Answer Common Questions About First-Line BP Meds

Questions continue to pop up about choosing BP meds for initial treatment of uncomplicated hypertension.

We’re used to selecting an ACEI or ARB, calcium channel blocker (CCB), or thiazide first...CV benefits seem similar overall.

But be ready with answers to common questions about nuances.

Is an ACEI preferred over an ARB? Not necessarily. Overall data suggest that ARBs reduce CV risk on par with ACEIs.

But ARBs cause fewer adverse effects, such as cough or angioedema, than ACEIs. And both have low-cost generics.

Choose an ARB over an ACEI if starting one of these.

Generally prescribe a long-acting ARB, such as telmisartan or olmesartan. This may reduce BP swings...or help with adherence. Keep in mind, losartan is the shortest-acting ARB...and often requires bid dosing.

But don’t switch from an ACEI to an ARB for a patient who’s on an optimized regimen with an ACEI and is tolerating it well.

Is there a “go-to” CCB? Yes, generally rely on amlodipine.

It’s the longest-acting dihydropyridine...causes less tachycardia...and has more data for improving CV outcomes in hypertension.

Keep in mind, peripheral edema is common with dihydropyridines.

But don’t jump to a diuretic for CCB-induced edema...it’s due to fluid “leaking” out of blood vessels, not sodium or water retention.

In this case, try reducing the CCB dose. Or consider adding an ACEI or ARB if more BP lowering is needed...this might counteract edema.

Is there a “best” thiazide? No, there’s not a clear winner.

Chlorthalidone is preferred in some BP guidelines because it shows CV benefit in key hypertension studies. And data suggest that indapamide reduces CV risk versus placebo in patients age 80 and up.

This MIGHT be because chlorthalidone or indapamide lasts longer, and lowers BP slightly more, than hydrochlorothiazide.

But recent data don’t find benefit with chlorthalidone over hydrochlorothiazide...and suggest chlorthalidone causes more hypokalemia.

And some experts believe ANY thiazide will have CV benefits as long as it controls BP...especially in combo with other BP meds.

Evaluate what’s practical. For many patients, consider hydrochlorothiazide. It comes in many combos, if more than 1 BP med is needed...and costs slightly less than chlorthalidone or indapamide.

Use our resource, Treatment of Hypertension, for help with educating about lifestyle changes, tailoring BP goals, and more.

Key References

  • Chen R, Suchard MA, Krumholz HM, et al. Comparative First-Line Effectiveness and Safety of ACE (Angiotensin-Converting Enzyme) Inhibitors and Angiotensin Receptor Blockers: A Multinational Cohort Study. Hypertension. 2021 Sep;78(3):591-603.
  • Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018 Jun;71(6):1269-1324.
  • Ishani A, Cushman WC, Leatherman SM, et al. Diuretic Comparison Project Writing Group. Chlorthalidone vs. Hydrochlorothiazide for Hypertension-Cardiovascular Events. N Engl J Med. 2022 Dec 29;387(26):2401-2410.
Prescriber Insights. December 2023, No. 391205



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