What medication is used to decrease diastolic blood pressure?

Medications for Decreasing Diastolic Blood Pressure

For decreasing diastolic blood pressure, a combination of an ACE inhibitor or ARB with a calcium channel blocker is recommended as first-line therapy, with thiazide/thiazide-like diuretics as an effective addition for resistant cases. 1

First-Line Medications

The 2024 ESC guidelines and 2020 ISH guidelines provide clear recommendations for managing elevated diastolic blood pressure:

For Non-Black Patients:

1. Start with an ACE inhibitor (like lisinopril) or ARB at low dose
2. Add a dihydropyridine calcium channel blocker (like amlodipine)
3. If needed, add a thiazide/thiazide-like diuretic

For Black Patients:

1. Start with a low dose ARB plus a dihydropyridine calcium channel blocker or
2. Start with a dihydropyridine calcium channel blocker plus a thiazide/thiazide-like diuretic
3. Increase to full dose as needed

Medication Selection Rationale

• ACE inhibitors (like lisinopril): Effectively reduce diastolic BP by inhibiting the renin-angiotensin system. Lisinopril has demonstrated superior reductions in both systolic and diastolic BP compared to hydrochlorothiazide 2, 3.

• Calcium channel blockers (like amlodipine): Particularly effective for diastolic hypertension as they directly relax vascular smooth muscle, reducing peripheral vascular resistance 4.

• ARBs: Similar efficacy to ACE inhibitors but with fewer side effects like cough.

• Thiazide/thiazide-like diuretics: Effective when combined with other agents, especially for resistant hypertension.

Treatment Algorithm

1. Initial therapy: Start with combination therapy for most patients with confirmed hypertension (BP ≥140/90 mmHg)

   • Preferred combinations: RAS blocker (ACE inhibitor or ARB) with a dihydropyridine CCB 1
   • Use single-pill combinations when possible to improve adherence

2. If target not achieved:

   • Increase to a three-drug combination: RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic 1

3. For resistant hypertension:

   • Add spironolactone (most effective fourth-line agent)
   • If spironolactone not tolerated, consider amiloride, eplerenone, doxazosin, clonidine, or beta-blocker 1

Target Blood Pressure

• A diastolic BP target of <80 mmHg should be considered for all hypertensive patients 1
• If systolic BP is already at target (120-129 mmHg) but diastolic BP remains ≥80 mmHg, consider intensifying treatment to achieve diastolic BP of 70-79 mmHg 1

Important Considerations

• Combination therapy is superior: Evidence shows combination therapy is more effective than monotherapy for most patients 1
• Fixed-dose single-pill combinations improve adherence and should be used when possible 1
• Avoid combining two RAS blockers (ACE inhibitor and ARB together) as this is not recommended 1
• Beta-blockers should generally be reserved for patients with specific indications like angina, post-MI, or heart failure 1

Special Populations

• Elderly patients (≥65 years): Target systolic BP of 130-139 mmHg
• Very elderly (≥85 years) or those with frailty: Consider more lenient targets (<140/90 mmHg)
• Black patients: Calcium channel blockers and thiazide diuretics are particularly effective 1

By following this evidence-based approach, diastolic blood pressure can be effectively managed to reduce cardiovascular risk and improve outcomes.