What is the initial approach to managing a patient with hypertension, high sodium intake, and a sedentary lifestyle, with blood pressure readings of 138/88 mmHg and normal laboratory results?

Initial Management: Lifestyle Modification First

For this patient with BP 138/88 mmHg (Grade 1 hypertension) and modifiable risk factors but no evidence of high cardiovascular risk, the correct answer is B: Lower salt intake and enhance physical activity. 1

Rationale for Lifestyle-First Approach

This patient has Grade 1 hypertension (systolic 130-139 mmHg) without indicators of high total cardiovascular risk—no diabetes, no prior cardiovascular events, and normal laboratory results except elevated sodium intake. 1 In patients with Grade 1 hypertension at low-to-moderate cardiovascular risk, lifestyle interventions should be implemented first, with pharmacological therapy delayed for several weeks to months while monitoring response. 1

The 2024 ESC guidelines explicitly state that for patients with elevated BP who are not at high cardiovascular risk, lifestyle measures with close BP monitoring should be the initial recommendation. 1 Immediate antihypertensive medication (option A) is reserved for Grade 2 hypertension (≥160/100 mmHg) or Grade 1 hypertension with high/very high cardiovascular risk. 1, 2

Specific Lifestyle Interventions Required

Salt Reduction (Priority #1)

• Restrict dietary sodium to approximately 2 g/day (equivalent to 5 g salt/day or one teaspoon). 1
• This patient's serum sodium of 160 mEq/L suggests excessive salt intake, making sodium restriction particularly effective. 1
• Salt reduction in hypertensive patients reduces systolic BP by 4-6 mmHg and diastolic BP by 2.5-4 mmHg. 1
• Most dietary sodium comes from processed foods, so focus counseling on avoiding these. 1

Physical Activity Enhancement (Priority #2)

• Prescribe at least 150 minutes/week of moderate-intensity aerobic exercise (brisk walking, jogging, cycling, swimming). 1
• Alternative: 75 minutes/week of vigorous-intensity exercise. 1
• Aerobic exercise reduces systolic BP by 7-8 mmHg and diastolic BP by 4-5 mmHg in hypertensive patients. 1, 3
• Exercise sessions can be broken into 10-minute increments totaling 30 minutes daily. 3
• For this sedentary patient, start with achievable goals like daily brisk walking. 1

Additional Beneficial Modifications

• Increase potassium intake by 0.5-1.0 g/day through dietary sources (bananas, spinach, avocado) or potassium-enriched salt substitutes (75% sodium chloride/25% potassium chloride). 1
• Target a sodium-to-potassium ratio of 1.5-2.0 for optimal BP reduction. 1
• Stress management techniques given the patient's stressful job, though specific BP-lowering effects are less well-quantified. 4, 5
• Weight reduction if overweight (not specified in this case). 1

Why Not Immediate Medication (Option A)?

Starting antihypertensive drugs immediately would be premature and not guideline-concordant for several reasons:

• BP 138/88 mmHg is Grade 1 hypertension, not requiring immediate pharmacotherapy in low-risk patients. 1
• The patient has clear modifiable risk factors (high salt, sedentary lifestyle, stress) that should be addressed first. 1, 4
• Lifestyle modifications can achieve BP reductions comparable to single-drug therapy (5-8 mmHg systolic). 1, 3
• Drug therapy should only be initiated if BP remains uncontrolled after 3 months of lifestyle intervention in Grade 1 hypertension without high cardiovascular risk. 1

Why Not Just Monitoring (Option C)?

Simply advising BP monitoring without specific lifestyle interventions (option C) is inadequate because:

• Passive monitoring without intervention wastes valuable time when effective lifestyle measures are available. 1
• The patient has identifiable, modifiable risk factors requiring active intervention. 1
• Guidelines emphasize that lifestyle modifications should be implemented immediately, not deferred. 1, 6
• Monitoring alone does not address the underlying causes of elevated BP in this patient. 4, 5

Implementation Strategy

Provide specific, actionable instructions:

• Reduce salt to <5 g/day by avoiding processed foods, not adding salt at table, and reading food labels. 1
• Begin 30 minutes of brisk walking 5 days/week, gradually increasing intensity. 1
• Increase fruits and vegetables to 4-6 servings daily (DASH diet pattern). 1, 5
• Consider potassium-enriched salt substitute if no contraindications. 1

Follow-up timeline:

• Recheck BP in 4-8 weeks to assess response to lifestyle modifications. 1
• If BP remains ≥140/90 mmHg after 3 months of sustained lifestyle changes, initiate pharmacotherapy. 1
• Home BP monitoring can track progress and improve adherence. 2, 6

Common Pitfalls to Avoid

• Don't underestimate the BP-lowering power of lifestyle changes—combined interventions can reduce systolic BP by 10-15 mmHg. 1, 5
• Don't start medications prematurely in low-risk Grade 1 hypertension—this medicalizes a condition that may respond to lifestyle alone. 1
• Don't give vague advice—provide specific sodium targets, exercise prescriptions, and dietary recommendations. 1
• Don't forget to confirm the diagnosis—consider home BP monitoring or ABPM to exclude white coat hypertension before any treatment decisions. 2, 7