What is the best medication for high diastolic blood pressure?

Best Medications for High Diastolic Blood Pressure

For high diastolic blood pressure, a renin-angiotensin system (RAS) blocker (ACE inhibitor or ARB) is recommended as first-line therapy, particularly for non-Black patients. 1

First-Line Treatment Options

For Non-Black Patients:

• First choice: Low-dose ACE inhibitor (like lisinopril) or ARB 1
• Alternative: Dihydropyridine calcium channel blocker (CCB) 1

For Black Patients:

• First choice: Low-dose ARB + dihydropyridine CCB or CCB + thiazide/thiazide-like diuretic 1

Treatment Algorithm Based on Severity

1. For diastolic BP 90-99 mmHg (Stage 1 Hypertension):

   • Start with lifestyle modifications
   • For high-risk patients (with CVD, CKD, diabetes, organ damage, or aged 50-80): Start drug therapy immediately
   • For lower-risk patients: Try lifestyle modifications for 3-6 months, then add medication if BP remains elevated 1

2. For diastolic BP ≥100 mmHg (Stage 2 Hypertension):

   • Start drug treatment immediately along with lifestyle modifications
   • Consider two-drug combination if BP is >20/10 mmHg above target 1

Medication Selection Considerations

ACE inhibitors and ARBs are particularly effective for diastolic hypertension because they:

• Reduce peripheral vascular resistance without increasing heart rate 2
• Produce greater diastolic BP reductions compared to some other agents 3
• Do not cause metabolic side effects like hypokalemia or hyperglycemia 3

Combination Therapy

If BP is not controlled with monotherapy:

1. Increase to full dose of initial agent
2. Add a thiazide/thiazide-like diuretic
3. If still uncontrolled, add a dihydropyridine CCB 1

Important Considerations

• Fixed-dose single-pill combinations are recommended when using multiple agents to improve adherence 1
• Avoid combining two RAS blockers (ACE inhibitor and ARB) as this is not recommended 1
• Beta-blockers are not recommended as first-line agents unless there are specific indications like coronary heart disease or heart failure 1
• Target BP should be <130/80 mmHg for most adults to reduce cardiovascular risk 1

Special Populations

• Elderly patients: Start with lower doses (e.g., lisinopril 5 mg for those with GFR 30-60 ml/min) 4
• Black patients: ARBs may be better tolerated than ACE inhibitors with less cough and angioedema 1

Monitoring

• Assess BP control within 3 months of starting therapy 1
• Monitor for electrolyte abnormalities, particularly when using diuretics 5
• Take medications at the most convenient time of day to establish a habitual pattern and improve adherence 1

Remember that persistent diastolic hypertension significantly increases cardiovascular risk, and proper medication selection with appropriate dose titration is essential for effective management.