirmed in pregnant women, medication should be initiated within 30-60 minutes.

From 2017 to 2025: Key Changes

ACEi: Angiotensin-converting enzyme inhibitor, ARB: Angiotensin receptor blocker, BP: Blood pressure, CKD: Chronic kidney disease, COR: Class of Recommendation, CVD: Cardiovascular disease, DBP: Diastolic blood pressure, eGFR: Estimated glomerular filtration rate, ICH: Intracerebral hemorrhage, MRA: Mineralocorticoid receptor antagonist, PREVENT: Predicting Risk of CVD EVENTs, RAASi: Renin-angiotensin-aldosterone system inhibitor, RDN: Renal denervation, SBP: Systolic blood pressure

2. Blood Pressure Classification

The guideline maintains the 2017 classification. BP classification should be based on an average of at least 2 readings obtained on two or more occasions.

In-Office BP Measurement — Correct Technique

• No caffeine, exercise, or smoking 30 min before measurement.
• 5 min quiet sitting; back supported, feet flat on the floor.
• Arm at heart level, no talking.
• At least 2 measurements, 1 min apart; take the average.
• Measure from both arms at the first visit.
• Correct cuff size: should encircle 80% of the arm.
• Avoid wearable devices (smartwatches, etc.) — insufficient accuracy.

Out-of-Office BP Monitoring

• ABPM (24-hour ambulatory BP): Significant if daytime ≥130/80, nighttime ≥110/65, 24-hour ≥125/75 mmHg.
• HBPM (Home BP monitoring): Measure in the morning before medication and in the evening before dinner; significant if ≥135/85 mmHg.
• Suspected White Coat HTN: In-Office ≥130/80 + ABPM/HBPM <130/80 → confirmatory test.
• Suspected Masked HTN: In-Office <130/80 + ABPM/HBPM ≥130/80 → high CVD risk.
• If SBP/DBP ≥160/100, treatment should be intensified without waiting for out-of-office monitoring.

3. Diagnostic Evaluation

3.1. Patient Evaluation — Laboratory and Diagnostic Tests

• Basic Laboratory Tests:
  • Fasting blood glucose or HbA1c
  • Lipid panel (LDL, HDL, TG)
  • Electrolytes (Na, K, Cl, bicarbonate)
  • Serum creatinine + eGFR calculation
  • Spot urine albumin/creatinine ratio
  • Urinalysis (dipstick + microscopy)
  • TSH (in suspected secondary HTN)
• ECG and Imaging:
  • ECG: Evaluation for left ventricular hypertrophy
  • Echocardiography: If clinically indicated
  • Fundoscopy: Suspected retinal damage
  • Renal Doppler: Suspected renovascular HTN
  • 24-hour urine aldosterone/cortisol: Secondary HTN
  • Sleep study: Suspected obstructive sleep apnea

3.2. Secondary Hypertension Screening 

Secondary hypertension can be seen in 5-25% of adult hypertensive patients. Further investigation should be done if any of the following clinical clues are present:

Primary Aldosteronism Screening — Important Point: The presence of hypokalemia is no longer a prerequisite for the screening decision. Screening is recommended in all patients with resistant hypertension. You do not need to discontinue antihypertensive drugs other than MRAs (spironolactone/eplerenone) before screening. During screening, MRAs must be discontinued at least 4 weeks in advance.

4. Drug Initiation Threshold & CVD Risk Assessment

The 2025 guideline uses the PREVENT™ (Predicting Risk of CVD EVENTs) model instead of the ASCVD score. The critical threshold is ≥7.5% ten-year CVD risk.

• Goal: <130/80 mmHg for all adults. Achieving <120 mmHg SBP is encouraged in cases with high CVD risk.
• About the PREVENT Score:
  • Replaced the older ASCVD (Pooled Cohort Equations) model.
  • Includes age, sex, BP, smoking, lipids, diabetes, CKD, obesity, and social determinants.
  • Online calculator: American Heart Association PREVENT calculator.
  • Threshold: ≥7.5% = high risk → initiate drug at 130/80 mmHg.

5. Lifestyle Modifications

Lifestyle modifications are strongly recommended for all adults (COR 1). Their effects on lowering blood pressure are summarized in the table below:

Practical Tips for Sodium Restriction:

• Label reading: ≤ 140 mg/serving = low sodium
• Watch out for the ‘Salty 6’: bread/rolls, pizza, sandwiches, cold cuts/deli meats, soup, burritos
• Hidden sodium: cheese, canned vegetables, ketchup, restaurant meals
• NSAID use increases sodium retention → avoid if possible
• Alcohol, caffeine, decongestants (phenylephrine, pseudoephedrine) raise BP → use with caution

6. Pharmacological Treatment

6.1. First-Line Agents

6.2. Alternative and Second-Line Agents

6.3. Drug Selection Strategy — Algorithm

• Stage 1 HTN — Monotherapy or SPC:
  • Can start with a single agent; especially in cases close to target BP.
  • Preferred: Thiazide-type diuretic, ACEi, ARB, or DHP-CCB.
  • If response is insufficient, increase dose or add a second agent.
  • Titrate slowly in elderly patients with orthostatic risk.
  • High-risk Stage 1 (ASCVD >7.5%, Black race) → Initiate combination with SPC.
• Stage 2 HTN — SPC Preferred:
  • Agents from two different classes; single-pill combination (SPC) preferred.
  • SPC: better adherence, faster BP control.
  • Recommended combination: RAASi + thiazide-type diuretic or DHP-CCB.
  • If response is insufficient, add a third agent.
• Combinations to Avoid:
  • ACEi + ARB: Risk of hyperkalemia + AKI (CONTRAINDICATED).
  • ACEi or ARB + Aliskiren: Same mechanism, high risk.
  • Verapamil/Diltiazem + Beta blocker: Bradycardia, AV block.
  • Two different BBs together: Restrict to isolated monotherapy.
• Useful Combinations:
  • RAASi + Thiazide: RAASi reduces the hypokalemic effect of the diuretic.
  • DHP-CCB + RAASi: CCB’s ankle edema is reduced by RAASi.
  • Thiazide + K+-sparing diuretic: Controls thiazide-induced hypokalemia.
  • Thiazide + Loop diuretic: Acceptable in selected conditions.

6.4. BP Goals

6.5. Medication Adherence Strategies

• Prefer 1 dose daily (adherence is higher compared to multiple doses).
• Prescribe SPC (single-pill combination) — reduces pill burden, increases adherence.
• Synchronize prescription refill tracking with medication appointments.
• Use telehealth, SMS reminders, smartphone apps.
• Screen for stress, anxiety, depression → non-adherence is higher in these groups.
• Provide simple, visual materials if health literacy is low.
• If non-adherence is detected, converse without judgment; understand the patient’s perspective.

7. Special Populations

7.1. Diabetes + Hypertension

• BP goal: < 130/80 mmHg (COR 1).
• If CKD eGFR <60 or albuminuria ≥30 mg/g is present: ACEi or ARB is recommended (COR 1) → delays progression of diabetic kidney disease.
• If mild albuminuria (<30 mg/g) is present: ACEi/ARB could be considered (COR 2a).
• Do not combine ACEi + ARB.
• Thiazide-type diuretic or DHP-CCB if RAASi is contraindicated.

7.2. Chronic Kidney Disease (CKD)

• BP Goal and Drug Selection:
  • SBP < 130 mmHg target (COR 1, Level A).
  • eGFR <60 + albuminuria ≥30 mg/g: RAASi (ACEi or ARB — not both) is recommended.
  • Check electrolytes and eGFR 2-4 weeks after initiating ACEi/ARB.
  • eGFR drop > 30% → reduce or discontinue drug; perform further investigation.
  • ACEi/ARB can be continued even at eGFR <30 (NEPHRON-D trial).
  • Prefer loop diuretic over thiazide at eGFR <30.
• Monitoring Parameters:
  • Potassium: Hyperkalemia monitoring (especially in RAASi + K+-sparing combinations).
  • Serum creatinine and eGFR: Every 2-4 weeks (upon dose change).
  • Aldosterone/renin ratio: In suspected primary aldosteronism.
  • Spot urine albumin/creatinine: Annual follow-up.
  • Minimize systolic blood pressure variability.

7.3. Heart Failure (HFrEF) + Hypertension

7.4. Cerebrovascular Disease + Hypertension

7.5. Pregnancy and Hypertension

• BP Management in Pregnancy — 2025 New Recommendations:
  • SBP ≥160 or DBP ≥110 mmHg → confirm within 15 min → initiate drug within 30-60 min (COR 1) — lower to <160/<110.
  • Chronic HTN (pre-pregnancy or diagnosed <20th week) → treat with a goal of <140/90 mmHg (COR 1 — NEW).
  • Recommend low-dose aspirin to those at risk of preeclampsia (COR 1 — NEW).
• CONTRAINDICATED Drugs in Pregnancy (COR 3 Harm — 2025 updated):
  • ACEi, ARB, direct renin inhibitors
  • Atenolol (NEW — added 2025)
  • Nitroprusside (NEW)
  • Mineralocorticoid receptor antagonists (MRA) (NEW)
• SAFE Drugs in Pregnancy:
  • Labetalol (IV and oral), hydralazine (IV), nicardipine (IV)
  • Oral: methyldopa, nifedipine LA

7.6. Elderly Patients and Resistant Hypertension

• Elderly Patient (≥65 Years):
  • BP goal: < 130/80 mmHg; frail patient → shared decision-making.
  • Orthostatic hypotension screening: Measurement at 1st and 3rd minute after standing.
  • Intensive BP lowering is still beneficial in orthostatic HTN, can be maintained with careful monitoring.
  • Combined BP variability + hypotensive episodes are associated with cognitive decline.
  • When initiating medication, use low dose, slow titration; reduce the iatrogenic fall risk.
  • Diuretics should be used more cautiously regarding fluid loss.
• Resistant Hypertension:
  • Definition: Target BP cannot be reached with the maximum tolerated 3 drugs (including a diuretic).
  • Before true resistance is confirmed: rule out non-adherence, white coat effect, drug/substance-induced HTN.
  • Review the entire medication list; remove or adjust drugs that affect BP (COR 1).
  • Investigate secondary causes (especially primary aldosteronism, OSA).
  • Add spironolactone as the 4th agent → the most effective add-on agent.
  • Renal denervation (RDN): In selected cases in resistant HTN; multidisciplinary team evaluation (COR 1).
  • Shared decision-making; discuss pros/cons of RDN vs. medical therapy.

8. Hypertensive Emergency and Severe Hypertension

Important Warning — 2025 New Recommendation: For asymptomatic severe hypertension (>180/120 mmHg) in adult patients admitted for non-cardiac reasons with no target organ damage, acute BP lowering using an additional intravenous or oral antihypertensive agent is not recommended (COR 3 Harm). This approach can cause harm and provides no benefit.

9. Team-Based Care and Follow-Up

9.1. Multidisciplinary Team-Based Care (COR 1, Level A)

9.2. Follow-Up After Treatment Initiation / Intensification

• Monthly follow-up for uncontrolled HTN patients with newly initiated medication or changed doses until target BP is reached (COR 1, B-R).
• Medication adherence + BP response should be evaluated at every visit.
• Electrolyte + creatinine check 2-4 weeks after RAASi initiation.
• Review home BP monitoring (HBPM) data prior to the clinical visit.
• EHR and patient registries: Use the registry system to identify uncontrolled HTN patients.
• Telehealth (synchronous or asynchronous): An effective tool for remote monitoring + medication titration (COR 2a, B-R).

9.3. Social Determinants of Health (SDOH) and Health Equity 

Socioeconomic status, access to food, housing conditions, exposure to stress and discrimination affect BP control. In Black adults, hypertension begins earlier, is more severe, and complications are seen more frequently. Thiazide-type diuretics and CCB monotherapy may be more effective than ACEi/ARB in this group.

• Screen for SDOH barriers in every patient (transportation, medication access, health literacy, financing).
• Consider initial combination therapy (thiazide + CCB) first in Black patients.
• Community-based health workers and team care are effective in reducing racial disparities in BP control.
• Clinical decision support systems (EHR) and patient registries should be used to proactively identify high-risk patients.

10. Quick Reference Card — Summaries for the Clinician

When Do I Initiate Medication? 

✔ BP ≥ 140/90: For everyone ✔ BP ≥ 130/80 + CVD/DM/CKD/PREVENT≥7.5% ⚠ BP 130-139 + low risk: Lifestyle first for 3-6 months

What Are My BP Goals?

• General goal: < 130/80 mmHg
• High risk: < 130 mmHg; ideal < 120 mmHg
• Pregnancy (chronic HTN): < 140/90 mmHg
• Post-Stroke/TIA: < 130/80 mmHg

What Are My First-Choice Drugs?

• Thiazide-type diuretic (chlorthalidone preferred)
• ACEi or ARB (not together!)
• DHP-CCB (amlodipine)
• Stage 2 → Prefer SPC (single-pill combination)

When Do I Investigate Secondary HTN?

• Resistant HTN (no control with 3 drugs)
• Young age (<30 y), sudden onset
• Hypokalemia (drug-induced or spontaneous)
• Adrenal incidentaloma
• Sleep apnea, family history
• Paroxysmal HTN + sweating + palpitations

Caution in Pregnancy!

• CONTRAINDICATED: ACEi, ARB, Atenolol, MRA, Nitroprusside
• SAFE: Labetalol, hydralazine, methyldopa, nifedipine LA
• SBP ≥160 / DBP ≥110 → medication within 30-60 min!

Severe HTN in Hospital — 2025 Change

• NO target organ damage → DO NOT give additional IV/oral agents (COR 3 Harm)
• Continue regular medications; treat the underlying cause

This document is a summary guide prepared for healthcare professionals based on the 2025 AHA/ACC Hypertension Guideline (Circulation 2025;152:e114–e218). Clinical decisions should be based on the original guideline text and individual patient assessment.

TABLE OF CONTENTS

1. What is High Blood Pressure (Hypertension)?

    • Blood Pressure Categories Chart

    • Risk Factors (Controllable / Uncontrollable)

2. What Are the Consequences of High Blood Pressure?

    • Stroke, Heart Failure, Kidney Disease, and More

3. How Can I Improve My Blood Pressure?

    • Lifestyle Changes Chart

    • Why Should I Restrict Sodium?

    • High Blood Pressure Medications and Side Effects

4. African Americans and High Blood Pressure

5. How Do I Measure My Blood Pressure Correctly?

6. Resources and Reference Links

1. What is High Blood Pressure (Hypertension)?

Blood pressure is the force exerted by circulating blood against the walls of the blood vessels. It is measured in millimeters of mercury (mm Hg) and is written as two numbers (e.g., 112/78 mm Hg). High blood pressure usually has no symptoms; therefore, it is called the ‘silent killer.’ Nearly half of the American population over the age of 20 has high blood pressure, yet many are unaware of it.

Basic Definitions

• Systolic pressure (top number): The pressure in your blood vessels when your heart beats.
• Diastolic pressure (bottom number): The pressure in your blood vessels between heartbeats.
• Normal blood pressure: A value below 120/80 mm Hg.

Why is High Blood Pressure Dangerous? Left untreated, high blood pressure damages the heart, brain, kidneys, and eyes. It significantly increases the risk of heart attack, stroke, and kidney failure.

Blood Pressure Categories

Risk Factors

Controllable Factors:

• Smoking and secondhand smoke exposure
• Diabetes
• Obesity or being overweight
• High cholesterol
• Unhealthy diet (diet high in sodium, low in potassium, and excessive alcohol)
• Physical inactivity

Uncontrollable Factors:

• Family history of high blood pressure
• Race / ethnicity
• Advanced age
• Gender (higher risk in men)
• Chronic kidney disease
• Obstructive sleep apnea

Important Note: Socioeconomic status and psychosocial stress are also risk factors for hypertension. This situation can negatively affect access to basic life needs, medication use, access to healthcare professionals, and the capacity to adopt healthy lifestyle changes.

2. What Are the Consequences of High Blood Pressure?

High blood pressure is the first stone that paves the way for devastating health problems, much like a ‘domino effect’. If left uncontrolled, it can lead to a heart attack, stroke, heart failure, or kidney failure.

Affected Organ Systems

How Does High Blood Pressure Increase Stroke Risk? High blood pressure is one of the most important risk factors for stroke. Over time, it increases the workload of the heart and damages your blood vessels. People with high blood pressure are much more likely to have a stroke compared to people with normal blood pressure.

• Ischemic Stroke (87%) Caused by narrowed or blocked blood vessels that cut off blood flow to the brain and kill brain cells. High blood pressure damages the inner lining of the blood vessels, paving the way for this blockage.
• Hemorrhagic Stroke (13%) Occurs when a blood vessel in or near the brain ruptures. Chronic high blood pressure or age-related blood vessel damage is the main cause of this type of stroke.

How Can I Control High Blood Pressure? Even if you have previously had a stroke or heart attack, keeping your blood pressure under control can prevent a new event:

• Do not smoke; avoid exposure to secondhand smoke.
• Maintain a healthy weight.
• Eat a diet rich in fruits and vegetables, and low in sodium and saturated/trans fats.
• Get at least 150 minutes of moderate-intensity physical activity per week.
• Alcohol causes your blood pressure to rise.
• Take all medications exactly as prescribed.
• Know what your blood pressure should be and try to maintain that value.
• Do not skip your regular follow-up appointments.

3. How Can I Improve My Blood Pressure?

By treating high blood pressure, you can significantly reduce the risk of stroke, heart attack, heart failure, and kidney failure. Each of the lifestyle changes below reduces blood pressure by a certain amount:

Effect of Lifestyle Changes on Blood Pressure

SBP = Systolic Blood Pressure | BMI = Body Mass Index

Weight Loss To lose weight, you must burn more calories than you consume every day. Consult your healthcare professional for a healthy eating and physical activity plan. Losing at least 5% of your body weight will help lower your blood pressure.

Why Should I Restrict Sodium? Excess sodium in the blood pulls water into the blood vessels, increasing the amount of blood inside them; this leads to an increase in blood pressure. In some people, it can cause high blood pressure or make it even higher.

Daily Sodium Goals and Practical Tips

• Daily goal: 1,500 mg or less. Even a 1,000 mg reduction improves heart health.
• Ways to Reduce Sodium:
  • Read nutrition labels; products containing 140 mg or less of sodium are considered low sodium.
  • Avoid ready-made, packaged, and processed foods.
  • Do not use salt when cooking or at the table; prefer herbs and salt-free spices instead.
  • When eating out, ask for your food to be prepared without salt.
  • The ‘Salty 6’: bread, pizza, sandwiches, cold cuts, soup, burritos — the 6 foods containing the most salt.
  • Watch out for ‘hidden sodium’ sources like cheese, canned vegetables, frozen meals, and fast food.

Alcohol Alcohol can raise blood pressure. If you have difficulty cutting back on alcohol, ask your doctor for information about support groups.

Physical Activity Regular physical activity helps lower blood pressure, control weight, and reduce stress. Aim for at least 150 minutes of moderate-intensity or 75 minutes of high-intensity aerobic exercise per week. Start with activities you enjoy, such as brisk walking or cycling (Consult your family doctor before starting exercises, and adjust the durations according to their recommendations).

About High Blood Pressure Medications Depending on your risk level and blood pressure readings, one or more medications may be necessary. Your doctor may implement a trial process to find the most suitable combination for you.

Common Side Effects

• Weakness, fatigue, or sleepiness
• Cough
• Muscle cramps
• Headache, dizziness
• Erectile dysfunction
• Sleep problems
• Constipation or diarrhea
• Feeling thirsty, skin rash

Important Reminder:

• Take your medications exactly as prescribed; do not stop taking them without your doctor’s approval.
• Medication use usually continues for life even after your blood pressure returns to normal.
• If you experience side effects, do not stop taking the medication yourself — call your doctor.

How Do I Remember to Take My Medication?

• Take your medication at the same time every day.
• Combine taking your medication with a daily habit, like brushing your teeth.
• Use a weekly pillbox with separate compartments for each day.
• Ask family members or friends for reminders.
• Set a reminder on your smartphone or keep a medication calendar.

4. African Americans and High Blood Pressure

African Americans in the US have a higher rate of hypertension compared to other racial and ethnic groups. High blood pressure can be more severe in this group, and some medications may be less effective in these individuals. High blood pressure usually has no symptoms; therefore, it gets the name ‘silent killer’.

Special Dietary Recommendations:

• Aim for 1,500 mg or less of sodium per day (even a 1,000 mg reduction is beneficial).
• Consume 3,500–5,000 mg of potassium per day (bananas, potatoes, beans, spinach).
• Alcohol consumption can increase your blood pressure.
• Do at least 150 minutes of moderate-intensity aerobic exercise per week (Always consult your doctor before exercising).

Caution in Medication Treatment:

• Thiazide-type diuretics and/or calcium channel blockers may be more effective alone or in combination in African Americans.
• Your doctor may implement a trial process to find the most suitable combination for you.
• Continue medication treatment along with lifestyle changes.

Conditions Uncontrolled Hypertension Can Lead To:

• Heart attack and heart failure
• Stroke
• Kidney disease and kidney failure
• Erectile dysfunction
• Vision loss

5. How Do I Measure My Blood Pressure Correctly?

Preparation before and during the measurement is of great importance to get accurate results. Follow the steps below:

BEFORE MEASUREMENT:

• Do not smoke, exercise, consume caffeine, or drink alcohol 30 minutes before the measurement.
• Sit in a chair for at least 5 minutes with your left arm resting comfortably at heart level.
• Relax; sit upright, keep your feet flat on the floor, and have your back supported.
• Do not talk during the measurement.

DURING MEASUREMENT:

• Take at least 2 readings at least 1 minute apart; measure in the morning before taking medication and in the evening before dinner. Record all results.
• Use a properly calibrated and validated device. Check the cuff size.
• Place the bottom edge of the cuff just above the bend of the elbow.

⚠ HYPERTENSIVE CRISIS — EMERGENCY If your blood pressure is over 180/120 mm Hg, wait a few minutes and measure again. If it is still high, IMMEDIATELY CALL YOUR DOCTOR OR GO TO THE EMERGENCY ROOM.

6. Resources and Reference Links

Useful Websites and Videos

References

1. American Heart Association (AHA) (2021). Blood pressure fact sheets. heart.org
2. AHA (2021). Getting active to control high blood pressure. heart.org
3. AHA (2022). Recipes. recipes.heart.org
4. American Medical Association (2022). 7-step quick guide to measuring home blood pressure. ama-assn.org
5. CDC (2017). Tips for taking blood pressure medicines as directed [Video]. YouTube.
6. NHLBI (2020). Easy ways to add exercise to your life [Video]. YouTube.
7. NHLBI (2019). 3 Delicious Heart-Healthy Recipes [Video]. YouTube.
8. NHLBI (2022). Delicious healthy eating recipes for heart health. healthyeating.nhlbi.nih.gov
9. USDA (n.d.). Budget-friendly healthy eating. myplateprod.azureedge.us
10. USDA (2022). MyPlate. myplate.gov

This document is based on American Heart Association (AHA) resources. Please consult your healthcare professional for medical decisions.

Venous thromboembolism (VTE) is considered the third most common cause of cardiovascular death worldwide after myocardial infarction and stroke. Its incidence in the general population is approximately 1–2 per 1000 people annually and increases significantly with age.

Anticoagulation for at least 3 months is the standard treatment approach for acute VTE, and in recent years direct oral anticoagulants (DOACs) have become widely used in clinical practice. In particular, apixaban and rivaroxaban have become the two most commonly preferred agents in the treatment of acute pulmonary embolism and deep vein thrombosis.

However, until now, an important clinical question remained unanswered:

Is there a real difference in bleeding risk between apixaban and rivaroxaban?

An important study seeking to answer this question was published in the New England Journal of Medicine in 2026: the COBRRA Trial.

COBRRA Trial: Design

The COBRRA trial was an international, randomized, prospective clinical study.

• 2760 patients were included in the study
• Patients were randomized 1:1 into two groups
• Study population:
  • symptomatic pulmonary embolism
  • or proximal deep vein thrombosis

The treatment protocol was as follows:

Apixaban Group

• 7 days: 10 mg twice daily
• Afterwards: 5 mg twice daily

Rivaroxaban Group

• 21 days: 15 mg twice daily
• Afterwards: 20 mg once daily

The follow-up period was planned as 3 months.

The primary endpoint of the study was: Clinically relevant bleeding

This endpoint included the following two conditions:

• Major bleeding
• Clinically relevant non-major bleeding (according to ISTH criteria)

Main Results of the Study

Toplam 2760 hasta randomize edildi.

Klinik olarak anlamlı kanama oranları:

These results were statistically significant:

Relative risk: 0.46 (95% CI 0.33–0.65, p<0.001)

In other words: The bleeding risk was approximately 54% lower with apixaban.

All-cause mortality was quite low:

• Apixaban: 0.1%
• Rivaroxaban: 0.3%

Clinical Significance

This study is important from several perspectives.

1. First Direct Comparative Study

Until now, most DOAC studies were based on comparisons with warfarin.
There had been no direct randomized comparison between apixaban and rivaroxaban.

The COBRRA trial filled this gap.

2. Difference in Safety Profile

While both drugs are considered effective in preventing recurrent thromboembolism, this study demonstrates a clear advantage in favor of apixaban regarding bleeding safety.

3. Possible Impact on Clinical Practice

These results may influence treatment selection especially in the following patient groups:

• elderly patients
• patients at high bleeding risk
• those receiving concomitant antiplatelet therapy
• patients with limited renal function

Will the Guidelines Change?

Current international guidelines generally did not recommend a clear superiority among DOACs. The reason was the lack of direct comparative studies.

Since the COBRRA trial filled this gap, it may provide data in the future that could influence DOAC preference rankings in guidelines such as:

• European Society of Cardiology (ESC)
• American College of Chest Physicians (ACCP)
• American Society of Hematology (ASH)

Conclusion

The COBRRA trial is an important randomized study directly comparing two widely used DOAC agents in the treatment of acute venous thromboembolism.

The main message of the study is clear:

Compared with rivaroxaban, apixaban demonstrated similar efficacy while showing a significantly lower risk of clinically relevant bleeding.

This finding may lead us to reconsider treatment selection, especially in patients at high bleeding risk.

Reference

Castellucci LA et al. Bleeding Risk with Apixaban vs Rivaroxaban in Acute Venous Thromboembolism. New England Journal of Medicine. 2026;394:1051–1060

Organ transplantation is the treatment of a patient by surgically replacing organs that have been damaged to the point of being unable to function due to untreatable diseases with a healthy organ taken from a living or deceased person. Among these, heart transplantation can only be performed from a cadaver (a person whose brain death has been confirmed).

Who Can Undergo Heart Transplantation?

Heart patients under the age of 65 who have reached the end stage of heart failure despite all medical treatments and have a life expectancy of less than 1 year are candidates for heart transplantation. Patients of more advanced age can be included in the heart transplant program if they are found suitable after a careful evaluation of their physical characteristics beyond their chronological age. The necessity for a heart transplant most commonly arises due to serious and major irreversible damage to the heart muscle caused by a previous crisis related to the blockage of coronary vessels, or due to a severe decrease in the contractile power of the heart muscle—either congenital or subsequently occurring due to bacteria, viruses, etc.—known as cardiomyopathy. Other rare causes include rheumatic fever, hypertension, valve diseases that have led to heart muscle damage, congenital heart anomalies that cannot be surgically corrected, heart tumors, and patients with serious rhythm disorders resulting from various diseases that continue in a life-threatening manner and cannot be stopped despite all kinds of medication and pacemaker treatments.

Can Everyone Undergo Heart Transplantation?

Heart transplantation is recommended by specialist physicians after ensuring that all known treatment methods for patients with heart failure have been considered, applied, and tried. This is because these patients will lose their lives shortly if they do not receive a heart transplant. However;

• Patients who have developed irreversible high pulmonary hypertension (Pulmonary hypertension = high pulmonary pressure, high pulmonary vascular resistance) that cannot be treated due to long-term heart failure,
• Patients with severe obesity with a Body Mass Index (BMI) over 30,
• Patients with active, uncontrollable infections,
• Patients who have developed irreversible other organ dysfunctions (especially kidney failure) due to advanced diabetes (Diabetes Mellitus),
• Patients with an untreatable tumoral (cancer) disease,
• Serious osteoporosis (bone loss),
• Patients with psychiatric disorders or alcohol/drug addiction are not suitable candidates for heart transplantation.

How to Get on the Heart Transplant List?

When the cardiologist who knows and follows the patient’s medical history thinks that a heart transplant is necessary for the treatment of the disease, they present the case to the heart transplant and artificial heart support systems council. A preliminary evaluation is made by discussing the patient’s medical history, all treatments performed, current status, latest tests, physical capacity, and other details. Then, the patient’s condition is thoroughly evaluated by the regularly convened board. Other necessary tests and consultations (psychiatry, endocrinology, nephrology, dentistry, etc.) are planned. If the patient is found suitable for a heart transplant as a result of all these evaluations by the heart transplant and artificial heart support systems council, they are placed in the heart transplant program according to their urgency and recorded in the organ waiting list. The average waiting time for heart transplantation is approximately 6-7 months for patients on the emergency list.

Heart Transplant Surgery, Intensive Care, and Afterward

Once the team sent to retrieve the organ examines the heart during the surgery and declares it suitable, the patient to receive the heart transplant is taken into surgery at the recipient hospital. Thus, the operation process begins. While the heart transplant is being performed, the patient is connected to a heart-lung machine. The goal is to perform the transfer of the organ and the operation within 4 hours. For this, a very good organization and an expert team are required. After the heart transplant, the patient is taken to the cardiac surgery intensive care unit. The patient remains connected to a respiratory device for the first 8-24 hours. Immunosuppressive (immune-suppressing) drugs are started while the patient is still in surgery to prevent rejection. Because these drugs are administered, the patient is very susceptible to infection. Therefore, the patient is given the most careful care possible. If everything goes well, the patient is usually transferred to a ward room on the 3rd to 5th day on average. Close monitoring is performed for rejection during the initial period. The patient is usually discharged after 20 days. According to the physician’s recommendation, the patient is generally called for follow-up at the 1st, 3rd, 6th, and 12th months.

Results of Heart Transplantation (Life Expectancy)

• Heart transplant surgeries continue to be the distinguished treatment approach for patients who have reached the final stage and will not respond to medication or surgical treatments. The fact that organ donation is not at the desired level—not only in our country but even in leading countries in heart transplantation—makes it mandatory to use the hearts to be used for transplantation in the most efficient way. Providing available organs to the recipients who need them most and will benefit the most is increasing in importance every day.
• Immunosuppressive treatment, developments in immunological monitoring, and the fight against sterilization and infection have been the cornerstones for the good survival results in the last 20 years. Particularly as a result of developments in immunosuppressive treatment, death rates due to rejection have decreased significantly.
• Looking at the results of leading centers in heart transplantation worldwide, the 1-year survival rate after heart transplantation is over 85%, and the 5-year survival rate is over 70%. At Türkiye Yüksek İhtisas Hospital, the one-year survival rate is 88%, the five-year survival rate is 76%, and the 10-year survival rate is over 54%.

Heart Transplant Numbers and Organ Donation in the World and Türkiye ​

• The need for heart transplantation is greater than the organ supply. In America, there are approximately 5-6 million heart failure patients, with 500,000 patients added each year. The number of patients waiting for a heart transplant is approximately 25,000-30,000. However, the number of heart transplants performed is approximately 2,500–3,000 per year (10-15% of the waiting patients). 20-40% of the patients lose their lives before a heart transplant can be performed.
• The money spent on patients with heart failure is approximately 34 billion dollars per year. In Türkiye, the number of heart failure patients is approximately 1.5 million. The number of patients in need of a heart transplant is approximately 3,000-5,000. However, according to the records in the National Coordination Center (UKM) data, the number of heart transplants performed is 50-60 (1-2%) per year.

Pediatric Heart Transplantation

Many causes lead to heart failure, such as rheumatic heart valve diseases and congenital structural anomalies; congenital and acquired diseases of the inner layer of the heart, the heart muscle, and the heart membrane; volume-loading diseases such as severe anemia, excessive blood or fluid transfusion, and hormonal reasons; babies of diabetic mothers; and rhythm and conduction disorders of the heart. Despite all medical treatments or all surgical correction operations in children with congenital heart disease, patients’ heart failure may not improve. For these patients, heart transplantation or artificial heart devices can be life-saving. A pediatric heart transplant and artificial heart device program was launched at Türkiye Yüksek İhtisas Hospital in 2012 together with the pediatric cardiology and heart transplant group. Our clinic intervenes in patients with end-stage heart failure from all age groups.

Diagnosis and Symptoms of Heart Failure

• Pain in the chest,
• Shortness of breath (labored breathing),
• Weakness,
• Fatigue,
• Tiring easily,
• Inability to show resistance to simple illnesses (such as the common cold or flu),
• Swelling of the ankles,
• Weight loss due to decreased appetite,
• Frequent urination,
• Deterioration of heart rhythm and rapid heartbeat,
• Blood accumulation in the lungs.

Since blood cannot sufficiently reach the tissues, the patient has difficulty while climbing a slope or stairs, feels forced to rest frequently, and swelling (edema) occurs in the ankles. In severe cases, bruising increases along with shortness of breath. Along with this, blood accumulation may occur in the lungs. Despite all these symptoms, heart failure can only be understood as a result of examinations and tests performed. Sometimes, there may be no symptoms even if heart failure is present.

Treatment of Heart Failure

The first stage of treatment begins with a change in the patient’s nutritional lifestyle. It is necessary to significantly reduce the intake of fat and especially salt. Since salt increases water retention in the body, it prevents the reduction of swelling in the body. If less salt is taken, water excretion through urine increases and swelling decreases. Thus, the workload of the heart is reduced. Patients with heart failure must stay away from tiring tasks that require heavy strength. However, just as a person leading a sedentary life experiences a loss of strength and conditioning, the heart muscle also loses strength. To prevent this, an exercise program should be implemented under a doctor’s supervision. The second stage in treatment is carried out with medications. As for the third stage; devices to eliminate rhythm disorders and corrective surgeries (coronary bypass, valve surgery, etc.) directed at the disease causing heart failure can be applied. However, if the aforementioned treatments are applied but the condition cannot be corrected in the treatment of end-stage heart failure, the most effective treatment methods are heart transplantation and auxiliary artificial heart devices that support the functioning of the heart.

Heart support devices (HSD) are high-technology devices produced to take over the pumping duty of the heart in patients with end-stage heart failure. There are models whose mechanical parts can be placed inside the chest or abdomen, as well as paracorporal (outside the body) models. Generally, the battery is located outside the body. The fundamental reason leading to the development of these devices is that some of the patients waiting on the heart transplant candidate list are lost during the waiting period due to limitations in finding donors. There have been major developments regarding HSDs in the last 10 years, and significant progress has been made toward reaching ideal devices. While the 1-year survival rate was 50% in the first-generation artificial support devices, this rate was reported as 68-86% in the 2nd generation devices and around 90% in the 3rd generation devices. Following the successful results obtained with systems used in the treatment of cardiogenic shock in the early years, multi-purpose use is increasing today with the aims of keeping the patient alive until transplantation (bridge to transplantation) and improving heart failure (bridge to recovery). In the REMATCH study concluded in the USA in 2002, the superiority of implantable HSDs over optimal medical treatment in terms of survival and quality of life in patients not suitable for heart transplantation resulted in the granting of FDA approval for long-term use (destination therapy). In patient selection, besides updated indications, the cardiac and extracardiac characteristics of the patient are the primary determinants, while in device and system selection, preference for the one most suitable for the patient’s clinical picture is essential. In recent years, along with well-known pulsatile systems, interest in miniaturized flow pumps has been increasing. Consequently, it is suggested that in the next decade, the transformation of HSDs into a special field of expertise within heart failure surgery, new organizations inside and outside hospitals, and financing regulations in the health system will necessitate a total institutional restructuring in societies.

Heart transplantation and artificial heart support devices are performed by fully equipped hospitals authorized by the R.T. Ministry of Health, which have experienced teams in organ transplantation and artificial heart systems and carry out heart transplantation programs.

Who Needs an Auxiliary Artificial Heart Device and When?

Auxiliary heart support devices are mainly used for the following purposes in patients with end-stage heart failure:

• For short-term use (short-term applied devices) in patients who suddenly develop heart failure, to prevent deterioration in other organ functions and to keep the patient alive until a long-term support system is applied,
• For the purpose of recovery (short-term applied devices) in diseases that cause sudden heart failure such as inflammation of the heart muscle (Myocarditis) but heal completely as a result of drug treatment, in order to keep the patient alive during the severe period of the disease,
• To keep the patient alive until heart transplantation (long-term applied devices) in patients who are on the waiting list for heart transplantation but whose heart failure progresses while waiting for a heart,
• For lifelong use (long-term applied devices) to increase the life span and quality of patients who cannot undergo heart transplantation for various reasons (advanced age, serious kidney, liver disease, etc.),
• To provide the chance of heart transplantation later (long-term applied devices) in patients who cannot undergo heart transplantation due to high pulmonary (lung) resistance/pressure (PVR), as a decrease in PVR can be seen after VAD implantation.

If severe failure has developed in both the right and left sides of the heart, a total artificial heart device is placed.

Total Artificial Heart Device

It is the device that is placed in stead of the diseased heart after it is removed from the body and carries out the circulation. It keeps the patient alive for temporary purposes, that is, until heart transplantation.

Frequently Asked Questions and Problems Regarding Auxiliary Artificial Heart Devices

Artificial heart support devices are in two different groups: those placed inside the body (implantable, miniature) and those outside the body (paracorporal). Which one will be installed is determined according to the characteristics of the patient’s heart failure and general condition. Although the artificial heart support device surgery varies according to the type of device installed, if no complications develop, it is a surgery that lasts 4-6 hours on average. The pump stays inside your chest and is directly connected to your heart. It pumps blood from the left side of your heart into your aorta (the large blood vessel that carries blood from your heart to other parts of your body). Patients whose surgery is finished wake up in a special transplant room in the intensive care unit; they are disconnected from the respiratory device when all findings return to normal. Blood comes out of the pump in a continuous flow, like water coming out of a garden hose. This continuous flow is different from the pulse of a normal heart and as a result, you may not be able to feel your pulse. There is no need to worry, this is a normal situation. These patients have to use blood-thinning medications for as long as they live with the device and consult their doctors for the doses of these medications by having regular blood tests. The pump works with a small external computer called a controller. The pump and controller are connected to each other by a small cable (driveline) passing through the skin in your upper abdominal region. The controller runs the pump and also provides text messages and audible alarms for you to check the operation of the system. The controller works with two batteries or one battery and wall electricity. The entire system is portable and weighs approximately 1.5 kg. You can attach a carrying case to your waist or carry it on your shoulder, so you take the system everywhere you go.

Artificial Heart Device Program

The Artificial Heart Support Device Program at our hospital began in 1990 and has continued to the present day. In 2001, the first intracardiac heart pump in Türkiye was successfully implanted in our patient. Technological developments regarding artificial heart support devices are closely monitored by our teams. Today, miniaturized heart pumps used in leading transplant centers worldwide are also utilized for our patients at our hospital. In 2013, for the first time at our hospital, total artificial heart devices were successfully implanted in two of our patients.