When and how to recommend 'alternative approaches' in the management of high blood pressure.

Several nonpharmacologic therapies, such as sodium restriction and weight loss, have been promoted by hypertension guidelines based on the trial evidence supporting their capacity to lower blood pressure. However, many patients may not respond or be able to adhere to these nonpharmacologic treatments. Despite numerous formal diet and lifestyle recommendations, the prevalence of hypertension continues to grow worldwide. As such, additional approaches are needed to help combat this public health epidemic. In this review, we outline the evidence supporting the efficacy of a number of alternative approaches for blood pressure lowering. On the basis of the recommendations by a recent American Heart Association scientific statement, we also provide guidance on when and how to implement these methods in clinical practice. The available evidence supports several approaches, including Transcendental Meditation, device-guided slow breathing, and aerobic, resistance, and isometric exercises. Nonetheless, many questions remain, and future recommendations for using alternative approaches will need to be updated as new trials are published.