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If high blood pressure can be identified early enough, when still in its very mildest stages, the first line of defense would be an attempt to modify the risk factors associated with it.

Of course, we cannot do anything about our heredity, age, race, or sex. However, we can lose weight, exercise more, stop smoking, and improve our eating habits. We may even be able to alter our personality. In most cases, the mainstay of hypertension treatment is medication. It brings blood pressure down quickly and keeps it down, and although it does not cure the disease, it does prevent the serious and even life-threatening complications that can result if high blood pressure is left untreated. Since there are so many different hypertension drugs, it would be nice to have a review and comparison in one place.

It is up to the clinician, through systematic therapeutic trials, to identify the drug that is the most efficacious, well tolerated in low doses, convenient, and affordable to the patient and society. We should use the drugs proven to reduce morbidity and mortality as much as possible. However, we are occasionally forced to individualize and choose based on other factors and choose the best hypertension drug for each of us in particular.

How to lower high blood pressure?

The first step is usually a prescription for one of five types of medication: a diuretic, a beta-blocker, an ACE (angiotensin converting enzyme) inhibitor, an angiotensin II receptor antagonist, or a calcium channel blocker. If these drugs, either alone or in combination, fail to bring blood pressure under control, your doctor could seek for other classes of drugs. These drugs usually make no difference in the way you feel. Therefore, it is easy to disregard them. Nevertheless, it is important to take them faithfully according to the prescribed schedule, because if you do not take them on a regular basis, they will not do their hidden, but lifesaving job.

Review of hypertension drugs

Diuretics, such as Lasix, Diuril, hydrochlorothiazides or Esidrix, HydroDIURIL, and Aldactone, make it difficult for the kidneys to retain water and salt. This leads to water and salt filtration out into the urine. Increasing the amount of urine reduces the amount of fluid in the bloodstream, and hence puts too much of pressure on artery walls. Because some important chemicals wash out along with the water and salt, a doctor may prescribe supplements. Most commonly, a potassium supplement goes with the diuretic.

Beta blockers reduce high blood pressure by throttling back the force and speed of the heart pumping. They may also reduce blood pressure by a direct effect on the body’s master control or the central nervous system. Propranolol is the granddaddy of the beta-blocker family, and the first of its class approved by the Food and Drug Administration for use in the United States. Among the other beta-blockers famous on the market today are metoprolol (Lopressor), atenolol (Tenormin), bisoprolol (Zebeta), and carvedilol (Coreg).

ACE inhibitors are benazepril (Lotensin), captopril (Capoten), enalapril (Vasotec), fosinopril (Monopril), lisinopril (Prinivil, Zestril), moexipril (Univasc), perindopril (Aceon), quinapril (Accupril), ramipril (Altace), and trandolapril (Mavik). ACE inhibitors block the production of angiotensin II. This is a chemical the body produces to raise blood pressure. Angiotensin’s role is to maintain equilibrium when blood pressure drops, so it acts directly on the arteries, tightening them up to raise the pressure. The ACE inhibitors can bring blood pressure down quickly but in very rare cases can cause kidney damage or a reduction in the number of white blood cells. This can lead to an increased susceptibility to infection. If one of these drugs fails to reduce blood pressure sufficiently, the doctor can usually prescribe a version that includes a diuretic for extra pressure reduction to improve your condition.

Angiotensin II receptor antagonists is a new class of drugs. It works to lower blood pressure by blocking angiotensin from binding to receptors in the smooth muscles of the blood vessels. This blocking action stops the angiotensin from tightening the arteries and this effect is able to stops raising the blood pressure. Currently, there are seven angiotensin II receptor antagonists, and those are valsartan (Diovan), Candesartan (Atacand), eprosartan (Teveten), irbesartan (Avapro), losartan potassium (Cozaar), olmesartan (Benicar), and telmisartan (Micardis). Most of these drugs are also available combined with a diuretic as medicines to reduce high blood pressure or hypertension.

Calcium channel blockers are the most widely prescribed drugs in the United States today for hypertension treatment. Like so many of the other drugs used for hypertension, they act by dilating the arteries. They also work by reducing resistance to the flow of blood. They have proved to be beneficial not only for high blood pressure, but also for angina, and other problems of a weakened heart patients are complaining of. Included in this group are amlodipine (Norvasc), bepridil (Vascor), diltiazem (Cardizem, Dilacor XR, Tiazac), felodipine (Plendil), isradipine (DynaCirc), nicardipine (Cardene), nimodipine (Nimotop), nisoldipine (Sular), and verapamil (Calan, Covera-HS, Isoptin, Verelan). Some calcium channel blockers are now available combined with an ACE inhibitor in a single pill, and among these new double-threat medications are brands named Lexxel, Lotrel, and Tarka hypertension drugs.

Importance of hypertension drug therapy

In addition to these leading types of blood pressure medication, there is a number of other potent drugs that relax the muscles in the arterial walls, thus helping with hypertension. Some act directly on the muscles, while others work by inhibiting the production or effect of adrenaline, a powerful stimulant released by the body in response to stress. Among these drugs are doxazosin (Cardura), clonidine (Catapres), guanfacine (Tenex), hydralazine (Apresoline), methyldopa (Aldomet), minoxidil (Loniten), and prazosin (Minipress). Though many of the blood pressure drugs are results of major scientific breakthroughs, it is all too easy to underestimate their value. There is nothing very magical about the way they work and what they do not do. However, these drugs are able to make patients feel demonstrably better on a day-to-day level. In fact, because hypertension is so often a disease without symptoms, we are usually more aware of the drugs’ side effects and inconvenience than of their lifesaving properties. However, in terms of the number of patients helped, and the number of years added to these patients’ lives, these drugs rank among the most important of any in use today.

For which hypertensive patients is a beta-blocker the drug of first choice?

To lower blood pressure in patients with angina pectoris, a beta-blocker is the drug of first choice doctor should know. There is no evidence, but it also seems reasonable to use a beta-blocker as first choice in patients where the drug should treat more than the hypertension. For example, those are patients with frequent recurrent migraine or patients with sympathetic hyperactivity, resting tachycardia, and palpitations. It is important to know that beta-blockers should not be hypertension drug of choice in patients with asthma or other forms of obstructive airways disease.

For which hypertensive patients is an ACE inhibitor the drug of first choice?

ACE inhibitors prolong survival in patients with congestive heart failure, so they are therefore the obvious first choice in patients with hypertension and CHF. It is not yet clear whether ACE inhibitors have a unique renal protective effect in diabetic nephropathy as well.
Moreover, a recent study suggests that ACE inhibitors increase the risk of hypoglycemia in treated diabetic patients. There are no proven therapeutic differences between the ACE inhibitors, so drug choice could bases on convenience and cost of the hypertension drugs.

For which hypertensive patients is a calcium antagonist the drug of first choice?

There are no outcome studies to identify who would experience special beneficial effects using calcium antagonist. It is clear that post-MI patients with left ventricular dysfunction do worse with diltiazem as one of hypertension drug, than with a placebo. A recent unpublished but highly publicized study also suggests that patients receiving a calcium antagonist for hypertension have a significantly increased risk of myocardial infarction. This is clear when compared to patients receiving diuretics or beta-blockers. Neither of these studies is definitive, but they do reinforce the message in this and the previous letter, and emphasize the need for prospective randomized controlled studies measuring morbidity and mortality.

For which hypertensive patients are other drugs useful?

From the large controlled studies of the treatment of mild hypertension, it is clear that in at least 50% of patients the hypertension is possible to control with a thiazide alone. The additional drugs used in these studies, for patients not controlled with a thiazide include reserpine in three studies, methyldopa in two studies, hydralazine in two studies, and beta-blockers in two studies as well. We thus can have some confidence in the effectiveness of these drugs used in combination with a thiazide in hypertension treatment. In patients with moderate to severe hypertension, three to four drugs are often required to control adequately high blood pressure. We, therefore, are fortunate to have a wide armamentarium of drugs to choose from and our doctor should help make that choice.