I am no expert in treating medical conditions other than psychiatric.  However, as a physician who treats hundreds of patients who also suffer from high blood pressure and having a mild problem, myself, I try to keep up to date.  My favorite hypertensive medications are ACE inhibitors and diuretics.  These should be combined with a healthy diet, exercise, and weight loss.  Certain vitamins, minerals, and supplements are also of real value.

The ACE Inhibitors captopril (Capoten) or enalaprilat (Vasotec) are both very inexpensive and have excellent added health benefits.  They are covered on a separate web page, ACE Inhibitors.  In general, they are my first choice.

Diuretics like hydrochlorothiazide (HCTZ) should be the first medication used for high blood pressure or the second one added to the first one when the first one is not successful by itself, a common event.  HCTZ is very inexpensive. 

Alpha-adrenergic agonist like clonidine (Catapres) is a popular, inexpensive, and effective anti-hypertensive for those who can tolerate the excessive sleep, constipation, dry mouth, and other side-effects.  These tend to disappear after the first week of therapy.

Beta-blockers like propranolol are also very inexpensive and have done well in research.  They can lower your exercise tolerance, so they may not be the best choice for athletically active individuals. Atenolol is in this group.

Angiotensin II receptor blockers are more expensive and should usually be reserved for patients for whom the above initial strategies have not been enough.  These are candesartan (Atacand), irbesartan (Avapro), olmesartan (Benicar), losartan (Cozaar), valsartan (Diovan), telmisartan (Micardis), and eprosartan (Teveten).  Recent evidence suggests these medications do not lower mortality as much as other HBP meds and are inferior to ACE inhibitors.

Calcium-channel blockers also have been found useful, although there are some warnings of higher rates of death even from longer acting members of the family.  They are also more expensive.  These include nifedipine (Adalat), diltiazem (Cardizem), verapamil (Covera), isradipine (Dynacirc), verapamil-SR (Isoptin), nimodipine (Nimotop), amlodipine (Norvasc), felodipine-SR (Plendil), nifedipine (Procardia), nisoldipine-SR (Sular), diltiazem-SR (Tiazac), and verapamil-SR (Verelan).  

Many other older medications are available for high blood pressure and some are still in use, especially for patients not responding to initial treatment.

Of course, salt avoidance, a healthy diet, weight loss and exercise are each very useful and important.  Several inexpensive natural supplements have been shown to lower high blood pressure in double-blind studies, but the research on each is definitely insufficient and no long term studies exist. Coenzyme Q10 and stevioside are covered under Non-Medical Rx.  Both have very few or no side-effects.  Both have been shown to reduce stress on the heart with CoQ10 particularly well researched.  Stevioside is the least expensive hypertensive treatment I have found, costing as little as $3 per month, but it is poorly researched.  Unfortunately, it is not known whether CoQ10 or stevioside help you live longer, while it has been well proven that ACE inhibitors, diuretics, beta-blockers, and angiotensin receptor blockers each increase longevity in individuals with hypertension.

Usually, more than one medication is needed to get blood pressure down to the normal healthy range.  The research on high blood pressure medications is very extensive and I will not attempt to tackle it on my website anymore than I would attempt to manage a patient with serious hypertension.  That is a job for internists and family practice physicians who deal with this extremely important health issue every day.

HCTZ/Clonidine Best for Reducing Pulse Pressure: In retrospective analyses of the Veterans Affairs Single-Drug Therapy for Hypertension Study with 6 classes of antihypertensive agents: 1292 men with diastolic blood pressure of 95 to 109 mm Hg on placebo were randomized to receive hydrochlorothiazide (12.5-50), atenolol (25-100 mg), captopril, clonidine (0.1-0.3 bid), diltiazem, prazosin (2-10 mg bid), or placebo. Mean baseline systolic, diastolic, and pulse pressures were 152, 99, and 53 mm Hg. Reductions in pulse pressure during titration were greater (P<0.001) with clonidine (6.7 mm Hg) and hydrochlorothiazide (6.2 mm Hg) than with captopril (2.5 mm Hg), diltiazem (1.6 mm Hg), and atenolol (1.4 mm Hg); reduction with prazosin (3.9 mm Hg) was similar to all but clonidine. After 1 year, pulse pressure was reduced significantly more (P<0.001) with hydrochlorothiazide (8.6 mm Hg) than with captopril and atenolol (4.1 mm Hg with both); clonidine (6.3 mm Hg), diltiazem (5.5 mm Hg), and prazosin (5.0 mm Hg) were intermediate. Pulse pressure changes with six classes of antihypertensive agents in a randomized, controlled trial. Cushman WC, et al. Memphis, Tennessee. . Hypertension 2001 Oct;38(4):953-7.

Thiazide Preferred Initial Med in Huge ALLHAT Study: ALLHAT, a randomized, double-blind, active-controlled hypertension treatment trial in 42,418 patients, reported that a thiazide-type diuretic (chlorthalidone) was superior to a calcium channel blocker (amlodipine), an angiotensin-converting enzyme inhibitor (lisinopril), and an alpha1-blocker (doxazosin) in preventing the new onset of heart failure (HF). However, questions have been raised regarding the validity of the HF diagnosis. A careful review of records for 2778 HF hospitalizations in 1935 patients found the percent agreements with site physician diagnoses were 71%, 80%, and 84% for ALLHAT, Framingham, and reviewers' judgment, respectively. Using these 3 criteria, relative risks for new-onset HF compared with chlorthalidone were, respectively, 1.46 for amlodipine; 1.18 for lisinopril; and 1.79 for doxazosin. Thiazide-type diuretics should be the preferred first-step therapy for prevention of HF in high-risk patients with hypertension. The Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) Heart Failure Validation Study: diagnosis and prognosis. Einhorn PT, et al. National Heart, Lung, and Blood Institute, Bethesda, MD. . Am Heart J 2007 Jan;153(1):42-53.

Six Compared: Left Ventricular Mass Reduced by Captopril, HCTZ, or Atenolol: Georgetown University Circulation. 1997 Apr 15;95(8):2007-14

Six Anti-Hypertensives Compared in Single Study: In a 1-year DB PC study 1292 men with mild diastolic blood pressures given placebo or one of six drugs: hydrochlorothiazide (12.5 to 50 mg per day), atenolol (25 to 100 mg per day), captopril (25 to 100 mg per day), clonidine (0.2 to 0.6 mg per day), a sustained-release preparation of diltiazem (120 to 360 mg per day), or prazosin (4 to 20 mg per day), diltiazem was successful in lowering DBP below 95 in 59%, atenolol 51%, clonidine 50%, hydrochlorothiazide 46%, captopril 42%, and prazosin 42% vs. placebo 25%. Diltiazem was best for African-Americans: 64%, captopril for younger European-Americans (55%), and atenolol for older European-Americans (68%). Drug intolerance was clonidine (14%) and prazosin (12%) than with the other drugs. Single-drug therapy for hypertension in men. A comparison of six antihypertensive agents with placebo. The Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents. Materson BJ, Reda DJ, et al. Veterans Affairs, Miami, FL. N Engl J Med. 1993 Apr 1;328(13):914-21.

For Lowering High Blood Pressure, the Systolic Lowering is What Counts: In an analysis for trials including 12,903 patients ages 30-49, 14,324 ages 60-79 years, and 1209 very old (over 79), antihypertensive treatment reduced SBP/DBP by 8.3/4.6 mm Hg in young, by 10.7/4.2 mm Hg in old, and by 9.4/3.2 mm Hg in very old, resulting in ratios of DBP to SBP lowering of 0.55, 0.39, and 0.32 (P=0.004 for trend with age). Treatment reduced the risk of all cardiovascular events, stroke and myocardial infarction in the 3 age strata to a similar extent. Absolute benefit increased with age and with lower ratio of DBP to SBP lowering. In patients with a larger-than-median reduction in SBP, active treatment consistently reduced the risk of all outcomes irrespective of the decrease in DBP or the achieved DBP, even if the achieved DBP averaged <70 mm Hg. Systolic and diastolic blood pressure lowering as determinants of cardiovascular outcome. Wang JG, Staessen JA, et al. University of Leuven, Belgium. Hypertension. 2005 May;45(5):907-13. 

Two Low Dose Meds Better than One High Dose for Mild-Moderate HBP: Superior control of blood pressure by combinations of low doses of two drugs compared with monotherapy in regular doses as 1^st line treatment. Can J Cardiol. 2002 Dec;18(12):1317-27

Treatment of Isolated Systolic Hypertension Effective: In 268 patients who participated in the Systolic Hypertension in the Elderly Program (SHEP) DB PC 14-year study with both a placebo group with isolated systolic hypertension and 187 controls who had normal blood pressures. The 14-year death and cardiovascular illness rates among the SHEP participants were 58% for those in the treatment group versus 79% for those in the placebo group (p = 0.001). Those with treatment were 60% worse than normal controls, but elderly without treatment for isolated systolic hypertension were 200% worse than normal controls. Kim Sutton-Tyrrell, University of Pittsburgh, December 8/03 Archives of Internal Medicine 163:2677-2678,2728-2731.

ALLHAT Findings: A diuretic-based regimen, often in conjunction with a beta-blocker, reduces morbidity and mortality. Use of a calcium-channel blocker-based treatment program in the elderly, especially in those with isolated systolic hypertension, reduces morbidity and mortality both in diabetics and nondiabetic patients. Use of ACE inhibitors or angiotensin receptor blockers (ARBs) will decrease cardiovascular endpoints in hypertensive individuals with diabetes and renal disease. Some trials report that the use of a regimen that includes an ACE inhibitor or an ARB may be more effective than calcium-channel blockers in reducing myocardial infarction and the occurrence of heart failure in certain population groups.

ALLHAT: Diuretics Best; Pravastatin Didn’t Help Mild Hypercholesterolemics: Diuretics had slightly fewer episodes of congestive heart failure, heart attacks and strokes than those taking either of two other types of blood pressure medicines -- calcium channel blockers and ACE inhibitors. However, over five years, there was no difference in mortality. Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), started in 1994, was conducted at 623 hospitals and clinics at a cost of about $120 million. With about 42,000 volunteers, it was the largest clinical study of blood pressure treatment ever conducted in the United States.  If blood pressure was not controlled with the first medication, doctors could add a second medicine from categories not included in the study. By the end, about 40 percent in each group was on a second medicine. 10,000 ALLHAT participants with mildly elevated cholesterol, found that the cholesterol-lowering drug pravastatin did not do significantly better in reducing mortality or heart attack rates than a program of "usual care." Volunteers were randomly assigned to get either the drug or usual care, which consisted of dietary advice and whatever other treatment their physicians advised, over five years. The researchers attributed the unexpected result to the fact that cholesterol levels fell significantly in both groups -- about 17% in those assigned to pravastatin, and about 8% in those getting usual care. By the end of the study, it turned out, nearly one-quarter of the usual care patients had been prescribed a "statin," Wash Post 12/18/02

BP Target 120-130 Systolic Best: Data from 1590 hypertensive patients with type 2 diabetes in the Irbesartan Diabetic Nephropathy Trial (IDNT), a randomized, double-blind, placebo-controlled trial performed in 209 clinics worldwide with a 2.6 yr follow-up found that when baseline BP, which averaged 159/87 mmHg, was lower to only SBP >149 mmHg, it was associated with a 2.2-fold increase in the risk for doubling serum creatinine or ESRD compared with SBP <134 mmHg. Progressive lowering of SBP to 120 mmHg was associated with improved renal and patient survival, an effect independent of baseline renal function. Below this threshold, all-cause mortality increased. There was no correlation between diastolic BP and renal outcomes. Independent and additive impact of blood pressure control and angiotensin II receptor blockade on renal outcomes in the irbesartan diabetic nephropathy trial: clinical implications and limitations. Pohl MA, et al. Cleveland Clinic Foundation. . J Am Soc Nephrol 2005 Oct;16(10):3027-37.

BP Target Diastolic 82 Best: In the HOT Study (Hypertension Optimal Treatment), an open, prospective, randomised, international trial with blinded end points including 18,790 patients, ages 50-80 with a primary hypertension (100 < or = PAD < or = 115 mmHg). The patients were randomised in 3 target diastolic blood pressure: < or = 80 mmHg (n = 6,262), < or = 85 mmHg (n = 6,264), < or = 90 mmHg (n = 6,264). The felodipine LP, a long acting dihydropyridine, was selected as a first line therapy, other hypertension drugs combined if necessary. The lowest incidence of cardiovascular events was observed at a diastolic blood pressure level of 82.6 mmHg. There was no increased risk below this level even in the hypertensive patients with medical history of coronary heart disease or stroke. In the diabetic population, the diastolic blood pressure decrease from 90 to 80 reduced the incidence of the major cardiovascular events by 51%. Effect of intensive antihypertensive treatment and of aspirin in a low dose in the hypertensive. The HOT (Hypertension Optimal Treatment) study. Mallion JM, et al. CHU Grenoble. Arch Mal Coeur Vaiss. 1999 Aug;92(8):1073-8.

Beta-Blocker Reduced Endurance, But Clonidine: Endurance time was reduced 35% by atenolol but not by transdermal clonidine or placebo. Neither active drug interfered with the progress of the conditioning program, Comparative effects of transdermal clonidine and oral atenolol on acute exercise performance and response to aerobic conditioning in subjects with hypertension. Arch Intern Med. 1989 Jul;149(7):1551-6

Clonidine's Long-Term Effect in Rats: Long-term clonidine administration decreased the levels of norepinephrine, dopamine, serotonin, GABA and taurine. Japan. Masui 2006 Mar;55(3):330-7.

Alzheimer's Reduced by Hypertension Treatment: In the Longitudinal Population Study in Sweden, the risk of dementia at age 80 is higher in people who had high blood pressure 15 years earlier (Lancet 347:1141, 1996). However, in the Honolulu Aisa study of 1,300 Japanese American men, Alzheimer's risk was 65% lower in those who had been treated for hypertension vs. those whose blood pressures were untreated (Stroke 37:1161, 2006).

Tight BP Control Preserves Vision in Diabetes: A tight BP control policy aiming for a BP less than 150/85 mm Hg was better for preserving eye retina than a less tight BP control policy aiming for a BP less than 180/105 mm Hg. In a study of 1148 type 2 diabetics with HBP and followed for 2.6 years, ACE inhibitors or beta-blockers were used for the 758 tight control patients. By 4.5 years after randomization, there was a highly significant difference in microaneurysm count with 23.3% in the tight BP control group and 33.5% in the less tight BP control group having 5 or more microaneurysms (P = .003). The effect further increased by 7.5 years (RR, 0.66; P<.001). There was no detectable difference in outcome between the 2 randomized therapies of angiotensin-converting enzyme inhibition and beta-blockade. Risks of progression of retinopathy and vision loss related to tight blood pressure control in type 2 diabetes mellitus: UKPDS 69. Matthews DR, Stratton IM, et al; UK Prospective Diabetes Study Group. Oxford Centre for Diabetes, England. Arch Ophthalmol. 2004 Nov;122(11):1631-40

Thomas E. Radecki, M.D., J.D.

modern-psychiatry.com