What is the best antihypertensive medication for primary hypertension (HTN) in a white male with hypercholesterolemia and hypertension (HTN)?

From the Guidelines

For a white male with primary hypertension and high cholesterol, an ACE inhibitor (like lisinopril 10-40 mg daily) or an ARB (such as losartan 50-100 mg daily) would be an excellent first-line choice. These medications effectively lower blood pressure while offering cardiovascular protection, as supported by the 2018 guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1. A thiazide diuretic (like hydrochlorothiazide 12.5-25 mg daily) could be added if blood pressure goals aren't met with monotherapy. For cholesterol management, a moderate-intensity statin such as atorvastatin 10-20 mg daily would be appropriate alongside the blood pressure medication, as suggested by the european guidelines on cardiovascular disease prevention in clinical practice (version 2012) 1. This combination addresses both conditions simultaneously, reducing overall cardiovascular risk. ACE inhibitors and ARBs work by blocking the renin-angiotensin-aldosterone system, which helps relax blood vessels and lower blood pressure while potentially offering kidney protection. Regular monitoring of kidney function and electrolytes is important when starting these medications, particularly in the first few weeks of treatment. Lifestyle modifications including reduced sodium intake, regular exercise, and weight management should accompany any medication regimen.

Some key points to consider when choosing an antihypertensive medication include:

• The patient's race and ethnicity, as certain medications may be more effective in certain populations, as noted in the 2018 guideline 1
• The presence of comorbid conditions, such as high cholesterol, which may influence the choice of medication
• The potential for adverse effects, such as weight gain and dyslipidemia, associated with certain medications, as discussed in the european guidelines on cardiovascular disease prevention in clinical practice (version 2012) 1
• The importance of regular monitoring and lifestyle modifications to achieve optimal blood pressure control and reduce cardiovascular risk.

In terms of specific medication choices, the 2018 guideline 1 recommends ACE inhibitors and ARBs as first-line treatments for hypertension, while the european guidelines on cardiovascular disease prevention in clinical practice (version 2012) 1 suggest that these medications are effective in reducing cardiovascular morbidity and mortality. Thiazide diuretics may also be considered, particularly if blood pressure goals are not met with monotherapy. Ultimately, the choice of medication will depend on individual patient factors and should be guided by the most recent and highest-quality evidence available.

From the FDA Drug Label

CLINICAL PHARMACOLOGY 12. 1 Mechanism of Action Lisinopril inhibits angiotensin-converting enzyme (ACE) in human subjects and animals. Although lisinopril was antihypertensive in all races studied, Black hypertensive patients (usually a low-renin hypertensive population) had a smaller average response to monotherapy than non-Black patients Administration of lisinopril to patients with hypertension results in a reduction of both supine and standing blood pressure to about the same extent with no compensatory tachycardia

The best antihypertensive medication for primary hypertension (HTN) in a white male with hypercholesterolemia and hypertension (HTN) is lisinopril as it has been shown to be effective in reducing blood pressure in non-Black patients, including those with low-renin hypertension 2.

• Key benefits of lisinopril include:
  • Reduction of both supine and standing blood pressure
  • No compensatory tachycardia
  • Effective in patients with low-renin hypertension
  • Can be used in combination with other medications, such as hydrochlorothiazide, for additive blood pressure lowering effects.

From the Research

Antihypertensive Medication Options

The choice of antihypertensive medication for primary hypertension (HTN) in a white male with hypercholesterolemia and hypertension (HTN) depends on various factors, including the patient's medical history, lifestyle, and other health conditions.

• According to a study published in 2024 3, calcium channel blockers (CCBs) combined with statins showed a significantly greater reduction in LDL-C levels than statins alone.
• Another study published in 2020 4 recommends using a combination of antihypertensive agents, including thiazide diuretics, CCBs, angiotensin-converting enzyme inhibitors (ACEIs), and angiotensin receptor blockers (ARBs), for the treatment of hypertension.
• A study published in 2014 5 compared the effects of ACEIs and ARBs on total mortality and cardiovascular events in people with primary hypertension, and found no evidence of a difference between the two classes of drugs.

Combination Therapy

Combination therapy, which involves the use of multiple antihypertensive agents, may be effective in managing hypertension and hypercholesterolemia.

• The study published in 2024 3 found that triple combination therapy (two antihypertensives and a statin) was associated with better blood pressure-lowering effects than double combination therapy (one antihypertensive and a statin).
• Another study published in 2002 6 found that thiazide-type diuretics were superior in preventing major forms of cardiovascular disease and were less expensive than other antihypertensive agents.

Angiotensin Receptor Blockers (ARBs)

ARBs are a class of antihypertensive agents that have been shown to be effective in managing hypertension and reducing the risk of cardiovascular events.

• A study published in 2022 7 found that ARBs exert a comparable effect to ACEIs in lowering blood pressure levels, but have better pharmacological tolerability.
• The same study found that ARBs have a relevant protective role in preventing cardiovascular and renal damage, as well as major adverse cardiovascular events, in hypertensive patients.