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Drug Treatment of High Blood Pressure

By

George L. Bakris

, MD, University of Chicago School of Medicine

Last full review/revision Mar 2021| Content last modified Mar 2021
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Topic Resources

High blood pressure High Blood Pressure High blood pressure (hypertension) is persistently high pressure in the arteries. Often no cause for high blood pressure can be identified, but sometimes it occurs as a result of an underlying... read more High Blood Pressure is very common. It often does not cause symptoms; however, high blood pressure can increase the risk of stroke Overview of Stroke A stroke occurs when an artery to the brain becomes blocked or ruptures, resulting in death of an area of brain tissue due to loss of its blood supply (cerebral infarction) and symptoms that... read more , heart attacks Acute Coronary Syndromes (Heart Attack; Myocardial Infarction; Unstable Angina) Acute coronary syndromes result from a sudden blockage in a coronary artery. This blockage causes unstable angina or heart attack (myocardial infarction), depending on the location and amount... read more Acute Coronary Syndromes (Heart Attack; Myocardial Infarction; Unstable Angina) , and heart failure Heart Failure (HF) Heart failure is a disorder in which the heart is unable to keep up with the demands of the body, leading to reduced blood flow, back-up (congestion) of blood in the veins and lungs, and/or... read more Heart Failure (HF) . Therefore, it is important to treat high blood pressure. People with high blood pressure should make changes in their lifestyle Lifestyle changes High blood pressure (hypertension) is persistently high pressure in the arteries. Often no cause for high blood pressure can be identified, but sometimes it occurs as a result of an underlying... read more Lifestyle changes to help reduce blood pressure. However, if such changes do not sufficiently reduce blood pressure, drug treatment is needed.

Drugs that are used in the treatment of high blood pressure High Blood Pressure High blood pressure (hypertension) is persistently high pressure in the arteries. Often no cause for high blood pressure can be identified, but sometimes it occurs as a result of an underlying... read more High Blood Pressure are called antihypertensives. With the wide variety of antihypertensives available, high blood pressure can be controlled in almost anyone, but treatment has to be tailored to the individual. (See also High Blood Pressure High Blood Pressure High blood pressure (hypertension) is persistently high pressure in the arteries. Often no cause for high blood pressure can be identified, but sometimes it occurs as a result of an underlying... read more High Blood Pressure .) Treatment is most effective when the person and doctor communicate well and collaborate on the treatment program.

Different types of antihypertensives reduce blood pressure by different mechanisms, so many different treatment strategies are possible. For some people, doctors use a stepped approach to drug therapy: They start with one type of antihypertensive and add others as necessary. For other people, doctors find a sequential approach is preferable: They prescribe one antihypertensive, and if it is ineffective, they stop it and prescribe another type. For people with blood pressure at or above 140/90 mm Hg, usually two drugs are started at the same time. In choosing an antihypertensive, doctors consider such factors as

  • The person's age, sex, and race

  • The severity of high blood pressure

  • The presence of other conditions, such as diabetes or high blood cholesterol levels

  • Potential side effects, which vary from drug to drug

  • The costs of the drugs and of tests needed to check for certain side effects

A majority of people (more than 74%) ultimately require two or more drugs to reach their blood pressure goal.

Most people tolerate their prescribed antihypertensive drugs without problems. But any antihypertensive drug can cause side effects. So if side effects develop, a person should tell the doctor, who can adjust the dose or substitute another drug. Usually, an antihypertensive drug must be taken indefinitely to control blood pressure.

Adrenergic blockers

Adrenergic blockers include alpha-blockers, beta-blockers, alpha-beta blockers, and peripherally acting adrenergic blockers. These drugs block the effects of the sympathetic division, the part of the autonomic nervous system Autonomic nervous system The peripheral nervous system consists of more than 100 billion nerve cells (neurons) that run throughout the body like strings, making connections with the brain, other parts of the body, and... read more that can rapidly respond to stress by increasing blood pressure.

Alpha-blockers are no longer used as the main therapy because they do not decrease the risk of death. Peripherally acting adrenergic blockers are usually only used if a third or fourth type of drug is needed to control blood pressure.

Angiotensin-converting enzyme inhibitors

Angiotensin-converting enzyme (ACE) inhibitors lower blood pressure in part by dilating arterioles. They dilate arterioles by preventing the formation of angiotensin II, a chemical produced in the body that causes arterioles to constrict. Specifically, these inhibitors block the action of angiotensin-converting enzyme, which converts angiotensin I to angiotensin II (see figure Regulating Blood Pressure Regulating Blood Pressure: The Renin-Angiotensin-Aldosterone System High blood pressure (hypertension) is persistently high pressure in the arteries. Often no cause for high blood pressure can be identified, but sometimes it occurs as a result of an underlying... read more Regulating Blood Pressure: The Renin-Angiotensin-Aldosterone System ). These drugs are particularly useful for people with coronary artery disease Overview of Coronary Artery Disease (CAD) Coronary artery disease is a condition in which the blood supply to the heart muscle is partially or completely blocked. The heart muscle needs a constant supply of oxygen-rich blood. The coronary... read more Overview of Coronary Artery Disease (CAD) or heart failure Heart Failure (HF) Heart failure is a disorder in which the heart is unable to keep up with the demands of the body, leading to reduced blood flow, back-up (congestion) of blood in the veins and lungs, and/or... read more Heart Failure (HF) , whites, young people, people with protein in their urine because of chronic kidney disease Chronic Kidney Disease Chronic kidney disease is a slowly progressive (months to years) decline in the kidneys’ ability to filter metabolic waste products from the blood. Major causes are diabetes and high blood pressure... read more or diabetic kidney disease Kidney damage in diabetes People with diabetes mellitus have many serious long-term complications that affect many areas of the body, particularly the blood vessels, nerves, eyes, and kidneys. (See also Diabetes Mellitus... read more Kidney damage in diabetes , and men who develop sexual dysfunction as a side effect of another antihypertensive drug.

Angiotensin II receptor blockers

Angiotensin II receptor blockers (ARBs) lower blood pressure by a mechanism similar to the one used by angiotensin-converting enzyme inhibitors: They directly block the action of angiotensin II, which causes arterioles to constrict. Because the mechanism is more direct, angiotensin II receptor blockers may cause fewer side effects.

Calcium channel blockers

Calcium channel blockers cause arterioles to dilate by a completely different mechanism. They are particularly useful for blacks and older people. Calcium channel blockers are also useful for people who have angina pectoris Angina Angina is temporary chest pain or a sensation of pressure that occurs while the heart muscle is not receiving enough oxygen. A person with angina usually has discomfort or pressure beneath the... read more , certain types of rapid heart rate, or migraine headaches Migraines A migraine headache is typically a pulsating or throbbing pain that ranges from moderate to severe. It can affect one or both sides of the head. It is often worsened by physical activity, light... read more . Calcium channel blockers may be short-acting or long-acting. Short-acting calcium channel blockers are not used to treat high blood pressure. Reports suggest that people using short-acting calcium channel blockers may have an increased risk of death due to heart attack, but no reports suggest such effects for long-acting calcium channel blockers.

Centrally acting alpha agonists

Centrally acting alpha-agonists lower blood pressure through a mechanism that somewhat resembles that of adrenergic blockers. By stimulating certain receptors in the brain stem, these agonists inhibit the effects of the sympathetic division of the nervous system. These drugs are rarely used now.

Direct vasodilators

Direct vasodilators dilate blood vessels by another mechanism. A drug of this type is almost never used alone; rather, it is added as a second drug when another drug alone does not lower blood pressure sufficiently.

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Diuretics

A thiazide or thiazide-type diuretic (such as chlorthalidone or indapamide) may be the first drug given to treat high blood pressure. Diuretics can cause blood vessels to widen (dilate). Diuretics also help the kidneys eliminate sodium and water, decreasing fluid volume throughout the body and thus lowering blood pressure.

Thiazide diuretics cause potassium to be excreted in the urine, so potassium supplements or a diuretic that does not cause potassium loss or that causes potassium levels to increase (a potassium-sparing diuretic) sometimes must be taken with a thiazide diuretic. Usually, potassium-sparing diuretics are not used alone because they do not control blood pressure as well as thiazide diuretics do. However, the potassium-sparing diuretic spironolactone is sometimes used alone.

Diuretics are particularly useful for blacks, older people, obese people, and people with heart failure or chronic kidney disease.

More Information

The following is an English-language resource that may be useful. Please note that THE MANUAL is not responsible for the content of this resource.

  • American Heart Association: High blood pressure: Comprehensive resource to help people understand causes of high blood pressure and manage the lifestyle changes required for treatment

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