Drugs used for blood pressure reduction

For uncomplicated elevated blood pressure (BP) (ie elevated BP without other comorbidities) in nonpregnant adults, clinical trial data suggest that suitable first-line drugs are:

• angiotensin converting enzyme inhibitors (ACEIs)
• angiotensin II receptor blockers (ARBs)
• dihydropyridine calcium channel blockers
• thiazide and thiazide-like diuretics.

Overall, first-line drug classes have similar efficacy in reducing BP. It is uncertain whether any differences in outcomes among drug classes in clinical trials are due to the small differences in BP achieved or to non–BP-related drug effects.

The choice of first-line drug is influenced by individual patient factors such as comorbidities, and the potential adverse effects of the drug; for example:

• an ACEI or ARB is indicated in patients with heart failure with reduced ejection fraction (HFrEF) or chronic kidney disease, and after myocardial infarction
• a dihydropyridine calcium channel blocker is useful in patients with stable angina.

Second-line drug therapies to reduce BP are potassium-sparing diuretics, beta blockers, alpha blockers, nondihydropyridine calcium channel blockers, centrally acting alpha-2 agonists and direct-acting vasodilators. The choice of second-line drug depends on both drug and individual patient factors. There is some evidence that spironolactone is more effective than beta blockers and alpha blockers when added to maximum doses of 3 BP-lowering drugsWilliams, 2015.

Beta blockers are no longer recommended as first-line therapy in patients with uncomplicated elevated BP because they are less effective than the first-line drugs in reducing the risk of stroke. However, they have a clear place in the management of patients with heart failure with reduced ejection fraction (HFrEF) and patients with coronary artery disease.