Which blood pressure (BP) medication targets diastolic blood pressure?

Medications Targeting Diastolic Blood Pressure

ACE inhibitors and ARBs are the most effective first-line medications for targeting diastolic blood pressure, followed by calcium channel blockers (CCBs). 1

First-Line Medication Options

For patients with elevated diastolic blood pressure, the following medications are recommended in order of effectiveness:

1. ACE inhibitors or ARBs

   • Most effective for diastolic hypertension, especially in patients under 55 years 1
   • Examples include lisinopril, which has been shown to produce greater reductions in both systolic and diastolic BP compared to hydrochlorothiazide 2
   • Particularly effective in white patients under 55 years according to the British Hypertension Society's AB/CD algorithm 1

2. Calcium Channel Blockers (CCBs)

   • Effective second-line option for diastolic hypertension 1
   • Recommended as first-line for patients ≥55 years or Black patients of any age 1
   • Dihydropyridine CCBs (like amlodipine) are particularly effective

3. Beta-blockers

   • Can be effective for diastolic hypertension, especially in younger patients
   • Labetalol specifically has been shown to be effective for malignant hypertension with elevated diastolic pressure 3

4. Thiazide/Thiazide-like Diuretics

   • Less effective for isolated diastolic hypertension but useful in combination therapy
   • Chlorthalidone or indapamide (thiazide-like) are preferred over HCTZ 1

Medication Selection Based on Patient Characteristics

• Age considerations:

  • Patients <55 years: ACE inhibitors or ARBs preferred 1
  • Patients ≥55 years: CCBs may be more effective 1

• Race considerations:

  • Black patients: CCBs are generally more effective than ACE inhibitors/ARBs 1
  • White patients: ACE inhibitors/ARBs tend to be more effective 1

• Comorbidities:

  • Diabetes or CKD: ACE inhibitors or ARBs preferred for their renoprotective effects 1
  • Heart failure: ACE inhibitor/ARB + evidence-based beta-blocker recommended 1

Treatment Approach

1. Start with monotherapy:

   • Begin with an ACE inhibitor or ARB for most patients with elevated diastolic BP
   • Lisinopril has been shown to be particularly effective for diastolic BP reduction 2, 4

2. If target not achieved:

   • Add a second agent from a complementary class (ACE/ARB + CCB) 1
   • Consider fixed-dose combinations to improve adherence 1

3. For resistant hypertension:

   • Add a third agent (typically a thiazide-like diuretic) 1
   • Consider spironolactone as a fourth agent 1

Target Blood Pressure

• The European Society of Cardiology recommends a diastolic BP target of <80 mmHg for all hypertensive patients 3
• In cases where systolic BP is at target (120-129 mmHg) but diastolic BP remains ≥80 mmHg, intensifying treatment to achieve a diastolic BP of 70-79 mmHg may be considered 3

Important Considerations

• Avoid combining ACE inhibitors with ARBs as this increases adverse effects without additional benefit 1
• Monitor for adverse effects, including electrolyte disturbances and renal function changes 1
• Start low, go slow: begin with lower doses and titrate gradually, especially in older patients 1
• Regular monitoring of blood pressure, renal function, and electrolytes is essential 1

Evidence Supporting ACE Inhibitors for Diastolic Hypertension

Lisinopril has been shown to be particularly effective for diastolic hypertension:

• Produces significant reductions in diastolic BP, with studies showing reductions from 98 mmHg to 81-82 mmHg 5
• Has been demonstrated to be superior to atenolol in reducing systolic BP while providing comparable diastolic BP reduction 4
• Achieves target diastolic BP (<90 mmHg) in up to 96% of patients with mild to moderate hypertension 5

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