What is the best medication for treating hypertension?

Best Medication for Hypertension

The best medications for treating hypertension are thiazide or thiazide-like diuretics, ACE inhibitors, ARBs, and long-acting dihydropyridine calcium channel blockers, which can be used as first-line agents based on high-quality evidence. 1

First-Line Medication Options

The World Health Organization (WHO) strongly recommends the following classes of medications as first-line treatment for hypertension:

• Thiazide and thiazide-like diuretics
• Angiotensin-converting enzyme (ACE) inhibitors
• Angiotensin receptor blockers (ARBs)
• Long-acting dihydropyridine calcium channel blockers (CCBs)

These recommendations are supported by high-quality evidence showing their effectiveness in reducing blood pressure and cardiovascular events. 1

Medication Selection Considerations

When selecting among first-line agents, consider:

1. Patient-specific factors:

   • For patients with albuminuria (≥30 mg/g creatinine): ACE inhibitors or ARBs are preferred 2
   • For Black patients: Calcium channel blockers may be more effective as first-line therapy 2
   • For patients with heart failure: ACE inhibitors, ARBs, or beta-blockers are preferred 1
   • For patients with chronic kidney disease: ACE inhibitors may slow kidney disease progression 1

2. Combination therapy:

   • More than 70% of hypertensive patients will eventually require at least two antihypertensive agents 2
   • Single-pill combinations are recommended to improve adherence 1, 2
   • Effective combinations include:
     • ACE inhibitor or ARB + calcium channel blocker
     • ACE inhibitor or ARB + thiazide diuretic
     • Calcium channel blocker + thiazide diuretic

Important caveat: ACE inhibitors and ARBs should never be used simultaneously due to increased risk of hyperkalemia and acute kidney injury without added benefit 2

Treatment Goals

Treatment goals should be tailored based on patient characteristics:

• General population: <140/90 mmHg 1, 2
• Patients with cardiovascular disease: <130 mmHg systolic 1, 2
• High-risk patients (diabetes, CKD, high CVD risk): <130 mmHg systolic 1, 2
• Adults under 65 years: Target systolic BP 120-129 mmHg if tolerated 1, 2
• Adults 65 years and older: Target systolic BP 130-139 mmHg 1, 2

Monitoring and Follow-up

• Monthly follow-up after initiation or change in antihypertensive medications until target is reached 1
• Follow-up every 3-5 months for patients with controlled blood pressure 1
• Monitor serum creatinine/eGFR and potassium levels at baseline and at least annually, especially for patients on ACE inhibitors, ARBs, or diuretics 2

Lifestyle Modifications

Lifestyle modifications should accompany pharmacological treatment:

• Regular aerobic exercise (≥150 min/week of moderate intensity or 75 min/week of vigorous intensity) 1, 2
• Body weight control (target BMI 20-25 kg/m²) 1, 2
• Dietary modifications (DASH or Mediterranean diet) 2
• Sodium restriction (approximately 2g per day) 2
• Limiting alcohol consumption 1, 2

Common Pitfalls to Avoid

1. Inadequate dosing: Many patients require dose titration or combination therapy to reach target BP
2. Inappropriate combinations: Avoid combining ACE inhibitors with ARBs
3. Ignoring orthostatic hypotension: Monitor for this especially in elderly patients
4. Neglecting to monitor electrolytes and renal function: Particularly important with ACE inhibitors, ARBs, and diuretics
5. Using immediate-release nifedipine: This should be avoided in hypertensive crises 3
6. Discontinuing medications during pregnancy: While ARBs should be avoided in pregnancy due to fetal risk, abrupt discontinuation of all antihypertensive medications can be harmful 2, 4

By following these evidence-based recommendations, clinicians can effectively manage hypertension and reduce the risk of cardiovascular morbidity and mortality in their patients.