What are the best antihypertensive medications for isolated diastolic hypertension (IDH), characterized by elevated diastolic blood pressure with normal systolic blood pressure?

From the Guidelines

For isolated diastolic hypertension, the most effective first-line medications are ACE inhibitors, ARBs, and dihydropyridine calcium channel blockers, as recommended by the 2024 ESC guidelines 1. These medications are preferred due to their ability to relax blood vessels and reduce peripheral resistance, which has a significant impact on diastolic pressure.

• ACE inhibitors, such as lisinopril (10-40 mg daily), are a good option as they block the renin-angiotensin system that causes blood vessel constriction, and also provide additional benefits for patients with diabetes or kidney disease.
• ARBs, such as losartan (25-100 mg daily), are another effective option as they also block the renin-angiotensin system, and have been shown to be effective in reducing blood pressure.
• Dihydropyridine calcium channel blockers, such as amlodipine (2.5-10 mg daily), work by preventing calcium from entering muscle cells of the heart and blood vessels, allowing them to relax, and are also a good option for isolated diastolic hypertension. If a single medication doesn't adequately control diastolic pressure, combining two different classes at lower doses is often more effective than maximizing the dose of a single drug, as recommended by the 2024 ESC guidelines 1. Regular blood pressure monitoring is essential when starting or adjusting medication, ideally checking at the same time daily. Lifestyle modifications should accompany medication therapy, including reducing sodium intake, maintaining a healthy weight, regular exercise, limiting alcohol, and managing stress. It's also important to note that upfront low-dose combination therapy is recommended in persons with hypertension, with the potential advantages of fewer side effects and swifter blood pressure control being important for long-term adherence, as stated in the 2024 ESC guidelines 1.

From the FDA Drug Label

CLINICAL STUDIES ... In controlled clinical studies of patients with mild to moderate hypertension, patients were treated with lisinopril 20 mg to 80 mg daily, hydrochlorothiazide 12. 5 mg to 50 mg daily or atenolol 50 mg to 200 mg daily; and in other studies of patients with moderate to severe hypertension, patients were treated with lisinopril 20 mg to 80 mg daily or metoprolol 100 mg to 200 mg daily. Lisinopril demonstrated superior reductions of systolic and diastolic compared to hydrochlorothiazide in a population that was 75% Caucasian

1 INDICATIONS & USAGE 1. 1 Hypertension Amlodipine besylate tablets is indicated for the treatment of hypertension, to lower blood pressure.

The best antihypertensive medications for isolated diastolic hypertension (IDH) are not explicitly stated in the provided drug labels. However, based on the available information:

• Lisinopril has been shown to reduce diastolic blood pressure in patients with mild to moderate hypertension.
• Amlodipine is indicated for the treatment of hypertension, but the label does not specifically address isolated diastolic hypertension. It is essential to note that the provided drug labels do not directly address the treatment of isolated diastolic hypertension, and therefore, no definitive conclusion can be drawn. 2 3

From the Research

Antihypertensive Medications for Isolated Diastolic Hypertension (IDH)

• IDH is characterized by elevated diastolic blood pressure with normal systolic blood pressure.
• The first-choice treatment for hypertension in adults without diabetes or cardiovascular or renal disease is single-agent therapy with the thiazide diuretic chlortalidone or, when this drug is not available, the thiazide diuretic hydrochlorothiazide 4.
• Thiazide diuretics, such as chlortalidone and hydrochlorothiazide, have been shown to reduce all-cause mortality in hypertensive patients, preventing about 2 to 3 deaths and 2 strokes per 100 patients treated for 4 to 5 years 4.
• ACE inhibitors, such as lisinopril, are also effective in reducing mortality and the incidence of stroke, and can be used as an alternative to thiazide diuretics 4.
• Combination therapy, such as a single-pill combination of irbesartan and hydrochlorothiazide, can also be effective in reducing blood pressure and achieving guidelines-recommended goals 5.
• The choice of antihypertensive medication should be based on individual patient characteristics, such as the presence of diabetes or cardiovascular disease, and the potential for adverse effects 4, 6, 7.

Specific Medications

• Chlortalidone: a thiazide diuretic that has been shown to be effective in reducing mortality and the incidence of stroke 4.
• Hydrochlorothiazide: a thiazide diuretic that can be used as an alternative to chlortalidone, and has been shown to be effective in reducing blood pressure and achieving guidelines-recommended goals 4, 5.
• Irbesartan: an angiotensin II receptor antagonist that can be used in combination with hydrochlorothiazide to reduce blood pressure and achieve guidelines-recommended goals 5.
• Lisinopril: an ACE inhibitor that can be used as an alternative to thiazide diuretics, and has been shown to be effective in reducing mortality and the incidence of stroke 4.
• Nitrendipine: a calcium channel blocker that has been shown to be effective in reducing blood pressure and achieving guidelines-recommended goals in patients with isolated systolic hypertension 8.