What type of medication is effective for treating hypertension?

Optimal Medications for High Blood Pressure

For most adults with hypertension, start with ACE inhibitors (such as lisinopril), ARBs, thiazide diuretics (such as chlorthalidone), or calcium channel blockers (such as amlodipine) as first-line therapy, with combination therapy required for most patients to achieve blood pressure control. 1

First-Line Medication Classes

The following four drug classes have demonstrated the most effective reduction in blood pressure and cardiovascular events and are recommended as first-line treatments: 1

• ACE inhibitors (e.g., lisinopril) 1, 2
• ARBs (angiotensin receptor blockers) 1
• Dihydropyridine calcium channel blockers (e.g., amlodipine) 1, 3
• Thiazide and thiazide-like diuretics (e.g., chlorthalidone, indapamide) 1, 4

All four classes are equally effective at reducing cardiovascular events, though thiazide diuretics demonstrate superior prevention of heart failure compared to other classes and are the most cost-effective option. 4, 5

Treatment Algorithm Based on Patient Characteristics

For Uncomplicated Hypertension (No Comorbidities)

• Start with any of the four first-line classes, with thiazide diuretics preferred due to superior heart failure prevention and cost-effectiveness 4
• Chlorthalidone is specifically favored over hydrochlorothiazide based on trial evidence 4

For Specific Comorbidities

Heart failure with reduced ejection fraction or post-myocardial infarction:

• Start with ACE inhibitor or ARB as first-line 4, 2

Diabetes with albuminuria or diabetic nephropathy:

• ACE inhibitors for type 1 diabetes 1
• ACE inhibitors or ARBs for type 2 diabetes 1

Established coronary artery disease:

• ACE inhibitor or ARB as first-line 4

Black patients:

• Calcium channel blocker preferred due to superior effectiveness in preventing heart failure and stroke in this population 4

Women of childbearing potential:

• Use calcium channel blocker or thiazide diuretic; avoid ACE inhibitors and ARBs due to teratogenicity 4

Post-myocardial infarction, angina, or heart rate control needs:

• Beta-blockers should be combined with other first-line agents 1

Combination Therapy Strategy

Most patients with confirmed hypertension (BP ≥140/90 mmHg) require combination therapy as initial treatment. 1

Preferred Two-Drug Combinations:

• RAS blocker (ACE inhibitor or ARB) + dihydropyridine calcium channel blocker 1
• RAS blocker + thiazide/thiazide-like diuretic 1
• Fixed-dose single-pill combinations are strongly recommended to improve adherence 1, 6

Three-Drug Combination (if BP not controlled):

• RAS blocker + dihydropyridine calcium channel blocker + thiazide/thiazide-like diuretic, preferably as single-pill combination 1

Four-Drug Regimen (Resistant Hypertension):

• Add spironolactone 25-50 mg daily to the three-drug combination 1, 6
• If spironolactone not tolerated: consider eplerenone, beta-blocker, centrally acting agent, alpha-blocker, or amiloride 1, 6

Critical Contraindications and Cautions

Never combine two RAS blockers (ACE inhibitor + ARB together) - this is explicitly not recommended. 1

Avoid thiazide diuretics + beta-blockers in patients with metabolic syndrome or high diabetes risk due to increased risk of new-onset diabetes. 4

Monitor for:

• Electrolytes (particularly potassium) when using thiazide diuretics or ACE inhibitors/ARBs 4, 2
• Orthostatic hypotension, especially in elderly patients 4
• Renal function when using ACE inhibitors or ARBs 1

Blood Pressure Targets

Target BP: 120-129/70-79 mmHg for most adults under 65 years, if tolerated 1

For patients ≥65 years: Target systolic BP 130-139 mmHg 4

Avoid lowering diastolic BP below 60 mmHg in patients with coronary artery disease, diabetes, or age >60 years, as this may increase cardiovascular risk. 6

Timeline and Monitoring

• Achieve target BP within 3 months of treatment initiation 1, 6
• Reassess monthly after initiating or changing medications until target achieved 6, 4
• Once controlled, follow-up every 3-5 months 6

Medication Timing

Take medications at the most convenient time of day to improve adherence - timing does not affect cardiovascular outcomes. 1 Encourage taking medications at the same time each day in a consistent setting. 1