High blood pressure (hypertension)

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Choosing blood pressure medications

For people who have stage 2 high blood pressure (higher than 160/100)

If you have stage 2 high blood pressure, you have a systolic pressure of 160 mm Hg or higher or a diastolic pressure of 100 mm Hg or higher. If both readings are high, you also have stage 2 high blood pressure. In this case, you'll likely need to take at least two high blood pressure medications when you start treatment.

As with stage 1 hypertension, your doctor will likely prescribe a thiazide diuretic. Diuretics work by flushing excess water and sodium from the body, thus lowering your blood pressure. Along with a diuretic, your doctor may recommend that you also take:

  • ACE inhibitors. This medication helps blood vessels relax by blocking the production of a hormone that causes blood vessels to narrow. Frequently prescribed ACE inhibitors include captopril (Capoten), lisinopril (Prinivil, Zestril) and ramipril (Altace). 
  • Angiotensin II receptor blockers. This medication allows blood vessels to widen by preventing a hormone called angiotensin from affecting vessels. Frequently prescribed angiotensin II receptor blockers include losartan (Cozaar), olmesartan (Benicar) and valsartan (Diovan).
  • Beta blockers. This class of drugs works by reducing nerve signals to the heart and blood vessels, thus lowering blood pressure. Frequently prescribed beta blockers include metoprolol (Lopressor, Toprol XL), nadolol (Corgard) and penbutolol (Levatol).
  • Calcium channel blockers. This medication prevents calcium from going into heart and blood vessel muscle cells, thus causing the cells to relax, which lowers blood pressure. Frequently prescribed calcium channel blockers include amlodipine (Norvasc), diltiazem (Cardizem, Dilacor XR) and nifedipine (Adalat, Procardia).

If none of these medications is effective in lowering your blood pressure, your doctor may recommend another medication, such as an alpha blocker, central-acting agent or vasodilator. These medications are potent and may cause more side effects than may other blood pressure medications.

When your blood pressure is very high, it's important to reduce it quickly to prevent or delay complications, such as damage to your arteries, heart failure or kidney damage. A two-drug combination generally works faster than does a single drug to get your blood pressure under control. Sometimes a third, or more, medication may be needed to achieve your blood pressure goal.

For people who have high blood pressure and other health problems

High blood pressure often goes hand in hand with other health problems. If you have a serious health condition in addition to high blood pressure, it's likely you'll need aggressive treatment. Those conditions include:

  • Heart failure
  • Previous heart attack
  • High risk of coronary artery disease
  • Enlarged or thickened left chamber of the heart (left ventricular hypertrophy)
  • Diabetes
  • Chronic kidney disease
  • Previous stroke

High blood pressure itself puts you at higher risk of having one of these conditions. If you already have one or more of these conditions plus high blood pressure, your chance of developing a life-threatening complication increases. A more aggressive treatment approach may reduce your risk of these complications.

Your doctor may recommend specific high blood pressure medications to treat these conditions, as well as additional medications for your high blood pressure. For example, if you have chest pain (angina), your doctor may recommend a beta blocker, which can lower your blood pressure and also prevent your chest pain, reduce your heart rate and decrease your risk of death. If you have diabetes and high blood pressure, taking a diuretic plus an ACE inhibitor can decrease your risk of heart attack and stroke. If you have diabetes, high blood pressure and kidney disease, you may need to add additional medications to the mix, such as an angiotensin II receptor blocker.

Reaching your blood pressure goal

Finding the dose or combination of high blood pressure medications that effectively controls your blood pressure often takes time and patience. The process can be challenging. But the stakes are high. If you don't reduce your blood pressure, you face such complications as heart failure, heart attack, stroke, kidney failure, dementia and vision loss.

Sometimes high blood pressure can be difficult to treat. If your high blood pressure doesn't decrease despite taking at least three different types of high blood pressure drugs, one of which should be a diuretic, you may have resistant hypertension. Resistant hypertension is blood pressure that's resistant to treatment. People who have controlled high blood pressure but are taking four different types of medications at the same time to achieve that control also are considered to have resistant hypertension.

Having resistant hypertension doesn't mean your blood pressure will never get lower. In fact, if you and your doctor can identify what's behind your persistently high blood pressure, there's a good chance you can meet your goal with the help of treatment that's more effective.

Don't be satisfied until you find a treatment strategy that reduces your blood pressure to the goal you and your doctor have set. It's not unusual to try several different medications or doses before finding what works best for you. Home monitoring of your blood pressure can help your doctor decide if your blood pressure treatment is working, or if a different dose or medication is necessary.

But the good news is that in most cases, a combination of lifestyle changes and medication can help you successfully control your blood pressure. Once that's done, your doctor may recommend a gradual reduction in medications while monitoring the effect on your blood pressure; however, don't attempt to do this on your own.

Keeping your blood pressure under control may take some time, but in the long run it may mean a longer life, with fewer health problems.

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References
  1. Chobanian AV, et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. New England Journal of Medicine. 2003;289:2560.
  2. Sheps SG, ed. Mayo Clinic 5 Steps to Controlling High Blood Pressure. Rochester, Minn.: Mayo Foundation for Medical Education and Research; 2008.
  3. Initial antihypertensive therapy: Drugdex Consults. Micromedex Healthcare Series. http://www.micromedex.com/. Accessed Nov. 12, 2008.
  4. Control your risk factors for high blood pressure. American Heart Association. http://www.americanheart.org/presenter.jhtml?identifier=581. Accessed Nov. 21, 2008.
  5. Taking medication for high blood pressure. American Heart Association. http://www.americanheart.org/presenter.jhtml?identifier=2141. Accessed Nov. 21, 2008.

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Dec. 18, 2008

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