How can I maintain good arterial health?

Maintaining Good Arterial Health

To maintain optimal arterial health, you must control blood pressure to <130/80 mmHg, lower LDL cholesterol to <100 mg/dL (ideally <70 mg/dL if you have cardiovascular disease), engage in at least 30 minutes of moderate aerobic exercise 5-7 days per week, adopt a Mediterranean diet rich in fruits and vegetables while limiting saturated fat to <7% of calories, and completely stop smoking. 1

Blood Pressure Management

Target blood pressure should be 120-129/70-79 mmHg for patients with peripheral arterial or aortic diseases, and <130/80 mmHg for those with diabetes or chronic kidney disease. 1

Lifestyle Modifications for Blood Pressure Control

• Restrict sodium intake to 5-6 grams per day, which can lower systolic blood pressure by 5-6 mmHg 1, 2
• Limit alcohol consumption to 20-30 grams of ethanol per day for men and 10-20 grams per day for women 1
• Reduce body weight to achieve BMI of 20-25 kg/m² and waist circumference <94 cm in men or <80 cm in women, as weight loss of 5-10% body weight provides approximately 1 mmHg reduction per kilogram lost 1, 2
• Increase consumption of fresh fruits, vegetables, and low-fat dairy products following a Mediterranean or DASH diet pattern 1

Pharmacological Blood Pressure Control

• If blood pressure exceeds 140/90 mmHg (or 130/80 mmHg with diabetes/chronic kidney disease), initiate combination therapy with a RAS blocker (ACE inhibitor or ARB) plus either a calcium channel blocker or thiazide-like diuretic 1, 3
• For resistant hypertension, add spironolactone 25-50 mg daily as the preferred fourth agent, which provides superior blood pressure reduction of 8-10 mmHg systolic 2
• Replace hydrochlorothiazide with chlorthalidone or indapamide for superior 24-hour blood pressure control 2

Lipid Management

Target LDL cholesterol should be <100 mg/dL for all patients with atherosclerotic disease, with further reduction to <70 mg/dL being reasonable for higher-risk patients. 1

Dietary Interventions for Lipid Control

• Reduce saturated fat intake to <7% of total calories and limit cholesterol to <200 mg/day 1
• Add plant stanols/sterols (2 grams/day) and viscous fiber (10 grams/day) to further lower LDL cholesterol 1
• Increase omega-3 fatty acid consumption through fish or capsules (1 gram/day) for cardiovascular risk reduction 1
• Adopt a Mediterranean diet rich in legumes, dietary fiber, nuts, fruits, and vegetables, which has demonstrated reductions in cholesterol and blood pressure 1

Pharmacological Lipid Management

• Initiate statin therapy if baseline LDL cholesterol is ≥100 mg/dL, targeting total cholesterol <190 mg/dL and LDL cholesterol <115 mg/dL 1
• Intensify LDL-lowering therapy (potentially requiring combination therapy) if on-treatment LDL cholesterol remains ≥100 mg/dL 1
• For patients with established cardiovascular disease, atorvastatin 80 mg/day reduces major cardiovascular events by 22% compared to 10 mg/day 4

Physical Activity

Engage in at least 30 minutes of moderate-intensity dynamic aerobic exercise (walking, jogging, cycling, or swimming) on 5-7 days per week, which reduces resting systolic and diastolic blood pressure by 3.0/2.4 mmHg overall and 6.9/4.9 mmHg in hypertensive patients 1

• Perform dynamic resistance training on 2-3 days per week, which provides significant blood pressure reduction and improvements in metabolic parameters 1
• Avoid isometric resistance exercises, as insufficient data supports their safety and efficacy 1
• For patients with aortic diseases, limit isometric exercise and individualize recommendations based on risk stratification 1

Smoking Cessation

Complete smoking cessation is crucial, as smoking causes acute blood pressure increases lasting >15 minutes after one cigarette and is associated with premature atherosclerotic cardiovascular disease 1

• Offer structural follow-up support including nicotine replacement therapy, varenicline, and bupropion, individually or in combination 1
• Avoid second-hand smoke and environmental particle air pollution 1
• Avoid cannabis use, which is associated with premature atherosclerotic cardiovascular disease 1
• Consider e-cigarettes only as a brief aid to quit tobacco smoking, not for long-term use or concurrent with traditional cigarettes 1

Additional Cardiovascular Risk Reduction

Antiplatelet Therapy

• Low-dose aspirin (75-100 mg/day) should be given to patients with 10-year cardiovascular risk ≥20% or cardiovascular death risk ≥5%, as it reduces serious vascular events by approximately 25% 1
• For patients with established cardiovascular disease, the benefits of aspirin clearly outweigh bleeding risks 1

Glycemic Control

• For patients with diabetes, maintain tight blood glucose control to reduce both microvascular and macrovascular complications 1
• Monitor for glucose metabolism derangements, as hypertension per se doubles the risk of developing type 2 diabetes 1

Common Pitfalls to Avoid

• Therapeutic inertia: Failing to intensify treatment when blood pressure or lipids remain uncontrolled at consecutive visits is the most common management error 2
• Inadequate diuretic therapy: Using hydrochlorothiazide instead of more potent thiazide-like diuretics (chlorthalidone or indapamide) or insufficient doses in volume-overloaded patients 2
• Assuming medication adherence without verification: Non-adherence accounts for up to 50% of apparent treatment failure; verify objectively through pharmacy refill records 2
• Ignoring secondary causes: Screen for primary aldosteronism (present in 15-20% of resistant hypertension), obstructive sleep apnea (≥80% of resistant hypertension), and medication interference (NSAIDs, decongestants, stimulants) 2
• Using drugs that worsen metabolic parameters: Diuretics and beta-blockers without intrinsic sympathomimetic activity often aggravate hypercholesterolemia and glucose intolerance 5

Monitoring Strategy

• Schedule visits every 2-4 weeks until blood pressure and lipid targets are achieved, then extend intervals 2, 3
• Confirm blood pressure control using out-of-office measurements (home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg) to exclude white coat effect 2, 3
• Monitor serum creatinine and potassium 2-4 weeks after initiating or changing therapy, particularly when using ACE inhibitors, ARBs, or spironolactone 2, 3
• Assess fasting lipid profile annually and within 24 hours of any acute cardiovascular event 1