2024 Top Story in Cardiology: Hypertension — Important New Lifestyle Options

This year has been exceptionally busy for me, as I had the privilege of co-chairing the recently published 2024 European Society of Cardiology (ESC) guidelines on the management of elevated blood pressure (BP) and hypertension.¹ This rigorous 2-year process resulted in a guideline that I strongly encourage you to read. I learned some things along the way. Indeed, one important area where my understanding and knowledge have advanced is in the lifestyle approaches that can help manage hypertension.

The 2024 ESC guidelines propose a simple new BP categorization:

• Non-elevated: less than 120/70 mm Hg in the office (pharmacological treatment is not recommended).

• Elevated: 120 to 139/70 to 89 mm Hg (pharmacological treatment is recommended for some, depending on cardiovascular disease [CVD] risk and follow-up BP measurements).

• Hypertension: 140/90 mm Hg or greater (confirmation and prompt pharmacological treatment is recommended).

All adults are encouraged to follow a healthy lifestyle to maintain a non-elevated BP or manage an elevated BP and hypertension. However, these lifestyle interventions are particularly critical for individuals with an elevated BP but a low predicted risk of CVD. Adults in this group are common and account for up to one-third of all CVD events, yet there is no evidence supporting pharmacologic treatment in these patients.

In that context, it is worth emphasizing that the 2024 ESC Guidelines provide two major new lifestyle approaches for managing elevated BP and hypertension.

• The first new option is potassium supplementation, either by dietary supplementation or potassium-enriched salt substitutes. The mechanistic and observational data supporting the benefits of potassium supplementation on BP are not new. However, recent CVD outcomes trials demonstrate the benefits of potassium supplementation where clinically appropriate. These outcome trials include the SSaSS² and DECIDE-Salt³ trials. Potassium-enriched salts typically contain 75% sodium chloride and 25% potassium chloride, while dietary potassium sources include foods such as bananas (450 mg per medium-sized banana), unsalted boiled spinach (840 mg per cup), and mashed avocado (710 mg per cup). The WHO recommends over 3.5 grams of dietary potassium per day. However, excessive supplementation should be avoided, especially in patients with chronic kidney disease, where guidelines recommend restricting dietary potassium to less than 2.4 grams per day.

• The second new option is to increasingly understand the BP-lowering benefits of resistance exercise training.⁴ Not everyone can perform the aerobic exercises traditionally recommended in BP management guidelines, and resistance exercise offers an important alternative for both clinicians and patients.