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CLINICAL STATEMENTS AND GUIDELINES

September 16, 2025 Circulation. 2025;152:e114–e218. DOI: 10.1161/CIR.0000000000001356 e142

80% in US populations.43,44 Weight gain with age and adverse lifestyles (as defined by Life’s Essential 845), rather than aging per se, are potent drivers of BP in­ creases over time.46,47 Lifestyle modification approach­ es (Table 12) are critically important strategies to slow the increase in BP and delay or prevent the onset of hypertension. Once patients have been diagnosed with hypertension, specific lifestyle and nonpharmacological strategies can lower BP, slow progression of BP eleva­ tion, reduce the amount of medication needed to con­ trol BP, and prevent CVD events and mortality.19–21,48,49 A Bayesian network meta-analysis assessed the comparative effectiveness of 22 lifestyle and stressreduction strategies for BP lowering.14 The DASH eat­ ing plan ranked as the most effective intervention for BP lowering, followed in order by aerobic exercise, iso­ metric resistance training, low-sodium/high-potassium salt interventions, and comprehensive lifestyle interven­ tions.14 Meditation and breathing control appeared to be the most effective stress-reduction strategies that

Table 12.  Lifestyle and Stress Reduction Interventions to Lower Blood Pressure

Intervention Target/Biomarker Evidence-Based Goals Approximate Mean Change in SBP (mm Hg)∗

References With Hypertension

Without Hypertension

Weight loss Body weight or BMI Aim for sustained ≥5% reduction in body weight or ≥3 kg/m2 reduction in BMI; expect about 1 mm Hg reduction for every 1-kg reduction in body weight −6 to −8 −3 to −5 2,6,14,52 Heart-healthy diet DASH eating pattern Consume a diet rich in fruits, vegetables, whole grains, and low-fat dairy products, with reduced content of saturated and total fat −5 to −8 −3 to −7 13–15,64,120 Reduced intake of sodium Dietary sodium intake; 24-h urinary so­ dium Optimal goal is <2300 mg/d, but aim for an ideal limit of <1500 mg/d −6 to −8 −1 to −4 16–18,79,120,121 Use of salt substitute Replace cooking/table salt (100% sodium chloride) with salt substitute (25%-30% potassium chloride, 65%-75% sodium chloride, and 0%-10% flavoring agents); 24-h urinary sodium and potassium Reduce dietary sodium intake as above −5 to −7 −5 20–22,93 Enhanced intake of potassium Dietary potassium intake; 24-h urinary potassium Aim for 3500-5000 mg/d, ideally by consumption of a diet rich in potassium; or alternative use of moderate-dose phar­ macological potassium supplementation (<80 mmol) −6 −3 to −6 25–27 Reduced alcohol intake Alcohol consumption Optimal goal is abstinence for all adults for best health outcomes; in patients who consume alcohol, aim for >50% reduction in daily intake to no more than 2 drinks/d in men or 1 drink/d in women −4 to −6 −3 29 Exercise Aerobic exercise 90-150 min/wk

65%-75% heart rate reserve −4 to −8 −2 to −7 14,33,36,120,122

Dynamic resistance 90-150 min/wk

50%-80% 1 rep maximum 6 exercises, 3 sets/exercise, 10 repetitions/set −2 to −7 −2 to −5 33,36,106,107

Isometric resistance 4 × 2 min (hand grip), 1 min rest between exercises, 30%-40% maximum voluntary contraction, 3 sessions/wk −5 to −10 −4 to −6 14,32,33,36,109,110

Meditation Transcendental meditation Training by a professional, followed by 2 × 20 min sessions/d while seated comfort­ ably with eyes closed −5 to −7 −5 14,119 Breathing control Slowing respiration Device-guided session to decrease respiration to <10 breaths/min for 15 min/d −5 −5 14 *Because inclusion/exclusion criteria and comparator groups vary across interventions, these values should not be compared directly to indicate comparative effective­ ness. Modified with permission from Whelton et al.123 Copyright 2018 American College of Cardiology Foundation and American Heart Association, Inc.

BMI indicates body mass index; DASH, Dietary Approaches to Stop Hypertension; and SBP, systolic blood pressure.

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