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Harvard Commentaries
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Reviewed by the Faculty of Harvard Medical School

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Getting the Best Value for Hypertension Medications

September 23, 2013

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.

Here are the most commonly prescribed drugs to lower blood pressure:

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.

Diuretics have a great track record over many decades. They prevent 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 were previously considered an excellent second-line drug to treat hypertension. But they are not as effective as most other drug classes. 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

Angiotensin-converting enzyme inhibitors (also known as ACE inhibitors) are now considered a possible first-line agent, either alone or in combination with a diuretic or calcium channel blocker. When starting a combination of two drugs, both drugs are prescribed at low doses. 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.
  • 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.

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