March 19, 2002
Last reviewed and revised on May 25, 2008 
By Howard LeWine, M.D.
Brigham and Women's Hospital
You have tried to lose weight and increase your exercise routine, you have limited your alcohol intake and have stopped smoking, but your blood pressure is still too high, according to your health care professional. Well, you are not alone. About one out of every four adult Americans has hypertension. Most don't know they have it, and of those who do know it, only about half have their blood pressure under control.
Controlling your blood pressure is one of the best ways to ensure yourself a long and productive life. The longer your blood pressure is too high, the more damage is done to your heart and blood vessels. As a result, your risk of heart attack and stroke is increased if your blood pressure is too high. So, getting it under control is the right thing to do.
Changing your lifestyle is the first step. If lifestyle changes haven't worked, drug therapy is the next choice for you and your health care professional to consider. The choice of drugs is important because treatment of high blood pressure is lifelong. Side effects and cost are very important considerations.
The National Heart, Lung and Blood Institute of the National Institutes of Health (NIH) publishes a set of recommendations for the diagnosis and treatment of high blood pressure. The last set of recommendations was published in December 2003 as the Seventh Report of the Joint National Committee on the Prevention, Detection and Treatment of High Blood Pressure. The report, known as the JNCVII report, provides physicians with a set of recommendations, including therapies to bring high blood pressure under control. New studies suggest that the guidelines need to be updated. The NIH plans to publish new recommendations in 2009. Here's what the JNCVIII report will likely state regarding the most prescribed medications:
Thiazide Diuretics
If you have uncomplicated high blood pressure, a thiazide diuretic is probably the best type of medication to try first. Hydrochlorothiazide and chlorthalidone have been used for decades. They are very inexpensive and can be started in low doses to avoid side effects.
With rare exceptions, no medication class has proved superior to diuretics in preventing adverse outcomes related to high blood pressure. They work well to enhance the effectiveness of other blood pressure medications when combination therapy is needed.
Beta-Blockers
The biggest change in recommendations will most likely occur with beta-blockers. They are still recommended as second-line agents for high blood pressure. However, beta blockers are less frequently used today as second-line therapy. They do lower blood pressure, just not as effectively as other medications. Long-acting beta-blockers are especially helpful in people who have a history of heart attack, migraine and benign essential tremor.
Angiotensin-Converting Enyzme Inhibitors
Many clinicians believe that the angiotensin-converting enzyme inhibitors (also known as ACE inhibitors) are a reasonable choice for many patients, especially if side effects are an issue with the diuretics or beta-blockers. The ACE inhibitors vary widely in cost per month.
Here are some important considerations:
- ACE inhibitors are usually very well tolerated. A dry cough is the most common side effect.
- No ACE inhibitor has been shown to be any better than any other in controlling high blood pressure. Most of them are available as generics.
Angiotensin-Receptor Blockers
Some people are troubled by side effects from the ACE inhibitors. About 10% of people taking an ACE inhibitor will develop an intolerable dry cough and request a change in medication because of this side effect. Angiotensin-receptor blockers have a similar action to ACE inhibitors, but without the cough.
Here are some important considerations:
- No ARB has been shown to be any better than any other in controlling high blood pressure.
- All are priced in the same range — about $40 per month.
- ARBs have not been shown to be any better than ACE inhibitors.
Calcium Channel Blockers
The calcium channel blockers include amlodipine, diltiazem, nifedipine and verapamil. Generics are available for each of them. African-Americans often do not experience the same blood pressure lowering effects from beta-blockers, ACE inhibitors and ARBs. Calcium channel blockers may be preferred in African-Americans when a thiazide diuretic alone is insufficient in controlling blood pressure.
Short-acting nifedipine should be avoided and the long-acting preparations should be used instead. Verapamil can cause constipation. Both verapamil and diltiazem can slow the heart rate, especially when combined with a beta-blocker.
Howard LeWine, M.D., is chief editor of Internet publishing, Harvard Health Publications. He is a clinical instructor of medicine at Harvard Medical School and Brigham and Women's Hospital. Dr. LeWine has been a primary care internist and teacher of internal medicine since 1978.
