Which anti-hypertensive (blood pressure medication) helps to lower diastolic blood pressure?

Antihypertensives for Lowering Diastolic Blood Pressure

Thiazide diuretics are the most effective first-line medications for lowering diastolic blood pressure, with mineralocorticoid receptor antagonists providing significant additional benefit in resistant cases. 1

First-Line Medication Options

• Thiazide and thiazide-like diuretics are particularly effective for diastolic hypertension and should be considered as first-line therapy due to their proven efficacy in reducing cardiovascular events 1, 2
• ACE inhibitors (like lisinopril) effectively reduce diastolic blood pressure by 13-17% when used as monotherapy, working through inhibition of the renin-angiotensin system 3, 4
• Calcium channel blockers (particularly dihydropyridines like amlodipine) are effective in lowering diastolic blood pressure through arterial vasodilation 2, 5
• ARBs provide similar benefits to ACE inhibitors but with fewer side effects like cough, making them valuable alternatives for diastolic hypertension 2

Comparative Effectiveness

• In the ALLHAT study, thiazide diuretics (chlorthalidone) demonstrated superior effectiveness in preventing cardiovascular disease events compared to amlodipine (calcium channel blocker) and lisinopril (ACE inhibitor) 6
• Mineralocorticoid receptor antagonists like spironolactone can lower diastolic blood pressure by an additional 10-12 mmHg when added to existing regimens in resistant hypertension 1
• Amiloride, an indirect aldosterone antagonist, reduced diastolic blood pressure by 15 mmHg when substituted for prior diuretic therapy in patients with low-renin hypertension 1
• In African American patients, amiloride showed greater diastolic blood pressure reduction (4.8 mmHg) compared to spironolactone (3.3 mmHg) when added to a two-drug regimen 1

Treatment Algorithm

1. Initial therapy: Start with a thiazide diuretic as first-line therapy for most patients with diastolic hypertension 1
2. Combination therapy: If blood pressure is not controlled with monotherapy, add either:
   • An ACE inhibitor/ARB or
   • A calcium channel blocker 2, 7
3. Resistant hypertension: For patients not reaching target on a three-drug regimen, add a mineralocorticoid receptor antagonist (spironolactone or amiloride) 1

Special Considerations

• Beta-blockers are not recommended as first-line therapy for uncomplicated hypertension but may be considered when there are compelling indications 2
• Combination therapy with an ACE inhibitor and calcium channel blocker shows complementary mechanisms of action and may be particularly effective for diastolic hypertension 8, 9
• Fixed-dose single-pill combinations improve adherence and should be preferred when combination therapy is indicated 2, 7

Blood Pressure Targets

• The target diastolic blood pressure should be <90 mmHg for most patients 1
• A more intensive target of <80 mmHg should be considered for patients with diabetes, chronic kidney disease, or established cardiovascular disease 2, 7
• For elderly patients (≥85 years) or those with moderate-to-severe frailty, more lenient blood pressure targets may be appropriate 2

Important Cautions

• Monitor for hyperkalemia when using mineralocorticoid receptor antagonists, especially in older patients, those with diabetes and/or chronic kidney disease, or when combined with ACE inhibitors or ARBs 1
• Combining two RAS blockers (ACE inhibitors, ARBs) is not recommended as it increases adverse effects without additional benefit 2
• Monitor for orthostatic hypotension, especially in older patients 2