Best drugs to treat high blood pressure

The least expensive medications may be the best for many people

Last updated: November 2014


High blood pressure is one of the leading causes of heart attacks and strokes, yet one in five of the about 80 million Americans with high blood pressure don't know they have it. That's partly because the condition usually doesn’t cause any obvious symptoms, and because some people don’t get medical checkups as often as they should. Doctors, too, don't always check blood pressure. Be sure to get yours checked at every doctor appointment. 

If you have high blood pressure, stick with your treatment. Studies show that about half of people treated for high blood pressure don't get it under control. That's unfortunate—and unnecessary. In some cases, a committment to making lifestyle changes—such as eating a healthful diet, losing weight, reducing salt intake, and getting regular exercise—can lower blood pressure enough so that medication may not be needed. When they don't, low-cost medicines can help.    

In most cases, the cause of high blood pressure is unknown. Anyone can develop it, even if they are thin, healthy, and exercise regularly. But several factors are known to increase the risk, including:

  • Age. About 65 percent of people 60 and older have high blood pressure.
  • Being overweight or obese.
  • Drinking too much alcohol.
  • Eating a high-salt diet.
  • Family history of high blood pressure.
  • Lack of exercise.
  • Race. Black Americans are more likely than Caucasians and Hispanic Americans to develop high blood pressure.
  • Smoking.

Hypertension is the medical term used to describe having high blood pressure.  The term can be easily misinterpreted—some may believe high blood pressure is related to “tension” or stress, but that is not usually true. High blood pressure is often linked to weight gain, poor diet, and sedentary lifestyle. Family history, getting older and gaining weight also play a role. A high salt diet may contribute as well 

For the same reasons, and perhaps due to genetic factors as well, black Americans are more likely to have high blood pressure and to develop it at a younger age. And studies indicate they are more sensitive than Caucasian people to the blood pressure-raising effects of salt in their diet.

Get screened

Your heart is a powerful muscle that pumps blood through your arteries. To withstand that pressure, healthy arteries need to be flexible. Anything that makes them less so—getting older, certain medications, and risk factors such as inactivity, obesity, and smoking, or having a genetic predisposition, for example—can make blood pressure rise. Over time, that excessive pressure can damage blood vessels throughout the body, and increase a person’s risk for heart attacks, strokes, and heart failure as well as kidney damage, vision loss, arterial blockages in the legs, and sexual impotency.

That’s why it’s important to detect high blood pressure early, so you can get proper treatment before the damage occurs. You should have your blood pressure checked at least once every two years, and more often if you're 50 or older or have other risk factors for hypertension. For most people, it's a good idea to have it done during every visit to a health-care provider.

If your initial reading is elevated, don't panic. A number of factors—including pain and emotional stress and even feeling nervous in the doctor’s office—can temporarily boost blood pressure. To improve the accuracy:

  • Don't smoke, exercise, or consume anything caffeinated for at least an hour before your appointment.
  • Go to the bathroom first, since a full bladder can affect the reading.
  • Sit with your feet flat on the floor for 5 minutes before the reading. Rest your arm on a table so it's at heart level. Remain quiet during the test.

If your blood pressure is high, your doctor may take another reading after about 5 minutes or so. If the reading is still elevated and you have no history of previous high readings, you should get another reading in a couple of weeks before initiating treatment. You can either come back to your doctor’s office, or take your blood pressure at home following your doctor’s recommendations. Good blood pressure equipment can be purchased at most drugs stores.  

In fact, in such circumstances, your doctor may ask you to measure your blood pressure several times or even every day over a period of a week or so. He or she will calculate the average of all the measurements to get a final reading. 

The reason to be sure your blood pressure is indeed elevated before starting on a medication is that the medicines used to treat it can have side effects. Plus, people with normal blood pressure should not take medicines because having excessively low blood pressure can be dangerous, increasing the risk for experiencing dizziness and putting some people at risk for accidents and falls.

What do the numbers mean?

Blood pressure is the force exerted by blood against the walls of your arteries as it flows through your body. It is measured as two numbers, one over the other—for example, 120 over 80. The measurement is in millimeters of mercury, expressed as “mmHg.” The systolic (upper) number is the pressure in the arteries when the heart contracts. The diastolic (lower) number is the pressure when the heart rests between contractions. An elevation in either or both of those numbers signals high blood pressure. See chart below for more details.

Importantly, even if your blood pressure is not elevated enough to be considered high, the risk of a heart attack or stroke increases as pressure rises above normal.

  Systolic measure (mmHg) Diastolic measure (mmHg) What to do
Normal 120 or less 80 or less Maintain a healthy lifestyle to keep blood pressure normal.
High-normal (Also called "pre-hypertension") 120 to 139 80 to 89 Make lifestyle changes to lower pressure to normal and to prevent it from rising over time: stop smoking, cut back on sodium, lose excess weight, exercise regularly, and drink alcohol moderately if at all.

Your doctor may discuss with you prescribing drugs if you also have diabetes, coronary heart disease, or kidney disease.
High for people under age 60 and people 60 or over with diabetes or kidney disease 140 or above 90 or above Make lifestyle changes. If pressure is not lowered to normal within a few month, start medication treatment.
High for people aged 60 and older who don’t have diabetes or kidney disease  150 or above 90 or above Make lifestyle changes. If pressure is not lowered to normal within a few months, start medication treatment.
Very elevated, all ages (sometimes referred to as stage 2 hypertension)  160 or above 100 or above Your doctor will prescribe medication in addition to recommending lifestyle changes.

Source: Adapted from (1) “The 2014 Evidence-Based Guidelines for the Management of High Blood Pressure in Adults,” a report from the panel members appointed to the eighth Joint National Committee (JNC8); Journal of the American Medical Association; Feb. 5, 2014; Vol. 311: 507-520. (2)  “Clinical Practice Guidelines for the Management of Hypertension in the Community, A Statement by the American Society of Hypertension and the International Society of Hypertension;” Journal of Clinical Hypertension; Dec. 17, 2013.

Make lifestyle changes first

Even if you don't have high blood pressure, it's important to take steps to keep it under control because it tends to get higher with age. 

That's especially important if you're a black American or have a family history of the condition, since both sharply increase the risk of developing it. And a healthy diet and lifestyle are essential if you already have high-normal (pre-hypertensive) readings.  

For people with high blood pressure, lifestyle measures can sometimes reduce or even eliminate the need for drugs. For example, research has found that the DASH diet (Dietary Approaches to Stop Hypertension) can be as effective as medication for some people with mild hypertension. This relatively low-sodium diet (1 teaspoon of sodium or less than 2,400 mg per day) relies on fruit, vegetables, and low-fat dairy products. The potassium in those foods, and possibly the calcium, too, appear to help control blood pressure. 

For people with normal blood pressure and no heart disease or stroke risk factors, the suggested 2,400 mg daily sodium limit, achievable by adopting the DASH diet alone, might help ward off the upward creep of blood pressure that can occur with age. Other steps include losing excess weight, exercising regularly, and drinking alcohol only in moderation, as shown in the table below.

See what other steps you can take in our Guide to a Healthy Heart

The power of lifestyle changes

The table below shows how much you can lower your systolic (upper) blood pressure level by making these recommended changes. 

Lifestyle change Estimated reduction in systolic blood pressure level
Adopt the DASH diet
Consume a diet rich in fruits, grains, vegetables, and low-fat dairy products and low in saturated and total fat.
8 to 14 mmHg
Be active
Engage in regular aerobic physical activity, such as brisk walking (at least 30 minutes a day, most days of the week).
4 to 9 mmHg
Cut back on salt
Reduce dietary sodium intake to no more than 2,400 milligrams a day, the amount in a teaspoon of salt.
2 to 8 mmHg
Drink moderately, if at all
Limit consumption to no more than two drinks (e.g., 24 oz of regular beer, 10 oz. wine, or 3 oz of 80-proof whiskey) a day for most men, and no more than one drink a day for women and lighter-weight men.
2 to 4 mmHg
Lose excess weight
Aim for a body mass index under 25.
2.5 to 10 mmHg for about every 11 pounds

Source: Adapted from the “The seventh report of the Joint National Committee on prevention, detection, evaluation and treatment of high blood pressure;” 2003; National Heart, Lung, and Blood Institute.   

Take the right medicines

If a healthy diet and lifestyle changes alone don't lower your blood pressure enough, or if your levels are very high to begin with, you should consider medication. The drugs used to treat high blood pressure are effective and relatively safe, and most are available as low-cost generics. But they can cause side effects, as listed in the table below. 

Many doctors will recommend initial treatment with a group of drugs called thiazide diuretics, sometimes known as "water pills." Studies have consistently shown these drugs (such as chlorthalidone, and hydrochlorothiazide) work for most people who take them, have been used for more than 50 years, are inexpensive, and have a very good safety record. In addition, they outperform all other types of high blood pressure drugs in reducing the risk of death from heart failure.     

Still, many doctors routinely prescribe other blood pressure medicines, including newer, more expensive ones. In addition to thiazide diuretics, the guidelines this report is based on recommend three types of drugs for potential initial treatment, or if a second (or even third) drug is needed to lower your blood pressure. They are: calcium channel blockers (CCBs); angiotensin-converting enzyme inhibitors (ACEIs); and angiotensin receptor blockers (ARBs).

Recommended first-choice blood pressure drugs (and their acronyms)

  • Thiazide diuretics
  • Calcium channel blockers - CCBs
  • Angiotensin-converting enzyme inhibitors -ACEIs
  • Angiotensin receptor blockers - ARBs

Do not use these types of drugs as a first treatment

  • Adrenergic neuronal depleting agents
  • Aldosterone receptor antagonists
  • Beta-blockers
  • Alpha blockers
  • Vasodilating beta blockers
  • Direct vasodilators
  • Central adrenergic antagonists
  • Loop diuretics 

There are many individual drugs within each group, but studies do not show that any one drug is safer or more effective than another in each group. Among the recommended blood pressure drugs, the specific type of blood pressure medicine is usually less important than getting your pressure under control. Your race and age, health status, and other factors may influence which type of drug your doctor recommends.

The latest guidelines on which this report is based also recommend against taking several other types of high blood pressure drugs as first-choice treatment. So, if you are prescribed a drug from one of these groups as initial treatment, you should ask your doctor why.  If you are prescribed a second drug—because the first one didn’t lower your pressure enough—and it is in one of these groups, again, ask why. 

Black Americans experience better results—lower blood pressure and prevention of heart attacks, heart failure, strokes, and death—when they are given a thiazide diuretic or a CCB as first-line treatment. And some studies point to the use of a thiazide diuretic first, with a CCB added to treatment if the diuretic doesn’t lower pressure to the desired goal.   

People with high blood pressure and kidney disease represent another special case. Studies suggest they should take an ACEI or ARB—either as first line treatment or as a second drug—because it’s better for their kidney disease.  

Because many black Americans with high blood pressure and kidney disease will need two (or more) medicines to reduce their pressure, a reasonable treatment choice is a thiazide diuretic plus an ACEI or ARB.

Warning: Don’t ever take an ACEI and ARB at same time.  The combination can damage your kidneys.

Another special case: If you have angina or coronary artery disease, have had a heart attack, or if you have certain heart-rhythm or heart muscle abnormalities, or heart failure, a beta blocker is the best choice if you are also given a high blood pressure diagnosis. Among them are metoprolol (Toprol-XL and generic), nadolol (Corgard and generic), and propranolol (Inderal and generic). They lower blood pressure and reduce the heart’s workload. If a beta-blocker doesn’t lower blood pressure enough, your doctor may add a second medicine that may also help counter your other problems. 

No matter what drug or combination of drugs you take, several steps can minimize the chance of side effects and increase the likelihood that you'll stick with therapy:

  • Get your blood levels of potassium checked periodically, since diuretics can reduce your levels of that mineral. Call your doctor if you have cramps, vomiting, or your heart rate or pulse increases, which can indicate low potassium levels.
  • Watch for signs of gout—for example, an inflamed big toe or knee.
  • If you also have diabetes, monitor your blood sugar level extra carefully because drugs for high blood pressure can cause it to fluctuate.
  • Follow the dosing instructions for your medication carefully and read the product label for possible side effects and other safety concerns you should be aware of.

Which blood pressure drug is right for you?

Drug Good candidates Common side effects
Thiazide diuretics
Chlorthalidone, hydrochlorothiazide, and others
Often the first choice, alone or with other drugs, for most otherwise healthy people. Frequent urination, low potassium levels, and erectile dysfunction.
ACE inhibitors
Benazepril (Lotensin and generic), enalapril (Vasotec and generic), lisinopril (Prinivil, Zestril, and generic), and others
Especially for people with diabetes, heart failure, kidney disease, or a history of heart attack or stroke.

Persistent dry cough, high potassium levels, reduced kidney function, and an uncommon allergic reaction (angioedema) especially in black Americans.

Not to be taken together with an angiotensin receptor blocker (ARB).







Angiotensin receptor blockers (ARBs)
Losartan (Cozaar and generic), candesartan (Atacand), and others
People who would otherwise be candidates for ACEIs but can't take them because of excessive coughing. 

Similar to ACEIs but less likely to cause coughing.

Not to be taken together with an ACEI.

Calcium-channel blockers
Amlodipine (Norvasc and generic), diltiazem (Cardizem and generic), and others
Black people and people who also have angina (chest pain), certain heart-rhythm abnormalities, and possibly migraines. Dizziness, fast or slow heartbeat, flushing, headaches, swollen gums, and, less often, breathing problems.

Treatment goals

The main goal of blood pressure treatment is to reduce the risk of heart attack and stroke. But the immediate goal is to lower blood pressure. To what level, though? 

Perhaps surprisingly, doctors don’t aim to reduce blood pressure to the “normal” level (120/80 mmHg) in people diagnosed with high blood pressure. That’s because studies show that goal is unrealistic for many people and can lead to the overuse of medications. Also, it’s unnecessary in terms of making a substantial impact in preventing heart attacks and strokes. That said, the lower your blood pressure is toward normal, the better. 

Blood pressure treatment goals:

Group with high blood pressure

Systolic goal

Diastolic goal

People 60 or over

Below 150

Below 90

People under age 60

Below 140

Below 90

People of all ages with diabetes

Below 140

Below 90

People of all ages with kidney disease, with or without high blood pressure

Below 140

Below 90

What else you need to know about the latest blood pressure guidelines

Don't rely on supplements

While a diet rich in potassium and possibly calcium can help control blood pressure, it's unclear if supplements have the same effect. And some recent research suggests that too much calcium from supplements might increase the risk of heart disease and other health problems.

As for potassium, the form in supplements (and salt substitutes) might not have the same effect as the kind in foods. And too much of it, even from food, can cause problems for people with heart failure or kidney disease, and for those who take certain blood pressure drugs, including ACE inhibitors, angiotensin receptor blockers, and potassium-sparing diuretics such as spironolactone (Aldactone and generic). So talk with a doctor before increasing your intake.

If you take diuretics, your doctor may prescribe a potassium supplement, because those medicines can lower potassium levels.


This report is based on two newly published guidelines on treating blood pressure. One was produced by a panel of experts convened by the National Heart Lung and Blood Institute.  It was published in the Feb 5, 2014, issue of the Journal of the American Medical Association and is available free here. This guideline is based on a rigorous assessment of the scientific evidence and updates widely used advice issued from a previous group of experts in 2003.  A second guideline comes from the American Society of Hypertension and the International Society of Hypertension. It was published in the Dec 17, 2013, issue of the Journal of Clinical Hypertension and is available free here.

Editor's Note:

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

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