What is the best management approach for a healthy 55-year-old male with no cardiac family history, exercising multiple times a week, with a recent blood pressure reading of 135/60 mmHg and a heart rate of 50 bpm?

Management of Elevated Systolic Blood Pressure with Wide Pulse Pressure in an Athletic Individual

This patient requires no antihypertensive medication at this time; instead, focus on lifestyle optimization with sodium restriction to approximately 2g/day, continued regular exercise (at least 150 minutes/week of moderate-intensity aerobic activity), and close monitoring with home blood pressure measurements. 1

Blood Pressure Assessment and Classification

• The systolic BP of 135 mmHg falls into the elevated BP category (120-139 mmHg), which does not meet the threshold for hypertension diagnosis (≥140/90 mmHg). 1

• Before any treatment decisions, confirm these readings with out-of-office measurements using home BP monitoring (HBPM) or ambulatory BP monitoring (ABPM), as screening office BP of 120-139/70-89 mmHg requires confirmation. 1

• The wide pulse pressure (135-60 = 75 mmHg) combined with bradycardia (HR 50) is consistent with athletic heart adaptation from regular exercise training, which increases stroke volume and arterial compliance. 1

Why No Medication is Indicated

• Antihypertensive drug treatment is only recommended when office BP is ≥140/90 mmHg. 1

• For BP in the 120-139/70-89 mmHg range in otherwise healthy individuals without diabetes or cardiovascular disease, lifestyle modification alone is the appropriate first-line approach. 1, 2

• This patient's excellent exercise habits (multiple times weekly) already provide substantial cardiovascular protection, with regular physical activity reducing all-cause mortality by 20% with just 1.5 hours per week of moderate-to-vigorous activity. 1

Lifestyle Optimization Strategy

Dietary Sodium Restriction

• Restrict sodium intake to approximately 2g per day (equivalent to about 5g of salt/day) to reduce BP. 1

• Adopt a Mediterranean or DASH-style diet emphasizing vegetables, fruits, whole grains, nuts, legumes, and fish. 1

Physical Activity Maintenance

• Continue current exercise regimen, ensuring at least 150 minutes/week of moderate-intensity aerobic exercise (or 75 minutes/week of vigorous exercise). 1

• Complement aerobic training with low- or moderate-intensity resistance training 2-3 times per week. 1

• The patient's bradycardia (HR 50) is a normal physiological adaptation to regular endurance training and requires no intervention in an asymptomatic individual. 1

Weight Management

• Aim for stable BMI of 20-25 kg/m² and waist circumference <94 cm (for men). 1

Alcohol Moderation

• Limit alcohol consumption to less than 100g/week of pure alcohol (approximately 7-10 standard drinks/week for men). 1

Monitoring Plan

Home Blood Pressure Monitoring

• Implement regular home BP monitoring to track trends and confirm office readings. 1

• Target home BP readings should remain <130/80 mmHg. 1

Follow-up Schedule

• Reassess BP in 3-6 months with repeat office measurements and review of home BP log. 1

• If BP rises to ≥140/90 mmHg on repeated measurements, initiate pharmacological therapy at that time. 1

Important Caveats

• The diastolic BP of 60 mmHg is at the lower acceptable range but not concerning (<70 mmHg would warrant caution). 1

• Do not prescribe beta-blockers or diuretics if medication becomes necessary in the future, as these impair exercise performance in endurance athletes. 1

• If antihypertensive therapy is eventually needed, calcium channel blockers or ACE inhibitors/ARBs are preferred in athletic individuals as they do not impair exercise capacity. 1

• Screen for secondary causes of hypertension only if BP becomes persistently elevated or if suggestive signs/symptoms develop. 1