What Is the Drug of Choice for Hypertension? High Blood Pressure

Medically Reviewed on 2/18/2022
What Is the Drug of Choice for Hypertension
Angiotensin-converting enzyme (ACE) inhibitors are the drug of choice for hypertension. Learn about other high blood pressure medications

Angiotensin-converting enzyme (ACE) inhibitors are the drug of choice for hypertension (high blood pressure). People who are unable to tolerate ACE inhibitors are given angiotensin II receptor antagonists or angiotensin receptor blockers (ARBs).

However, there is no one-size-fits-all treatment of hypertension. Because hypertension is caused by many factors, different medications act on different parts of the body. This means that controlling the condition may require the use of several medications.

What are the different classes of high blood pressure medications?

Blood pressure medications are divided into seven classes:

  1. ACE inhibitors: Block a key enzyme responsible for high blood pressure and that causes retention of sodium and water by the kidneys
  2. Angiotensin II receptor antagonists or ARBs: Produce similar effects to ACE inhibitors but may be tolerated better; may reduce coughing and other side effects
  3. Diuretics or water pills: Induce urination to rid the body of excess fluids and sodium
  4. Beta-blockers: Reduce heart rate and force with which blood is pumped from the heart; used in the treatment of cardiac arrhythmias and chest pain
  5. Calcium channel blockers: Prevent calcium from entering the muscle cells of the heart and arteries, as calcium in the cells causes the heart to contract and the arteries to narrow
  6. Peripherally acting alpha-adrenergic blockers: Relax the blood vessels
  7. Vasodilators: Allow blood vessels to dilate to allow more blood to flow through

What are treatment protocols for hypertension?

  • For people under age 55, the first line of treatment is an ACE inhibitor.
  • If the person is on calcium channel blocker or thiazide-type diuretic and they require a second drug, an ACE inhibitor will be administered.
  • If an ACE inhibitor is taken as the first line of treatment, a calcium channel blocker or thiazide-type diuretic will be added.
  • If a person requires a three-drug regimen, an ACE inhibitor or ARB, calcium channel blocker, and thiazide-type diuretic will be administered.

What are side effects of high blood pressure medications?

Common side effects of high blood pressure medicines include:

What lifestyle changes can help control high blood pressure?

Hypertension cannot be cured, and medications alone aren't enough to treat the condition. However, lifestyle changes can help control high blood pressure:

What causes hypertension?

Hypertension occurs when the force of your blood pushing against the walls of your blood vessels or artery walls is too high.

High blood pressure is caused by constriction of very small arteries known as arterioles, which control blood flow throughout the body. When the arterioles tighten, the heart must work harder to pump blood through the smaller space, and the pressure inside the vessels increases, resulting in various heart diseases.


Salt and sodium are the same. See Answer

What are risk factors for hypertension?

Risk factors for high blood pressure include:

  • Afro-Caribbean or South Asian ethnicity
  • Diet high in salt and fat
  • Lack of exercise
  • Being overweight
  • Excessive alcohol consumption
  • Smoking
  • Stress
  • Preexisting health conditions

What are symptoms of hypertension?

Hypertension is known as the “silent killer” because many people are unaware they have the condition. It often causes no signs or symptoms, even when blood pressure readings reach dangerously high levels.

If symptoms do occur, they may include:

Rare symptoms may include:

What are different types of hypertension?

  • Primary or essential hypertension: The most common type of high blood pressure that has no known cause. It usually develops over a long period of time and is often the result of lifestyle, environment, and genetics.
  • Secondary hypertension: This type is caused by a medical condition or medication. Secondary hypertension can be caused by various factors including:
    • Kidney problems
    • Sleep apnea
    • Thyroid or adrenal gland problems
    • Side effects of medicines such as glucocorticoids

What are complications of hypertension?

Hypertension causes complications and problems with the heart and blood vessels, such as:

What are normal and abnormal readings of hypertension?

According to the American College of Cardiology and American Heart Association blood pressure readings are divided into the following categories:

  • Normal: Systolic pressure less than 120 mm Hg and diastolic pressure less than 80 mm Hg.
  • Prehypertension: Systolic blood pressure between 120-139 mm Hg and diastolic blood pressure between 80-89 mm Hg. Although prehypertension is not a disease, it does identify people who are at risk of stage I or II hypertension in the future. Although no medication is required for this condition, lifestyle changes must be considered.
  • Stage I: Systolic blood pressure between 140-159 mm Hg and diastolic blood pressure between 90-99 mm Hg.
  • Stage II: Systolic pressure exceeds 160 mm Hg and diastolic pressure exceeds 100 mm Hg. To rule out cardiac and stroke issues, your doctor may prescribe medications, lifestyle changes, and a strict diet.
  • Hypertensive crisis: Systolic pressure higher than 180 mm Hg and diastolic pressure higher than 120 mm Hg (or just diastolic pressure higher than 120 mm Hg). 

What is a hypertensive crisis?

A hypertensive crisis is a significant or sudden increase in blood pressure readings and is divided into two categories:

  • Hypertensive emergency (>180-220 mm Hg over 120-130 mm Hg):
    • End-organ damage starts or progresses in cerebrovascular, cardiovascular, or renovascular systems.
    • To avoid catastrophic organ damage, blood pressure should be checked frequently and over a period of minutes to hours, rather than aiming for normal values.
  • Hypertensive urgency (>180 mm Hg/110 to 120 mm Hg):
    • End-organ damage is unlikely, but a gradual drop in blood pressure over hours or days is suggested.
    • Because chronically high blood pressure can cause end-organ damage, untreated hypertensive emergencies can occur.

What is the treatment for a hypertensive crisis?

A hypertensive crisis is a medical emergency. Methods for reducing stress and lowering blood pressure through intravenous or oral medications are among the treatment options.

The immediate goal of hypertensive crisis treatment is to gradually lower blood pressure to a safe level—not suddenly, as this can be dangerous. Depending on your specific situation and cause of hypertensive crisis, your target blood pressure and rate at which it should be reduced will differ.

The doctor will most likely implement specific treatment options listed below in a sequential order or according to the severity of your symptoms:

  • Sitting in a quiet room to rest: If you have a hypertensive crisis without other symptoms or organ damage (hypertensive urgency), your doctor may first advise you to sit in a quiet room to rest first.
  • Intravenous medications to lower blood pressure: Some medications such as angiotensin-converting enzyme inhibitors and sodium nitroprusside are given intravenously to help lower your blood pressure faster.
  • Oral medications to lower blood pressure: If you have a hypertensive crisis without other symptoms or organ damage (hypertensive urgency) or if your blood pressure has already been decreased with intravenous drugs, your doctor may recommend one or more oral pills to lower your blood pressure gradually.

In critical care, people must be given a continuous infusion of a titratable short-acting antihypertensive medication. Blood pressure should be reduced in a controlled manner.

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Medically Reviewed on 2/18/2022
Image Source: iStock Images

Choice of drug therapy in primary (essential) hypertension: https://www.uptodate.com/contents/choice-of-drug-therapy-in-primary-essential-hypertension

First line drugs for hypertension: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6513559/

2017 Guideline for High Blood Pressure in Adults: https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2017/11/09/11/41/2017-guideline-for-high-blood-pressure-in-adults

Hypertension: Drugs used to treat hypertension: https://medicine.georgetown.edu/hypertension-drugs/

Clinical Practice Guidelines for the Management of Hypertension in the Community: https://onlinelibrary.wiley.com/doi/full/10.1111/jch.12237