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high-intensity interval training elicits comparable BP reductions to moderate continuous exercise, with high-intensity interval training achieving greater improvement in physical fitness.386 In patients with known hypertension, engaging in physical activity is associated with reduced CVD mortality risk vs. sedentary patients with hypertension.387 An exaggerated BP response to exercise may yield diagnostic merits for predicting incident hypertension and CVD. In a meta-analysis, an exaggerated BP response to exercise was associated with an increased risk for masked hypertension.388 The risk of coronary heart disease also increases with higher systolic BP during exercise, independent of systolic BP at rest.389 Prior recommendations for at least 150 min/week of moderate intensity aerobic exercise (≥30 min, 5–7 days/week) can be maintained.1,390 Alternatively, 75 min of vigorous-intensity exercise per week over 3 days may be performed, with additional benefits derived by achieving 300 min of moderate-intensity or 150 min of vigorous-intensity aerobic physical activity per week.390,391 As acute aerobic exercise induces intensitydependent short-term reductions in ambulatory BP after exercise, patients with elevated BP and hypertension may benefit from daily exercise to improve their 24 h BP profile and avoid BP peaks on sedentary days.392 Aerobic exercise should be complemented by low- or moderate-intensity resistance training (2–3 times per week), e.g. dynamic resistance, starting at 2–3 sets of 10–15 repetitions at 40%–60% of one-repetition maximum393 or isometric resistance training with three sets of 1–2 min contractions, such as hand-grip, plank, or wall sit (Figure 16).381,394 In uncontrolled hypertension at rest, high-intensity exercise should be applied with caution, with resting systolic BP of >200 mmHg and diastolic BP of >110 mmHg indicating relative contraindications.395 Age, sex, gender,396 ethnicity, and comorbidities, as well as individual preferences, should be considered for individual exercise prescription. Detailed information on exercise prescription in terms of frequency, intensity, time (duration) and type and progression are available in the 2020 ESC Guidelines on sports cardiology and exercise in patients with cardiovascular disease,390 which include recommendations for pre-participation screening and cardiopulmonary exercise testing.390

8.2.3 Weight reduction and diet

Visceral obesity is common and associated with incident hypertension.397,398 An average weight loss of 5 kg has been associated with an average systolic and diastolic BP reduction of 4.4 and 3.6 mmHg, respectively.399 Data show that, starting at an index body mass index (BMI) of 40 kg/m2, a median weight loss of 13% is associated with a 22% lower risk for hypertension.400,401 Maintaining even moderate weight loss of 5%–10% of initial body weight can improve not only BP, but also glucose and lipid metabolism, and potentially reduce premature all-cause mortality.402–404 However, achieving long-term effects in patients with hypertension via weight loss is challenging and the magnitude of these effects remains unclear.405,406 Weight stabilization during middle-age appears to be an important and attainable goal to prevent obesity-related increase in BP later in life.407 Evidence-based diets, such as the Mediterranean diet and the Dietary Approaches to Stop Hypertension (DASH) diet, are established interventions in patients with hypertension to reduce their BP and CVD risk.408,409 Additional information on healthy dietary patterns is provided in the 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice and Supplementary data online.170 In combination with weight-loss and exercise interventions410 and low sodium intake,411 the DASH diet has added effect on BP reduction.412 Pharmacological treatment of obesity with orlistat achieved a slight reduction of 2.6 mmHg in systolic BP.413 The greatest BP-lowering effects of weight-loss medications may be achieved with the glucagon-like peptide 1 (GLP-1) receptor agonists.414–416 For example, in the Semaglutide Treatment Effect in People with Obesity (STEP-1) trial, the GLP-1 analogue semaglutide resulted in a mean weight reduction of 12.4% and a 5.1 mmHg reduction in systolic BP.415

8.2.4 Alcohol, coffee, and soft drinks

In a 2020 Cochrane review, the short-term effects of alcohol on BP were dose dependent; low-dose alcohol (<14 g) did not affect BP within 6 h, medium-dose (14–28 g) decreased both systolic and diastolic BP, and highdose alcohol (>30 g) first decreased BP up to 12 h and then increased BP following >13 h of consumption by 3.7 mmHg systolic and 2.4 mmHg diastolic.417 The trials in this Cochrane review included small numbers of women. In the longer term, no evidence has been found for a protective effect of chronic alcohol consumption on hypertension, for either sex. In contrast, even low-dose alcohol consumption (10 g/day) increases chronic risk of hypertension by 14% in men, but not in women.418 As per the 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice, men and women are recommended to stay within the upper limit of drinking alcoholic beverages (100 g/week of pure alcohol). Defining number of drinks depends on portion size, the standards of which differ per country, but translates to 8–14 g/drink.170 Emerging data indicate it is likely healthiest to avoid all alcohol, where possible.419 Coffee intake is not associated with a higher risk of hypertension in the general population; in fact, higher coffee consumption may be associated with a lower risk for incident hypertension.420 Data regarding the association between tea drinking and CVD are inconclusive, though mechanistic trials have suggested benefits on BP lowering.421 In contrast, energy drinks with high concentrations of ingredients such as taurine and caffeine increase BP and may lead to acute or chronic cardiovascular complications in young adults.422–424 Consuming two or more servings per day of sugar-sweetened beverages was associated with a 35% higher risk of coronary artery disease in women in the Nurses’ Health Study.425 In the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort, both sugar- and artificially sweetened soft drinks were associated with higher all-cause mortality.426 In children and adolescents, sugar-sweetened beverages increased systolic BP and the risk for incident hypertension.427 It is recommended to restrict free sugar consumption, in particular sugar-sweetened beverages, to a maximum of 10% of energy intake.

8.2.5 Smoking

To stop smoking is arguably the most effective measure in preventing major CVD events at the individual level, likely through improved vascular health.428–431 Estimated health benefits will be even more substantial looking at all-cause morbidity and mortality, e.g. including smoking cessation for cancer prevention. The effects of electronic cigarettes (e-cigarettes) on BP remain unclear and to date there are no robust outcomes data. However, growing evidence suggests that e-cigarettes can increase BP (see Supplementary data online).432,433 Among adults, smoking affects ambulatory BP by raising daily BP,434 but effects of chronic smoking on office BP appear to be small.435 Smoking cessation advice helps, but more intensive interventions are superior.436,437 As recommended by previous ESC Guidelines, smoking cessation is recommended to reduce CVD risk and improve non-CVD health.1,170

ESC Guidelines                                                                                                                                                                                          3957

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