Best Antihypertensive for High Diastolic Blood Pressure
For isolated or predominantly elevated diastolic blood pressure, ACE inhibitors (such as lisinopril) or calcium channel blockers (such as amlodipine) are the most effective first-line agents, with ACE inhibitors demonstrating superior diastolic blood pressure reduction in most populations. 1
First-Line Drug Selection
ACE Inhibitors (Preferred for Most Patients)
- Lisinopril specifically demonstrates greater diastolic blood pressure reductions (13-17%) compared to systolic reductions (11-15%) when given as monotherapy 2
- ACE inhibitors are recommended as first-line therapy alongside thiazide diuretics, ARBs, and calcium channel blockers for all patients with confirmed hypertension (BP ≥140/90 mmHg) 1
- Lisinopril produces comparable or superior diastolic BP reductions compared to atenolol and metoprolol, while also providing better systolic control 2, 3
- Start with lisinopril 10 mg once daily; this dose achieves target BP in approximately 72% of patients with diastolic hypertension 4
Calcium Channel Blockers (Alternative First-Line)
- Long-acting dihydropyridine CCBs like amlodipine are equally effective for diastolic BP control 1
- Amlodipine 5 mg monotherapy achieves target diastolic BP (<90 mmHg) in 71% of patients 4
- CCBs are particularly effective in Black patients, where they should be considered as initial therapy 1
Combination Therapy Strategy
When Monotherapy is Insufficient
- If diastolic BP remains ≥90 mmHg after 3 months, combination therapy is required 1
- The combination of low-dose amlodipine 2.5 mg with lisinopril 5 mg produces significantly greater diastolic BP reduction than either agent alone at higher doses 4
- Preferred combinations: ACE inhibitor + CCB, or ACE inhibitor + thiazide diuretic 1
- Single-pill combinations are strongly recommended to improve adherence 1
Three-Drug Regimen
- If BP remains uncontrolled on two drugs, add a thiazide/thiazide-like diuretic to the ACE inhibitor + CCB combination 1
- This triple combination should preferably be given as a single-pill formulation 1
Treatment Targets
Diastolic BP Goals
- Target diastolic BP <80 mmHg for most patients under 65 years 1
- For patients ≥65 years, focus on systolic BP <130 mmHg while monitoring diastolic BP 1
- Caution: Avoid lowering diastolic BP below 60 mmHg in patients with coronary artery disease, diabetes, or age >60 years, as this may increase cardiovascular risk 1
Monitoring Schedule
- Reassess monthly after initiating or changing medications until target BP is achieved 1
- Once controlled, follow-up every 3-5 months 1
- Achieve target BP within 3 months of treatment initiation 1
Race-Specific Considerations
Black Patients
- Start with a CCB (amlodipine) or CCB + thiazide diuretic combination rather than ACE inhibitor monotherapy 1
- ACE inhibitors are less effective as monotherapy in Black patients 1, 5
- If ACE inhibitor is needed, combine with CCB from the start 1
Non-Black Patients
- Start with low-dose ACE inhibitor (lisinopril 10 mg) 1
- Titrate to full dose (20-40 mg) before adding second agent 1
Common Pitfalls to Avoid
- Do not use beta-blockers as first-line therapy for uncomplicated hypertension with isolated diastolic elevation—they are less effective than ACE inhibitors, CCBs, or diuretics for BP reduction 1, 6
- Avoid combining two RAS blockers (ACE inhibitor + ARB)—this increases adverse effects without additional benefit 1
- Do not use short-acting formulations that require multiple daily dosing, as this reduces adherence 4
- In patients with diastolic BP 90-99 mmHg and low cardiovascular risk, attempt lifestyle modification for 3-6 months before starting medication 1
Resistant Diastolic Hypertension
If diastolic BP remains elevated despite three-drug therapy: