What is the best medication to lower elevated diastolic blood pressure?

Best Medications for Elevated Diastolic Blood Pressure

ACE inhibitors, ARBs, calcium channel blockers (CCBs), and diuretics (thiazides and thiazide-like drugs) are the most effective first-line treatments for lowering elevated diastolic blood pressure, as they have demonstrated the most effective reduction of BP and cardiovascular disease events. 1

First-Line Medication Options

Recommended First-Line Agents

• ACE inhibitors (e.g., lisinopril) effectively reduce diastolic blood pressure through inhibition of the renin-angiotensin system, with demonstrated superior reductions compared to hydrochlorothiazide 2
• ARBs provide similar benefits to ACE inhibitors but with fewer side effects like cough 1
• Dihydropyridine calcium channel blockers (e.g., amlodipine) effectively lower diastolic blood pressure by causing arterial vasodilation 1
• Thiazide and thiazide-like diuretics (e.g., chlorthalidone, indapamide) are particularly effective for diastolic hypertension 1

Treatment Algorithm

Step 1: Initial Therapy

• For most patients with confirmed hypertension (BP ≥140/90 mmHg), combination therapy is recommended as initial treatment 1
• Preferred combinations include a RAS blocker (ACE inhibitor or ARB) with either a dihydropyridine CCB or a diuretic 1
• Single-pill combinations are preferred to improve adherence 1

Step 2: Inadequate Response

• If BP is not controlled with a two-drug combination, increase to a three-drug combination (RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic) 1
• Preferably use a single-pill combination to maintain adherence 1

Step 3: Resistant Hypertension

• If BP remains uncontrolled with a three-drug combination, add spironolactone 1
• If spironolactone is not tolerated, consider eplerenone or add a beta-blocker 1
• Further options include centrally acting medications, alpha-blockers, hydralazine, or potassium-sparing diuretics 1

Special Considerations

Beta-Blockers

• Not recommended as first-line therapy for uncomplicated hypertension 1
• Should be combined with other agents when there are compelling indications such as angina, post-myocardial infarction, or heart failure 1
• When used, vasodilating beta-blockers (e.g., carvedilol, nebivolol) are preferred 1

Medication Timing

• Take medications at the most convenient time of day to improve adherence 1
• Establish a consistent routine for medication taking 1

Blood Pressure Targets

• The first objective should be to lower BP to <140/90 mmHg in all patients 1
• If well tolerated, target BP should be ≤130/80 mmHg for most patients 1
• Specifically for diastolic BP, a target of <80 mmHg should be considered for all hypertensive patients 1
• If systolic BP is at target (120-129 mmHg) but diastolic BP remains ≥80 mmHg, consider intensifying treatment to achieve diastolic BP of 70-79 mmHg 1

Important Cautions

• Avoid combining two RAS blockers (ACE inhibitor and ARB) as this is not recommended and increases adverse effects 1
• Lisinopril may be less effective in Black patients compared to other racial groups 2
• For patients with elevated diastolic BP, monitor for orthostatic hypotension, especially in older patients 1
• Consider more lenient BP targets (e.g., <140/90 mmHg) for patients with symptomatic orthostatic hypotension, age ≥85 years, or moderate-to-severe frailty 1

By following this evidence-based approach, most patients with elevated diastolic blood pressure can achieve appropriate blood pressure control, reducing their risk of cardiovascular events and mortality.