What is the best medication for a patient with hypertension?

Best Blood Pressure Medication for Hypertension

For most patients with hypertension, initial therapy should be a combination of a thiazide or thiazide-like diuretic, an ACE inhibitor or ARB, and a calcium channel blocker, with the specific choice guided by patient race, comorbidities, and blood pressure severity. 1

Initial Monotherapy Selection

For Black patients:

• Start with a dihydropyridine calcium channel blocker (like amlodipine 5-10mg daily) or a thiazide diuretic as first-line therapy 2
• CCBs are preferred over ACE inhibitors/ARBs in this population due to superior efficacy 2

For non-Black patients:

• ACE inhibitor (like lisinopril 10-40mg daily) or ARB (like losartan 50-100mg daily) is typically first-line 2
• A dihydropyridine CCB is an acceptable alternative, particularly with uncertain medical history 2

Dual Therapy Combinations

When monotherapy fails to achieve target BP <140/90 mmHg:

• Add an ACE inhibitor/ARB to amlodipine for complementary mechanisms, particularly beneficial with chronic kidney disease, heart failure, or coronary artery disease 2
• Alternatively, add a thiazide-like diuretic to amlodipine, especially effective for volume-dependent hypertension, elderly patients, or Black patients 2
• For Black patients specifically, amlodipine plus thiazide diuretic may be more effective than amlodipine plus ACE inhibitor/ARB 2

Triple Therapy for Uncontrolled Hypertension

The guideline-recommended triple therapy combination is:

• RAS blocker (ACE inhibitor or ARB) + calcium channel blocker + thiazide/thiazide-like diuretic 1, 2
• This targets three complementary mechanisms: renin-angiotensin system blockade, vasodilation, and volume reduction 2
• Chlorthalidone 12.5-25mg daily is preferred over hydrochlorothiazide due to longer duration of action 2, 3

Monitoring after adding a diuretic:

• Check serum potassium and creatinine 2-4 weeks after initiation to detect hypokalemia or renal function changes 2
• Reassess BP within 2-4 weeks, targeting achievement within 3 months 2

Resistant Hypertension (Fourth-Line Agent)

When triple therapy at optimal doses fails:

• Add spironolactone 25-50mg daily as the preferred fourth-line agent 1, 2
• This is specifically recommended by 2024 ESC guidelines for resistant hypertension 1
• Monitor potassium closely when combining with ACE inhibitor/ARB due to significant hyperkalemia risk 2

Alternative fourth-line options if spironolactone not tolerated:

• Eplerenone (alternative mineralocorticoid receptor antagonist) 1
• Bisoprolol or doxazosin 1
• Higher dose thiazide/thiazide-like diuretic or loop diuretic 1

Blood Pressure Targets

• Most patients: <140/90 mmHg minimum 2, 4
• Higher-risk patients or those <65 years: <130/80 mmHg 2, 4
• Adults ≥65 years: SBP <130 mmHg 4

Critical Pitfalls to Avoid

• Never combine ACE inhibitor with ARB - increases adverse events without additional benefit 2
• Do not add a fourth agent before optimizing triple therapy doses - violates guideline-recommended stepwise approaches 2
• Confirm medication adherence before assuming treatment failure - non-adherence is the most common cause of apparent resistance 2
• Avoid beta-blockers as third-line agents unless compelling indications exist (angina, post-MI, heart failure with reduced ejection fraction, or rate control needed) 2

Lifestyle Modifications (Additive BP Reduction of 10-20 mmHg)

• Sodium restriction to <2g/day 1, 2
• Weight management (target BMI 20-25 kg/m²) 2
• Regular aerobic exercise 2
• Alcohol limitation to <100g/week 2

Special Considerations

Peripheral edema with amlodipine:

• May be attenuated by adding an ACE inhibitor or ARB 2

Renal function monitoring:

• Essential when using ACE inhibitors/ARBs and diuretics 2
• Watch for hyperkalemia with ACE inhibitors/ARBs and hypokalemia with thiazide diuretics 2