What is the best medication for managing hypertension?

Best Medications for Hypertension Management

For most patients with hypertension, a combination therapy approach using a renin-angiotensin system (RAS) blocker (ACE inhibitor or ARB) with either a calcium channel blocker (CCB) or a thiazide/thiazide-like diuretic is recommended as the most effective first-line treatment. 1

First-Line Medication Options

• ACE inhibitors (e.g., lisinopril), ARBs (e.g., losartan), dihydropyridine CCBs, and thiazide/thiazide-like diuretics have demonstrated the most effective reduction of blood pressure and cardiovascular events 1
• Single-pill combinations of these medications improve adherence and should be preferred when combination therapy is used 1
• For most patients with confirmed hypertension (BP ≥140/90 mmHg), initial therapy should be a two-drug combination rather than monotherapy 1

Recommended Treatment Algorithm

1. Initial Treatment:

   • For most patients with hypertension: Start with a two-drug combination of a RAS blocker (ACE inhibitor or ARB) plus either a CCB or thiazide/thiazide-like diuretic 1
   • Preferably use a single-pill combination to improve adherence 1

2. If BP not controlled after 1-3 months:

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

3. If BP still not controlled (resistant hypertension):

   • Add spironolactone as fourth-line agent 1
   • If spironolactone is not tolerated, consider eplerenone, beta-blockers, or other agents 1

Special Considerations

• Beta-blockers are not recommended as first-line treatment unless there are specific indications such as angina, post-myocardial infarction, heart failure, or for heart rate control 1
• Combining two RAS blockers (ACE inhibitor and ARB) is not recommended due to increased adverse effects without additional benefit 1
• In Black patients, a CCB combined with either a thiazide diuretic or a RAS blocker should be considered 1
• In elderly patients (≥65 years), treatment should be initiated more gradually, with careful monitoring for orthostatic hypotension 1

Blood Pressure Targets

• For most adults: Target BP of 120-129/70-79 mmHg, provided treatment is well tolerated 1
• If achieving this target is not possible or treatment is not well tolerated, aim for "as low as reasonably achievable" 1
• For older patients (≥65 years): Target systolic BP of 130-139 mmHg 1
• For patients aged ≥85 years or with frailty: Consider more lenient targets (e.g., <140/90 mmHg) 1

Medication Efficacy and Benefits

• ACE inhibitors like lisinopril provide effective BP reduction without affecting heart rate or cardiovascular reflexes 2, 3
• ARBs like losartan are effective in lowering BP and have additional benefits in patients with left ventricular hypertrophy or diabetic nephropathy 4
• A 10 mmHg reduction in systolic BP decreases the risk of cardiovascular events by approximately 20-30% 5
• Combination therapy allows for lower doses of individual medications, potentially reducing side effects while maintaining efficacy 1

Common Pitfalls to Avoid

• Delaying intensification of therapy when BP targets are not met 1
• Using monotherapy in patients with moderate-to-severe hypertension, which is often insufficient 1
• Failing to consider medication adherence when BP is not controlled 1
• Using over-the-counter cold medications containing sympathomimetics (e.g., pseudoephedrine), which can significantly increase BP 6
• Combining NSAIDs with antihypertensive medications, as NSAIDs can antagonize the effects of RAS inhibitors and beta-blockers 6

By following this evidence-based approach to hypertension management, clinicians can effectively reduce blood pressure and minimize the risk of cardiovascular events, stroke, and mortality in their patients.