10.3 Nonpharmacologic Cardiovascular Management

The TCO's Implementation domain asks for non-pharmacologic intervention and treatment as well as drugs. For cardiovascular disease that is not a soft suggestion to "eat better." The 2025 AHA/ACC High Blood Pressure Guideline puts lifestyle on every plan — elevated BP, stage 1, stage 2, meds or no meds. Section 10.2 decided whether a tablet starts today. This section is the order you write in the after-visit summary and actually follow.

DASH and sodium are prescriptions

DASH (Dietary Approaches to Stop Hypertension) is a pattern: vegetables, fruits, low-fat dairy, whole grains, legumes, nuts, and lean protein, with limited saturated fat, sweets, and red meat. It is not a juice cleanse and it is not "low carb" by another name. Pair it with a meaningful sodium reduction. Teach patients to read labels, cook more, and treat restaurant soup and deli meat as concentrated salt. Many adults with hypertension do well aiming toward 1,500 mg of sodium per day if they can get there safely; even a 1,000 mg/day reduction from a high baseline moves BP. Do not wait to mention diet until the third drug fails.

Potassium-rich food (beans, potatoes, greens, fruit) supports BP control in people with intact kidneys. That is not the same order as a potassium-chloride salt substitute (below). Food-first potassium is the default. A salt packet is a drug-like exposure.

Weight, alcohol, and 150 minutes

If the patient has overweight or obesity, weight loss is antihypertensive therapy. A practical teaching number is on the order of about 1 mm Hg systolic drop per kilogram lost, with larger losses helping more — direction matters more than a fake precision to the tenth. Set a specific, followable target (for example 5% of body weight) rather than "try to lose some weight."

Alcohol raises BP and sabotages sleep and weight. Counsel moderation or less: if the patient drinks, stay within low-risk limits (no more than one standard drink a day for women, two for men is the usual ceiling people still quote — less is better, and zero is the right number for pregnancy, liver disease, or anyone who cannot stop at one). Binge patterns wreck the home-BP log you are about to praise.

Physical activity: at least 150 minutes per week of moderate-intensity aerobic activity (or 75 minutes vigorous), plus muscle-strengthening on two or more days, for adults who can do it. Brisk walking counts. Ten-minute bouts count. Sitting all day and taking a thiazide is not a complete plan. Screen for ACS symptoms before you write an unsupervised running prescription (Section 10.1). After ACS or revascularization, activity lives inside cardiac rehabilitation, not a printout that says "exercise."

Tobacco cessation is cardiovascular therapy

Smoking is not a lifestyle footnote. It is ongoing endothelial injury, a PAD accelerant, and a reason stents close. Ask, advise, and offer treatment every visit: combination nicotine replacement, varenicline, or bupropion as appropriate, plus a quit date and a follow-up. E-cigarettes are not a heart-healthy substitution you should endorse as CV therapy. Document the counseling; Evaluation later asks whether the person actually quit.

CPAP when OSA is in the room

Resistant hypertension, AF, treatment-resistant nocturnal BP, obesity, loud snoring, and witnessed apneas are an OSA story until you look. Diagnose with home sleep apnea testing or attended polysomnography as indicated. CPAP (or an equivalent effective therapy) is the cardiovascular intervention — it is not a durable-medical-equipment afterthought. Untreated OSA keeps the BP high after you have stacked three drugs and a lecture on soup. Refer, titrate, and ask about mask adherence the way you ask about pills.

Cardiac rehabilitation is a referral, not a pamphlet

After ACS, coronary revascularization, or a qualifying heart-failure diagnosis, refer to a cardiac rehabilitation program. That is tertiary prevention (Section 6.1) and it is Implementation today. Rehab packages supervised activity, education, and risk-factor work that a two-minute after-visit summary cannot replace. Do not delay the referral until "things settle" six months later. Do not substitute a printed sodium sheet. If geography or insurance is a barrier, document the attempt and use a hybrid or community program rather than silently dropping the order.

Home blood-pressure technique

Out-of-office confirmation only works if the numbers are real. Teach a validated upper-arm cuff, correct size, seated, back supported, feet on the floor, arm at heart level, cuff on bare skin. Rest five minutes. No caffeine, exercise, or tobacco for 30 minutes. Two morning and two evening readings for seven days, then average, commonly discarding day 1. Wrist and finger cuffs, talking through the reading, and measuring only during a headache are how white-coat and masked stories get scrambled. Have the patient bring the device in so you can watch a reading. Log the average in the note — Domain V later asks whether the intervention moved that average.

Salt substitutes: useful, except when they are dangerous

Potassium-chloride salt substitutes can lower sodium intake and raise dietary potassium — helpful in many adults with hypertension and normal kidney function who are not on potassium-raising drugs. They are not safe default advice in CKD, in hyperkalemia, or in patients on an ACE inhibitor, ARB, ARNI, or spironolactone (or potassium supplements, or trimethoprim). Those combinations produce emergency hyperkalemia. Ask what is in the shaker before you congratulate someone for "cutting salt." If you recommend a substitute, you own a potassium check, just as you would after starting lisinopril.

Stress reduction, limited extra caffeine if it clearly spikes that person's BP, and adequate sleep support the same physiology. They do not replace DASH, sodium work, or the 150-minute order when the stem asks for the highest-yield nonpharmacologic plan.

Vignette. A 46-year-old with elevated BP (126/74) and a PREVENT™ risk of 3% does not need a pill today. The visit is a failure if you only say "watch it." Write DASH, a sodium cut, a walking schedule to 150 minutes, a weight goal if BMI is high, and a home-BP technique with a 3-to-6-month recheck — that is the 2025 lifestyle clock from Section 10.2. A 63-year-old two weeks after NSTEMI and a stent who leaves without a cardiac-rehab referral has an incomplete Implementation note even if the high-intensity statin and beta blocker are perfect. A 74-year-old with eGFR 22 who switched to a potassium salt substitute because a magazine promised it was "heart healthy" needs the substitute stopped and a potassium drawn, not praise.

Exam trap. Nonpharmacologic items fail candidates who treat lifestyle as optional color commentary, who recommend salt substitutes the way they recommend tap water, or who think a pamphlet replaces cardiac rehab. Write the order the way you write lisinopril: drug-like specificity, a follow-up date, and a harm you are watching.