What is the best medication for treating hypertension?

Best Medications for Treating Hypertension

The best medications for treating hypertension are ACE inhibitors, ARBs, dihydropyridine calcium channel blockers (CCBs), and thiazide/thiazide-like diuretics as first-line treatments, preferably initiated as a combination therapy for most patients. 1

First-Line Medication Options

Recommended First-Line Agents:

• ACE inhibitors (e.g., lisinopril)
• ARBs (e.g., losartan)
• Dihydropyridine CCBs (e.g., amlodipine)
• Thiazide/thiazide-like diuretics (e.g., chlorthalidone, indapamide)

These medication classes have demonstrated the most effective reduction of blood pressure and cardiovascular disease events according to the 2024 ESC guidelines 1.

Treatment Algorithm

Step 1: Initial Treatment

• For confirmed hypertension (BP ≥140/90 mmHg): Start with combination therapy
• Preferred combinations:
  • RAS blocker (ACE inhibitor or ARB) + dihydropyridine CCB
  • RAS blocker + thiazide/thiazide-like diuretic
• Use single-pill combinations when possible to improve adherence 1

Step 2: If BP Not Controlled

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

Step 3: Resistant Hypertension

• If BP still not controlled with three-drug combination:
  • Add spironolactone
  • If spironolactone is not effective or tolerated, consider:
    • Eplerenone
    • Beta-blocker
    • Centrally acting medication
    • Alpha-blocker
    • Hydralazine
    • Potassium-sparing diuretic 1

Special Patient Populations

Diabetic Patients

• ACE inhibitors are considered first-line therapy in most patients with diabetes
• For patients with microalbuminuria or clinical nephropathy:
  • ACE inhibitors (type 1 and type 2 diabetes)
  • ARBs (type 2 diabetes) 1

African American Patients

• Thiazide diuretics and calcium channel blockers are more effective as first-line agents 2
• Beta-blockers and RAS inhibitors are less effective for reducing blood pressure 2

Elderly Patients

• Consider slower up-titration and lower dosing
• Age-stratified BP targets:
  • 130-139/80 mmHg for patients 65-79 years
  • 140-150/<80 mmHg for those ≥80 years 2

Blood Pressure Targets

• General target: 120-129/70-79 mmHg 1
• Diabetic patients: <130/80 mmHg 1, 2
• If achieving target is not possible or treatment is not well tolerated, BP should be treated to as low as reasonably achievable 1

Important Considerations

Medication Timing

• Take medications at the most convenient time of day to improve adherence
• Establish a habitual pattern of medication taking 1

Monitoring

• Monitor serum potassium and renal function within 3 months of starting ACE inhibitors, ARBs, or diuretics
• Follow-up every 6 months thereafter if levels remain stable 2
• Check BP control and adverse effects 4-12 weeks after initiation of treatment 2

Contraindications

• Avoid combining two RAS blockers (ACE inhibitor and ARB) 1
• Avoid ACE inhibitors and ARBs in pregnancy 2

Conclusion

The evidence strongly supports using combination therapy with agents from different classes for most hypertensive patients. Single-pill combinations improve adherence and should be utilized when possible. Treatment should be individualized based on comorbidities, with special consideration for diabetic patients, elderly patients, and different ethnic groups.