What are the most effective antihypertensive (high blood pressure) medications?

From the Guidelines

The most effective antihypertensive medications for reducing blood pressure and cardiovascular disease events are ACE inhibitors, ARBs, dihydropyridine CCBs, and diuretics, which are recommended as first-line treatments. According to the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1, these medication classes have demonstrated the most effective reduction of BP and CVD events.

Key Recommendations

• ACE inhibitors, such as lisinopril, are excellent choices, particularly for patients with diabetes or kidney disease.
• ARBs, like losartan, are also recommended as first-line options.
• Dihydropyridine CCBs, including amlodipine, work well for many patients, especially older adults and Black patients who may respond less favorably to ACE inhibitors.
• Diuretics, such as thiazides and thiazide-like drugs like chlorthalidone and indapamide, are also recommended as first-line treatments.

Combination Therapy

• Combination BP-lowering treatment is recommended for most patients with confirmed hypertension as initial therapy, with preferred combinations being a RAS blocker with a dihydropyridine CCB or diuretic 1.
• Fixed-dose single-pill combination treatment is recommended for patients receiving combination BP-lowering treatment.
• If BP is not controlled with a two-drug combination, increasing to a three-drug combination is recommended, usually a RAS blocker with a dihydropyridine CCB and a thiazide/thiazide-like diuretic, and preferably in a single-pill combination 1.

Special Considerations

• Beta-blockers, like metoprolol, are no longer first-line for uncomplicated hypertension but remain valuable for patients with heart failure or previous heart attacks.
• Medication choice should be individualized based on comorbidities, potential side effects, cost, and patient characteristics.
• The goal is typically to achieve blood pressure below 130/80 mmHg for most adults, though targets may vary based on age and comorbidities.

From the FDA Drug Label

Losartan is indicated for the treatment of hypertension in adults and pediatric patients 6 years of age and older, to lower blood pressure. Lowering blood pressure lowers the risk of fatal and nonfatal cardiovascular (CV) events, primarily strokes and myocardial infarction Numerous antihypertensive drugs, from a variety of pharmacologic classes and with different mechanisms of action, have been shown in randomized controlled trials to reduce cardiovascular morbidity and mortality, and it can be concluded that it is blood pressure reduction, and not some other pharmacologic property of the drugs, that is largely responsible for those benefits In controlled clinical studies, metoprolol has been shown to be an effective antihypertensive agent when used alone or as concomitant therapy with thiazide-type diuretics, at oral dosages of 100 to 450 mg daily In controlled, comparative, clinical studies, metoprolol has been shown to be as effective an antihypertensive agent as propranolol, methyldopa, and thiazide-type diuretics

The best antihypertensive medication is not explicitly stated in the provided drug labels. However, losartan and metoprolol are both effective antihypertensive agents.

• Losartan is indicated for the treatment of hypertension in adults and pediatric patients 6 years of age and older.
• Metoprolol has been shown to be an effective antihypertensive agent when used alone or as concomitant therapy with thiazide-type diuretics. It is essential to consider individual patient needs and consult published guidelines, such as those of the National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC), for specific advice on goals and management 2 3.

From the Research

Antihypertensive Medications

The following are some of the best antihypertensive medications:

• Thiazide or thiazide-like diuretics, such as hydrochlorothiazide or chlorthalidone 4
• Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, such as enalapril or candesartan 4, 5, 6
• Calcium channel blockers, such as amlodipine 4

First-Line Therapies

First-line therapies for hypertension include:

• Lifestyle modification, consisting of weight loss, dietary sodium reduction and potassium supplementation, healthy dietary pattern, physical activity, and limited alcohol consumption 4, 7
• Thiazide or thiazide-like diuretics, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and calcium channel blockers 4, 5, 6

Combination Therapies

Combination therapies, such as ACEI-thiazide diuretic combination therapy, may be more effective in achieving blood pressure goals than monotherapy 8

• Patients who initiated ACEI-thiazide diuretic combination therapy were more likely to achieve BP <130/80 mm Hg compared with their counterparts who initiated monotherapy with ACEI, thiazide diuretic, β blocker, or calcium channel blocker 8

Blood Pressure Targets

The target blood pressure levels are:

• <130/80 mm Hg for adults <65 years 4, 7
• <130 mm Hg for adults ≥65 years 4
• <140/90 mm Hg for patients with grade 1 hypertension and low or moderate total cardiovascular risk 7