Experts agree that high blood pressure and high cholesterol increase the risk of having a heart attack. So you might think they also agree on when you should take drugs to control them.

They don’t.

Earlier this year the American College of Physicians issued more lenient guidelines for blood pressure in people 60 and older: They don’t need drugs until their systolic, or upper, blood pressure number goes above 150, the ACP now says. But the American Heart Association sticks with the traditional cutoff of 140. And last year, the U.S. Preventive Services Task Force suggested that people who don’t have particularly high cholesterol levels can still benefit from cholesterol-lowering statin drugs.

“There are just too many groups 
issuing recommendations, and that has made things more confusing,” says Steven Nissen, M.D., chairman of the department of cardiovascular medicine at the Cleveland Clinic. 

Taking drugs when they aren’t needed can pose problems. Side effects of blood pressure medications include persistent coughing, diarrhea, nausea, and dizziness. Statins can cause muscle weakness, and possibly kidney damage and type 2 diabetes.

Here’s our guide through the maze, with advice from Nissen, other experts, and our Best Buy Drugs team:



Focus On Your Overall Risk

Though blood pressure and cholesterol levels are important, other factors play a role, too—including your age, gender, race, and whether you smoke or have diabetes.

“Everyone 40 and over should know their overall risk of having a heart attack or stroke,” says Marvin M. Lipman, M.D., Consumer Reports’ chief medical adviser.

So he and other experts recommend estimating your 10-year risk by using a calculator developed by the American College of Cardiology and the American Heart Association, at tools.acc.org/ASCVD-Risk-Estimator. The ideal is a 10-year risk that’s less than 7.5 percent.  

Don't Rush to Drugs

If your 10-year risk is greater than 10 percent, or if your LDL (bad) cholesterol level is over 190, you should start a statin. But if your risk is between 7.5 and 10, it can be worth trying lifestyle changes first, our consultants say.

That means stopping smoking, losing excess weight, being active, consuming a heart-healthy diet, drinking alcohol in moderation only, and getting blood sugar levels under control. If that doesn’t lower your risk enough after three to six months, consider a statin, even if your LDL cholesterol isn’t elevated.

The same basic strategy applies to blood pressure. If it’s moderately elevated (150 to 160 for people 60 and older; 140 to 150 for others), consider drugs only if several months of diet and lifestyle changes weren’t enough.

“Lifestyle changes can slash your risk of heart attack, and in some cases eliminate or reduce your need for medication,” Lipman says. For example, regular exercise can lower your systolic pressure by up to 9 points. And every 11 pounds of excess weight lost can reduce it by 2.5 to 10 points. And avoiding excess sodium (anything beyond 2,400 mg in a day) can lower it between 2 and 8 points in some people.  

Get the Right Medication

Statins are thought to work not only by lowering LDL cholesterol but also by stabilizing plaque deposits in the arteries, making the deposits less likely to rupture and send blood clots through the body.

People with a history of heart attack or stroke, or at very high risk of one (greater than 20 percent), should start with higher doses of a potent statin: 40 to 80 mg of atorvastatin (Lipitor and generic) or 20 to 40 mg of rosuvastatin (Crestor and generic). Other people who need a drug should start with lower doses of those or other statins: 40 mg of lovastatin (Mevacor and generic), pravastatin (Pravachol and generic), or simvastatin (Zocor and generic).

Doctors use several different kinds of drugs to lower blood pressure, and for people with levels above 150 it can take a combination to control the problem. Still, it usually makes sense to start with the oldest, safest, and least expensive drug: diuretics, or water pills, such as chlorthalidone or hydrochlorothiazide. If that doesn’t work, you may need to switch to or add an ACE inhibitor, calcium channel blocker, or other kind of drug.

Editor's Note: This article also appeared in the May 2017 issue of Consumer Reports magazine.

This article and related materials are made possible by a grant from the state Attorney General Consumer and Prescriber Education Grant Program, which is funded by the multistate settlement of consumer-fraud claims regarding the marketing of the prescription drug Neurontin (gabapentin).