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CLINICAL STATEMENTS AND GUIDELINES

September 16, 2025 Circulation. 2025;152:e114–e218. DOI: 10.1161/CIR.0000000000001356 e144

adults in China, with either a history of stroke or age ≥60 years and uncontrolled BP, were enrolled in a cluster-randomized trial comparing a salt substitute (75% sodium chloride/25% potas­ sium chloride) with regular salt. Use of the salt substitute was associated with SBP reduction by 3.3 mm Hg and significant relative reductions in stroke, MACE, and all-cause mortality of 12% to 14%, with no increase in risk for hyperkalemia.21 Although most of the data on salt substitutes come from trials performed in East Asia, no sig­ nificant heterogeneity of effect has been seen by global region.93,94 Because in the United States the majority of sodium intake comes from con­ sumption of processed foods or meals prepared in restaurants,89–91 use of a salt substitute may be of greatest benefit in individuals who consume most of their sodium at home, from salt added during food preparation or at the table. Limitations to use of salt substitutes include low availability in the United States of potassium-enriched salt substitutes in the ratios studied to date, poten­ tial concerns over taste, and the potential for hyperkalemia in individuals with CKD and those using drugs that reduce potassium excretion (eg, potassium-sparing diuretics). 5.	 Observational studies have consistently demon­

strated that individuals with higher dietary intake of potassium-rich foods (from natural sources such as fruits, juices, vegetables, and legumes) and/or a lower urinary sodium to potassium ratio have lower BP levels and lower stroke and mor­ tality rates.95–100 Accordingly, a number of studies have examined the effect of potassium supple­ mentation on BP. Moderate potassium supple­ mentation, on average, lowers BP by 6/4 mm Hg, with variation in effects on BP by potassium dose, sodium intake, presence of hypertension, and use of antihypertensive medication.16,26,27 The BP-lowering effects are greater among par­ ticipants with hypertension and those with higher urinary sodium excretion (greater intake) at base­ line, especially ≥4000 mg/day. There appears to be a U-shaped relationship between potassium supplementation and BP levels, with maximal lowering of BP at approximately 30 mmol/day supplementation and an increase in BP above 80 mmol/day supplementation. The BP increase at higher doses of potassium supplementation (>80 mmol/day) is most evident in those taking antihy­ pertensive therapy.26

6 SBP and DBP increase over time with any amount

of baseline alcohol intake. Compared with aver­ age alcohol intake of 12 g per day (1 standard drink), relative risks for hypertension incidence among individuals drinking 0, 24, 36, and 48 g per day were 0.89 (95% CI: 0.84-0.94), 1.11 (95% CI: 1.07-1.15), 1.22 (95% CI: 1.14-1.30), and 1.33 (95% CI: 1.18-1.49), respectively. Thus, risk for incident hypertension is lowest for those who abstain.101 Among normotensive individuals who consume alcohol enrolled in controlled tri­ als, reduction of alcohol intake by at least 50% or to abstinence is associated with BP reduction, especially for those drinking ≥4 drinks per day.29 For patients with hypertension, BP reduction is correlated with the percent reduction in alcohol intake and is greater for those with higher base­ line intake.28–31,102,103 Among individuals with alco­ hol intake ≥6 drinks per day who reduced intake by 50% on average, mean BP was lowered by 5.5/4.0 mm Hg. Reductions were significant but lower for participants with a baseline intake of 3 to 5 drinks per day. At ≤2 drinks per day, there was no significant reduction in BP observed with reduction of alcohol intake.29 There are no harms identified with alcohol reduction, but continued alcohol intake is associated with other noncar­ diovascular harm. Prior observational studies sug­ gesting health benefits with moderate alcohol intake appear to be partially confounded by other positive health factors and socioeconomic position and offset by other health risks.104 Thus, aiming for abstinence appears to be optimal.91,104

7 Increasing leisure-time physical activity reduces

BP significantly in adults with hypertension,39 and it has been an intrinsic component of weight reduc­ tion interventions used to reduce BP in patients with and without hypertension.1,3,4 Structured exer­ cise programs that involve aerobic exercise (eg, endurance activities such as jogging14,33,35–37,105), dynamic resistance (eg, weight lifting14,33,36,106,107), and static/isometric resistance training (eg, hand­ grip14,32–34,36,108–110) appear particularly effective for BP lowering in adults with or without hypertension. Even lower-intensity physical activity (eg, walking) that interrupts sedentary time can reduce BP.111–116 All types of structured exercise also appear to be safe, even for older adults with hypertension. Aerobic exercise reduces SBP on average by 4 to 7/3 to 4 mm Hg, with a slightly larger effect in patients with versus without hypertension.14,33,35 There is a dose response, with an average 2/1 mm Hg reduction for each additional 30 minutes of aerobic exercise per week and the largest BP reduction at 150 minutes per week.37 Dynamic resistance training alone appears to have a more modest effect on BP reduction (3/2 mm Hg) than aerobic exercise, with larger reductions in people with hypertension ver­ sus without.14,33,36,106,107 Isometric exercise may have the largest effect on BP reduction (mean reduc­ tions of approximately 8/4 mm Hg).14,32–34,36,108–110

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