The "2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome" retires, replaces, and expands upon the "2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults." The primary intended audience for this guideline is clinicians who care for patients across the spectrum of cardiovascular-kidney-metabolic syndrome, an interrelated condition characterized by the interconnections among metabolic risk factors (including obesity and type 2 diabetes), chronic kidney disease, and cardiovascular disease.

Current clinical practice guidelines for the primary prevention of cardiovascular disease recommend risk assessment to align the type and intensity of preventive efforts with an individual's risk. The 2025 American Heart Association/American College of Cardiology guideline for the prevention, detection, evaluation, and management of high blood pressure in adults and the 2026 American Heart Association/American College of Cardiology guideline on the management of dyslipidemia incorporate quantitative risk assessment, recommending the PREVENT (Predicting Risk of Cardiovascular Disease Events) equations to guide initiation and intensification of antihypertensive and lipid-lowering therapies, respectively. Given the growing awareness of the clustering of cardiovascular-kidney-metabolic risk factors along with the expanding armamentarium of cardioprotective therapies for obesity, diabetes, and chronic kidney disease, a harmonized approach that comprehensively assesses and addresses risk across these interconnected conditions is needed. The 2026 American Heart Association/American College of Cardiology guideline for the prevention, detection, evaluation, and management of cardiovascular-kidney-metabolic syndrome provides recommendations for the use of the PREVENT equations with outcome-specific risk thresholds for staging, detection of subclinical cardiovascular disease, and decision-making regarding initiation and intensification of cardiovascular-kidney-metabolic therapies. This approach integrates predicted risk (using PREVENT-CVD [cardiovascular disease], PREVENT-ASCVD [atherosclerotic cardiovascular disease], and PREVENT-HF [heart failure]) with the relative risk reduction expected from treatment for each outcome to estimate the expected benefit (ie, absolute risk reduction) from drug therapy. This scientific statement details the rationale for using outcome-specific PREVENT equations, the evidence base for selected risk thresholds, and the potential population-level impact of these recommendations. This scientific statement also offers practical guidance for applying risk assessment as the first step in shared decision-making and for addressing gaps in awareness, risk communication, and optimal implementation of evidence-based preventive therapies to improve outcomes in individuals with or at risk for cardiovascular-kidney-metabolic syndrome.

Innovation in the treatment of ascending aorta and arch pathology with novel catheter-based and hybrid procedures has driven the need for a strategy to guide their safe application. The ARCH-ARC (Aortic Arch Academic Research Consortium) was established to pragmatically develop consistent clinical end points and to standardize definitions for use in studies of these new technologies. The ARCH-ARC team, consisting of independent international specialists in cardiac surgery, vascular surgery, vascular medicine, cardiology, neurology, radiology, and clinical trials, along with US Food and Drug Administration, industry, and contract research organization representatives, held virtual meetings from 2021 to 2025. Consensus was used to identify appropriate clinical end points and to standardize definitions of end points for endovascular, hybrid, and open surgical procedures in clinical trials in the ascending aorta and arch. Drawing on previous ARC work in cardiac, neurological, renal, and bleeding end points, the ARCH-ARC focused on definitions and end points related to aortic arch-specific anatomy, pathology, and procedures and clinical, device, and imaging. The adoption of the ARCH-ARC consensus definitions and end points will provide a template for consistent adjudication and event reporting and facilitate comparisons of clinical research studies involving devices for ascending aorta and arch pathology.

Weight loss and weight loss maintenance are prominent topics of discussion for clinicians and health professionals involved in treatment to reduce obesity and the risk of cardiovascular disease. Because physical activity is a key component of comprehensive obesity treatment, this scientific statement summarizes the role of physical activity in promoting weight loss, weight loss maintenance, and cardiometabolic health, complementing lifestyle, pharmacological, and surgical-based weight loss intervention strategies. Independently of weight loss, physical activity and exercise programs improve major cardiometabolic risk factors, including hypertension, insulin resistance, and dyslipidemia, which are highly prevalent in patients with overweight or obesity. As a single treatment modality, physical activity and exercise programs are unlikely to result in clinically meaningful weight loss (ie, at least 5% loss of initial body weight) unless aerobic physical activity levels are exceptionally high. When combined with diet-induced negative energy balance, obesity medication, or surgical treatment, increased physical activity can augment total weight loss and improve cardiometabolic outcomes. Because clinicians and health professionals play a pivotal role in fostering and sustaining patients' health goals, this scientific statement also provides an overview of evidence-based strategies for targeted weight loss counseling and for leveraging digital technology, particularly to engage patients and achieve realistic physical activity goals.

The heart transplant allocation system is evolving in response to increasing demand for donor organs, technological advances, and changes in medical decision-making. In this evolving landscape, the historical focus of allocating donor hearts to the "sickest patients first" principle may warrant periodic reassessment and thoughtful safeguards to ensure responsible stewardship and fairness. It is important to note that ethical considerations are central to frontline transplantation cardiologists and cardiothoracic surgeons, who must balance their role in advocating for their individual patients while aligning with allocation policies designed to benefit all recipients equitably. The goals of this scientific statement are (1) to raise awareness of ethical principles in heart transplantation, (2) to review ethical implications of the past and current allocation systems, and (3) to encourage clinicians and stakeholders to address ethical issues that will provide the foundation for future allocation systems.

Cardiac intensive care units are specialized, high-acuity, and resource-intensive environments for the care of critically ill patients with cardiovascular disease. Over the past 60 years, medical and interventional therapeutic advances have improved survival and reduced the risk of life-threatening arrythmias in many common cardiovascular conditions. Nonetheless, some hospitals have maintained historical cardiac intensive care admission practices, resulting in admissions of low-acuity patients who could otherwise be cared for in a telemetry-equipped hospital ward environment. These triage practices may be partially attributable to a lack of guidance from international societies on contemporary cardiac intensive care admission standards. In this scientific statement, we propose cardiac intensive care triage practice standards for common cardiovascular conditions, summarize available prediction scores, and outline priorities for future health services research in this field.

Resources for observational comparative research have expanded enormously in recent years to include very large sources of granular, routinely collected health care data and modern statistical, epidemiologic, and econometric techniques. This scientific statement provides an overview of best practices and analytic considerations in observational comparative studies from the perspective of investigators, sponsors, publishers, and consumers of observational research. Observational comparative research is a component of the research landscape that fulfills a role distinct from that of interventional studies in the evaluation of drugs, surgical procedures, medical devices, and health policies. Sources of systematic error (ie, bias) in observational comparative studies include selection bias, information bias, and confounding. Principles from statistical science and econometrics can potentially be used to make causal conclusions from observational data. Target trial emulation is a useful framework to guide the rational design and illuminate the limitations of observational studies. As with interventional research, a formal study protocol should be prepared before every observational study to enhance rigor, reduce data manipulation, and promote transparency of study reporting. Selection of the study data source is a key decision early in the design stage of a study, and should be chosen on the basis of concordance between the needs of the specific study question and the properties of the data set. We recommend the use of causal directed acyclic graphs to clearly specify the study exposure, end points, confounders, colliders, moderators, and mediators. Taken together, these recommendations promote rational design choices and cautious interpretation of the results of observational comparative studies.

Transvenous pacing is increasingly recognized as problematic in patients with prior or concomitant tricuspid valve intervention, owing to risks of leaflet interference, prosthetic dysfunction, and progression of tricuspid regurgitation. Leadless pacemakers offer a valve-sparing alternative; however, their safety and performance in structurally altered right heart anatomy remain incompletely defined. We conducted a systematic review to evaluate procedural feasibility, electrical performance, device-valve interaction, and clinical outcomes of leadless pacemaker implantation in patients undergoing surgical or transcatheter tricuspid valve interventions. Thirty-four studies comprising 272 patients were included, encompassing surgical repair, bioprosthetic replacement, valve-in-valve procedures, transcatheter edge-to-edge repair, and transcatheter tricuspid valve replacement. Leadless pacemakers were implanted via transfemoral, transjugular, or direct surgical approaches, achieving a procedural success rate of 99.3%. Electrical performance was consistently favorable, with stable capture thresholds, sensing amplitudes, and impedance during follow-up. Device-valve interaction was infrequent and generally manageable. Leadless pacemaker-related complications were rare (1.1%), with no device-related mortality. Within the included studies of patients undergoing surgical or transcatheter tricuspid valve interventions, no study demonstrated worsening tricuspid regurgitation attributable to the leadless pacemaker or its delivery system. Across a broad spectrum of complex tricuspid anatomies, leadless pacemakers demonstrated excellent feasibility, durable electrical performance, and a low complication profile, supporting their role as a valve-sparing pacing strategy in this population. These findings support leadless pacing in patients with prior tricuspid intervention, although prospective comparative data are required to define its role relative to alternative pacing modalities.

It has long been accepted that observational analyses have an important role in evaluating use patterns and assessing the safety of different treatments, including cardiovascular devices, in clinical practice. With the proliferation of large electronic databases, there has been increasing interest in using observational analyses to also examine the comparative effectiveness of devices. However, these analyses are often met with skepticism because of concerns about whether they can generate credible evidence about causal effects. This is in part a result of the difficulty in meeting the assumptions necessary to interpret observational associations as causal effects and of the wide variability in analytic rigor. In this review, we outline frameworks and review methods for using observational analyses to answer questions about the effectiveness and safety of cardiovascular devices. We highlight the target trial framework as a practical tool for guiding observational comparative effectiveness analyses. We illustrate how the framework allows investigators planning and conducting observational analyses to organize their activities as responses to 3 prompting questions. First, what is the research question of the study (ie, "What do we want?")? Second, what are the resources-including background knowledge, research concepts, principles and methods, and available data-that can be brought to bear on the research question (ie, "What do we have?")? And third, what specific steps should be taken to use the available resources to answer the research question (ie, "What do we do?")? We focus our exposition on the evaluation of cardiovascular devices, for which randomized trial data are often limited and there is a strong need for real-world evidence. In this setting, real-world evidence is usually derived from observational comparisons of the treatment of interest with relevant comparator groups using data captured during routine care. A principled approach to the planning and conduct of observational analyses can improve the quality of real-world evidence generation and ensure that the results of observational studies on medical devices can support meaningful conclusions about the risks and benefits of new devices.

Coronary artery bypass grafting is a well-established, durable, and safe surgical intervention. However, coronary artery disease continues to progress after the procedure. Patients who have undergone bypass surgery present unique challenges in terms of secondary prevention resulting from the often severe and diffuse nature of their coronary disease, the complexities of their postoperative recovery, the burden of their comorbid conditions, and the importance of ensuring long-term graft patency and preventing further disease progression. New evidence and advances in secondary prevention strategies in the post-coronary bypass grafting population have emerged since the American Heart Association's 2015 scientific statement on this topic. Secondary prevention strongly correlates with improved outcomes after bypass surgery, providing the rationale and urgency for this updated scientific statement to promote evidence-based practical considerations and to improve their use.

Institutional and systemic practices and policies contribute to lower-quality care and adverse outcomes among diverse racial and ethnic groups and individuals with limited economic resources. There are ample opportunities to change the trajectory of patients with heart failure (HF) across racial and ethnic groups. Multiple studies and quality improvement initiatives have demonstrated strategies to improve the care of diverse racial and ethnic populations living with HF, yet dissemination remains limited. This state-of-the-art review examines structural racism in the context of HF, outlines evidence-based strategies for HF programs to improve access to advanced HF therapies and reduce disparities in treatment outcomes, and discusses priorities for implementation and dissemination science efforts to address structural causes of disparities in HF care.

The rapid evolution of machine learning techniques, combined with the growing availability of large and diverse data sets, is poised to transform heart failure research and clinical care. This review first provides an overview of key machine learning and artificial intelligence concepts used in heart failure research and then examines how diverse data modalities-including electronic health records, patient registries, biobanks, imaging, telemonitoring, and synthetic data-are leveraged to develop machine learning applications for heart failure diagnosis, prognosis, risk stratification, and personalized treatment strategies. While the potential is considerable, we highlight key barriers to clinical translation, such as data heterogeneity, algorithmic bias, lack of interoperability, and privacy concerns. The review also examines the need for explainable and equitable artificial intelligence systems and evaluates emerging solutions, including Federated Learning and synthetic data generation to address fairness and data privacy challenges. Beyond technical innovations, we underscore the importance of human-centered design, stakeholder engagement, and regulatory readiness. We conclude by identifying future priorities and calling for interdisciplinary collaboration to ensure the scalable, ethical, and effective integration of AI in heart failure management.

Stenosis and dolichoectasia of cranial arteries likely reflect distinct mechanisms. Their contributions to lacunar stroke and cerebral small-vessel disease (cSVD) remain contentious. We investigated the associations of large-artery stenosis (LAS) and arterial widening with stroke subtype, cSVD markers, incident infarcts, and clinical outcomes.

Vascular aging is a central determinant of healthy life span, not only influencing the susceptibility to cardiovascular diseases but also shaping the risk of systemic decline across multiple organs. It is driven by a variety of age-related factors, including cellular senescence, chronic inflammation, loss of proteostasis, mitochondrial dysfunction, genomic instability, epigenetic remodeling, and stem cell exhaustion. These processes interact with the unique mechanical and metabolic environment of the vasculature to create a distinctive pathological trajectory, manifested in part as arterial stiffening, impaired barrier integrity, and dysregulated vasomotor control. Recent advances in single-cell omics and cross-organ molecular clocks have revealed the heterogeneity and organ specificity of aging, underscoring the need for integrative frameworks that connect vascular biology with overall health. Meanwhile, the development of diverse therapeutic strategies-ranging from senolytic and immune-mediated clearance to metabolic and mitochondrial interventions-highlights the translational potential of targeting the aging vasculature. Looking ahead, multimodal biomarkers and precision medicine may transform vascular aging from an inevitable process into a modifiable determinant of health span.

Bias in clinical research affects not only the internal validity of studies but also the equitable distribution of health benefits derived from studies. Among the most impactful forms are selection bias, attrition bias, and algorithmic bias, each of which is capable of distorting participant representation, treatment effect estimates, and model performance across important subgroups. This scientific statement provides a reference for cardiovascular researchers and clinicians, integrating detection, correction, and prevention strategies to address these biases. Selection bias may be mitigated through approaches such as inverse probability weighting and adjustment for sociodemographic imbalances; attrition bias can be addressed using intention-to-treat analyses and multiple imputation for missing data that are missing at random; algorithmic bias requires fairness-aware modeling, diverse training data sets, and explainable artificial intelligence techniques. These 3 forms of bias are not exhaustive, but their careful management is essential to achieving scientific rigor, fairness, and real-world applicability, and requires multidisciplinary collaboration to embed equity and validity throughout the research lifecycle.

The United States is facing a growing health care affordability crisis. In 2024, national health expenditures totalled $5.3 trillion, or $15 474 per person, accounting for 18.0% of the U.S. economy. Spending on health care continues to rise, propelled by high prices for services, drugs, and devices; growing administrative complexity; chronic underinvestment in prevention, primary care, and public health; and the mounting burden of chronic conditions such as cardiovascular disease. Patients, even those with insurance, frequently face financial hardship, delayed or foregone care, and medical debt because of gaps in coverage and inadequate consumer protections. Addressing this crisis will require coordinated action across the health care system, guided by evidence and a commitment to shared responsibility among key stakeholders. This Presidential Advisory from the American Heart Association draws on interviews and listening sessions with patients, clinicians, payers, employers, health system leaders, and public health experts to examine the many dimensions of affordability and offer a practical framework for action. The Advisory presents 5 core principles to guide efforts to address the affordability crisis: ensuring access to high-quality care without financial hardship; minimizing cost sharing for high-value services; creating shared accountability across the health care system; investing in the workforce, infrastructure, and data systems needed to support progress; and addressing the social and structural factors that make care less affordable for many communities. The evidence, tools, and expertise to combat the health care affordability crisis already exist. What is needed now is the collective will to act.

Physical activity (PA) is essential for the cardiovascular, emotional, and social health of all children and adolescents. However, for pediatric patients with cardiomyopathy, decades of risk-averse clinical guidance have resulted in widespread PA restriction due to fears of sudden cardiac death and disease progression. This has contributed to sedentary behavior, poor cardiorespiratory fitness, and increased risk of secondary cardiometabolic conditions in this population. However, emerging data challenge this restrictive paradigm, showing that the risk of sudden cardiac death may not be higher in some patients with cardiomyopathy who exercise than in those who are less active, and that participation in PA may also have a positive effect on reverse remodeling. This American Heart Association scientific statement provides an evidence-based framework for the promotion of PA in pediatric patients with hypertrophic cardiomyopathy, dilated cardiomyopathy, restrictive cardiomyopathy, or arrhythmogenic cardiomyopathy, as well as those with implantable cardioverter defibrillators; outlines the physical, social, and emotional benefits of PA for these children and adolescents; and provides updated risk stratification strategies, including the use of advanced imaging, exercise testing, and genotype-specific data. This scientific statement underscores the importance of shared decision-making tailored to developmental maturity and family goals and emphasizes the need for longitudinal surveillance as clinical phenotypes evolve. With individualized assessment and informed shared decision-making, most children and adolescents with cardiomyopathy can safely engage in PA, with important implications for long-term cardiometabolic and psychologic health.

Myocarditis is an inflammatory disease involving the heart muscle and potentially the pericardium. While there are many potential causative agents, commonly grouped into infectious (viral, bacterial, parasitic) or noninfectious (autoimmune, systemic disorders, drugs, cancer related), the main pathological pathways ultimately lead to an inflammatory process of the myocardium resulting in necrosis and edema. As there are specific therapies available for patients with myocarditis, reliable and early diagnosis is crucial. Multimodality imaging, especially cardiovascular magnetic resonance, has made a noninvasive diagnosis feasible. Cardiovascular magnetic resonance can not only provide a diagnosis based on the updated Lake Louise criteria, but it also functions as a diagnostic gateway, leading to other imaging modalities, for example, positron emission tomography or computed tomography. Finally, imaging results can help to initiate treatment options as well as determine when a patient can return to work or exercise. This review will cover multimodal imaging in patients with myocarditis with a focus on cardiovascular magnetic resonance, providing case examples of how imaging can guide care and treatment in these patients. In addition, the review focuses on the recent European Society for Cardiology guideline on the management of myocarditis and pericarditis comparing the recommendation to the American College of Cardiology expert consensus statements and the Japanese Circulation Society guidelines.

Guideline-directed medical therapy (GDMT) is central to the care of heart failure with reduced ejection fraction, yet no standard metric exists to quantify its implementation.