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CLINICAL STATEMENTS AND GUIDELINES Circulation. 2025;152:e114–e218. DOI: 10.1161/CIR.0000000000001356 September 16, 2025 e141 from the HIPARCO-2 (Long-Term Effect of CPAP on BP in Patients With Resistant Hypertension) study demonstrate that participants with OSA and resistant hypertension adherent to CPAP therapy (≥4 hours/night) compared with nonadherent CPAP participants had statistically significant decreases in mean 24-hour ABPM, including nighttime SBP and DBP (−5.5 and −4.9 mm Hg, respectively) over a 59-month follow-up period.16 4 PREVENTION STRATEGIES Synopsis The etiology of primary (previously termed essential) hypertension is a complex interplay of genetics, lifestyle choices, and chronic stress. Even in those with a genetic predisposition to hypertension, healthy lifestyle behav iors can prevent hypertension. All of the therapies rec ommended for the treatment of hypertension in Section 5.1 (“Lifestyle and Psychosocial Approaches”) are useful in primordial prevention of hypertension and should be encouraged.1 These include weight loss for those with overweight or obesity; a heart-healthy diet such as the DASH (Dietary Approaches to Stop Hypertension) eat ing plan; no more than 2300 mg of sodium per day (with the ideal limit of no more than 1500 mg per day for most adults); dietary potassium 3500 to 5000 mg per day; aerobic and resistance exercise (≥150 minutes of mod erate physical activity per week and resistance exercise ≥2 days per week); and stress management practices. Intake of any alcohol is associated with higher SBP in a dose-response manner, including in individuals without hypertension.2 5 BP MANAGEMENT 5.1 Lifestyle and Psychosocial Approaches Recommendations for Lifestyle and Psychosocial Approaches Referenced studies that support the recommendations are summarized in the Evidence Table. COR LOE Recommendations Weight 1 A 1 In adults who have overweight or obesity, weight loss is recommended with a goal of at least 5% of body weight reduction to prevent or treat elevated BP and hypertension.1–9 Diet and Nutrients 1 A 2 In adults with or without hypertension, a heart- healthy eating pattern, such as the DASH eating plan, is recommended to prevent or treat elevated BP and hypertension.9–15 1 A 3 In adults with or without hypertension, reduction of dietary sodium intake* is recommended to <2300 mg/d, moving toward an ideal limit of <1500 mg/d to prevent or treat elevated BP and hypertension.4,12,16–19 2a A 4 In adults with or without hypertension, potas sium-based salt substitutes† can be useful to prevent or treat elevated BP and hypertension, particularly for patients in whom salt intake is related mostly to food preparation or flavoring at home, except in the presence of CKD or use of drugs that reduce potassium excretion where monitoring of serum potassium levels is indi cated.‡20–24 1 A 5 In adults with elevated BP or hypertension, mod erate potassium supplementation,§ ideally from dietary sources, is recommended to prevent or treat elevated BP and hypertension, except in the presence of CKD or use of drugs that reduce potassium excretion where monitoring of serum potassium levels is indicated.‡ 25–27 Alcohol 1 A 6 Adults with or without hypertension who currently consume alcohol should be advised to pursue a recommended goal of abstinence, or at least to reduce alcohol intake to ≤1 drink/d for women and ≤2 drinks/d for men to prevent or treat elevated BP and hypertension.‖ 28–31 Physical Activity 1 A 7 In adults with or without hypertension, increasing physical activity, through a structured exercise program that includes aerobic exercise and/or resistance training, is recommended to prevent or treat elevated BP and hypertension.1,3,4,14,32–39 Stress Reduction 2b B-R 8 In adults with or without hypertension, stress reduction through transcendental meditation may be reasonable to prevent or treat elevated BP and hypertension, as an adjunct to lifestyle or medica tion interventions.7,8,14,40 2b B-R 9 In adults with or without hypertension, other forms of stress management, such as breathing control techniques or yoga, may be reasonable to prevent or treat elevated BP and hypertension, as an adjunct to lifestyle or medication interven tions.14,41,42 *Dietary sodium reduction may be contraindicated in patients with severe, symptomatic orthostatic hypotension. †This recommendation refers to potassium-based salt substitutes, which typi cally contain 25% to 30% potassium chloride, 65% to 75% sodium chloride, and 0% to 10% flavoring agents. Products that refer to themselves as “salt substi tutes” that do not contain potassium chloride as a substitute for sodium chloride have unknown effects on BP. ‡Drugs that reduce potassium excretion include: potassium-sparing diuretics (eg, amiloride, triamterene), mineralocorticoid receptor antagonists (eg, spirono lactone, eplerenone, finerenone), angiotensin-converting enzyme inhibitors (eg, captopril, enalapril, lisinopril, benazepril, and others), angiotensin receptor block ers (eg, losartan, valsartan, candesartan, telmisartan, and others), and some im munosuppressive agents (eg, cyclosporine, tacrolimus). §Moderate potassium supplementation is <80 mmol/d (<80 mEq/d). ‖One standard drink (12 to 14 g alcohol) is equivalent to 12 oz of beer (5% alcohol by volume), 5 oz of wine (12% alcohol by volume), or 1.5 oz of distilled spirits (40% alcohol by volume). Synopsis BP tends to increase with age from young adulthood, with lifetime risks for incident hypertension exceeding Recommendations for Lifestyle and Psychosocial Approaches (Continued) COR LOE Recommendations Downloaded from http://ahajournals.org by on October 7, 2026