What are the best medications to lower diastolic blood pressure?

Best Medications to Lower Diastolic Blood Pressure

ACE inhibitors, ARBs, dihydropyridine calcium channel blockers, and thiazide/thiazide-like diuretics are the most effective medications for lowering diastolic blood pressure and should be used as first-line treatments. 1

First-Line Medication Options

• ACE inhibitors (such as lisinopril) effectively lower diastolic blood pressure and have been shown to reduce cardiovascular events, making them an excellent first-line choice 1, 2
• ARBs provide similar benefits to ACE inhibitors but with fewer side effects like cough, making them suitable alternatives 1
• Dihydropyridine calcium channel blockers (such as amlodipine) are highly effective at reducing diastolic blood pressure and are particularly beneficial in older patients and Black patients 1
• Thiazide and thiazide-like diuretics (such as chlorthalidone and indapamide) have demonstrated superior reduction of cardiovascular events compared to other classes and are cost-effective options 3, 4

Combination Therapy Approach

• For most patients with confirmed hypertension (BP ≥140/90 mmHg), combination therapy is recommended as initial treatment rather than monotherapy 1
• The preferred combinations include a RAS blocker (ACE inhibitor or ARB) with either a dihydropyridine calcium channel blocker or a thiazide/thiazide-like diuretic 1
• Fixed-dose single-pill combinations improve adherence and should be used when possible 1
• If blood pressure is not controlled with a two-drug combination, a three-drug combination (RAS blocker + calcium channel blocker + thiazide diuretic) is recommended 1

Specific Considerations for Diastolic Hypertension

• For patients with predominantly diastolic hypertension, ACE inhibitors and ARBs are particularly effective as they target the renin-angiotensin system that influences peripheral vascular resistance 5, 6
• The combination of an ACE inhibitor (like lisinopril) with a calcium channel blocker (like amlodipine) has shown superior diastolic blood pressure reduction compared to either agent alone 7
• In patients with diastolic dysfunction, ACE inhibitors and ARBs have demonstrated improvement in measures of diastolic function and are recommended as first-line agents 5

Special Populations and Considerations

• Beta-blockers are not recommended as first-line therapy for uncomplicated hypertension but should be used when there are compelling indications such as coronary artery disease, heart failure, or for heart rate control 1
• In Black patients, calcium channel blockers and thiazide diuretics may be more effective than ACE inhibitors or ARBs when used as monotherapy 1, 2
• In older adults (≥65 years), dihydropyridine calcium channel blockers and thiazide diuretics are often preferred due to better tolerability 1
• For patients with diabetes and hypertension, ACE inhibitors or ARBs are preferred first-line agents, particularly if albuminuria is present 1, 8

Monitoring and Follow-up

• Regular monitoring of serum creatinine, eGFR, and potassium levels is essential, especially for patients on ACE inhibitors, ARBs, or diuretics 1, 8
• Target blood pressure should generally be <140/90 mmHg for most patients, and <130/80 mmHg for those with diabetes or chronic kidney disease 1
• Medication should be taken at the most convenient time of day for the patient to establish a habitual pattern and improve adherence 1

Common Pitfalls to Avoid

• Combining two RAS blockers (ACE inhibitor and ARB) is not recommended due to increased risk of adverse effects without additional benefit 1
• Beta-blockers with intrinsic sympathomimetic activity should be avoided, and atenolol is less effective than other antihypertensive drugs 1
• Nondihydropyridine calcium channel blockers (verapamil, diltiazem) should be avoided in patients with heart failure with reduced ejection fraction due to their myocardial depressant activity 1