What is the aim of treatment?
Your doctor or practice nurse will advise on the target blood pressure level to aim for. It can vary from person to person. In general:
- For most people aged under 80 years, the usual target is to reduce blood pressure to 140/90 mm Hg or below in the surgery or clinic, or below 135/85 mm Hg when measured at home. For older patients the target may be set slightly higher (less than 150/90 mm Hg in the surgery or clinic, or below 145/85 mm Hg when measured at home).
- In some people, the target is to get it below 130/80 mm Hg. For example, if you have a cardiovascular disease such as a stroke or heart disease, if you have certain kidney diseases, and for some people with diabetes.
Which medicines are used to lower blood pressure?
There are five main classes of medicines that are used to lower blood pressure. There are various types and brands of medicine in each class. The following gives a brief overview of each of the classes. However, for detailed information about your own medication you should read the leaflet that comes inside the medicines packet.
Angiotensin-converting enzyme (ACE) inhibitors
These medicines work by reducing the amount of a chemical that you make in your bloodstream, called angiotensin II. This chemical tends to constrict (narrow) blood vessels. Therefore, less of this chemical causes the blood vessels to relax and widen, and so the pressure of blood within the blood vessels is reduced.
There are various types and brands of ACE inhibitors. For example, captopril, cilazapril, enalapril, fosinopril, lisinopril, perindopril, quinapril, ramipril, and trandolapril. An ACE inhibitor is particularly useful if you also have heart failure or diabetes. ACE inhibitors should not be taken by people with certain types of kidney problems, people with some types of artery problems, and if you are pregnant. You will need a blood test before starting an ACE inhibitor to check that your kidneys are working well. The blood test is repeated within two weeks after starting the medicine, and within two weeks after any increase in dose. Then, a yearly blood test is usual.
Angiotensin receptor blockers
These medicines are sometimes called angiotensin-II receptor antagonists. There are various types and brands. For example, candesartan, eprosartan, irbesartan, losartan, olmesartan, telmisartan and valsartan. They work by blocking the effect of angiotensin II on the blood vessel walls. So, they have a similar effect to ACE inhibitors (described above).
These medicines affect the way calcium is used in the blood vessels and heart muscle. This has a relaxing effect on the blood vessels. Again, there are various types and brands. For example, amlodipine, diltiazem, felodipine, isradipine, lacidipine, lercanidipine, nicardipine, nifedipine, nisoldipine, and verapamil. Calcium-channel blockers can also be used to treat angina.
Diuretics (water tablets)
Diuretics work by increasing the amount of salt and fluid that you pass out in your urine. This has some effect on reducing the fluid in the circulation, which reduces blood pressure. They may also have a relaxing effect on the blood vessels, which reduces the pressure within the blood vessels. The most commonly used diuretics to treat high blood pressure in the UK are thiazides or thiazide-like diuretics. Examples are bendroflumethiazide, chlorothiazide, chlortalidone, cyclopenthiazide, hydrochlorothiazide and indapamide. Only a low dose of a diuretic is needed to treat high blood pressure. Therefore, you will not notice much diuretic effect (that is, you will not pass much extra urine). You will need a blood test before starting a diuretic, to check that your kidneys are working well. You should also have a blood test within 4-6 weeks of starting treatment with a diuretic, to check that your blood potassium has not been affected. Then, a yearly blood test is usual.
Again, there are various types and brands. For example, acebutolol, atenolol, bisoprolol, metoprolol, oxprenolol, pindolol, propranolol, sotalol, and timolol. They work by slowing the heart rate, and reducing the force of the heart. These actions lower the blood pressure. Beta-blockers are also commonly used to treat angina, and some other conditions. You should not normally take a beta-blocker if you have asthma, chronic obstructive pulmonary disease (COPD), or certain types of heart or blood vessel problems.
What about side-effects?
All medicines have possible side-effects, and no medicine is without risk. However, most people who take medicines to lower blood pressure do not develop any side-effects, or only have mild side-effects. A full list of cautions and possible side-effects is listed on the leaflet inside the medicine packet. The most common ones are:
- ACE inhibitors – sometimes cause an irritating cough.
- Angiotensin receptor blockers – sometimes cause dizziness.
- Calcium-channel blockers – sometimes cause dizziness, facial flushing, swollen ankles, and constipation.
- Diuretics – can cause gout attacks in a small number of users, or can make gout worse if you already have gout. Impotence develops in some users.
- Beta-blockers – can cause cool hands and feet, poor sleep, tiredness, and impotence in some users.
If you do develop a side-effect, a different medicine may suit you better. There is a lot of choice so one can usually be found to suit. See your doctor if you develop any problem which you think is due to your medication.
Other medicines for high blood pressure
Apart from the five main classes of medicines listed above, sometimes other medicines are used to lower blood pressure. For example, methyldopa or alpha-blockers are sometimes used if there are problems with the more commonly used medicines.
Combinations of medicines
One medicine can reduce high blood pressure to the target level in less than half of cases. It is common to need two or more different medicines to reduce high blood pressure to a target level. In about a third of cases, three medicines or more are needed to get blood pressure to the target level. So, for example, you may need an ACE inhibitor plus a calcium-channel blocker (and sometimes also another medicine) to control your blood pressure. This is just an example, and various combinations of medicines can be used.
In some cases, despite treatment, the target level is not reached. However, although to reach a target level is ideal, you will gain benefit from any reduction of high blood pressure.
So, which is the best medicine or combination of medicines?
The one or ones chosen may depend on such things as: if you have other medical problems; your ethnic origin; if you take other medication; possible side-effects; your age; etc.
For example: beta-blockers and calcium-channel blockers can also treat angina; ACE inhibitors also treat heart failure; some medicines are not suitable if you are pregnant; some are thought to be better if you have diabetes; some tend to work better than others in people of Afro-Caribbean origin; etc.
If you do not have any other medical problems that warrant a particular medicine, then current UK guidelines give the following recommendations as to usual medicines that should be used. These recommendations are based on treatments and combinations of treatments that are likely to give the best control of the blood pressure with the least risk of side-effects or problems.
Treatment is guided by the A/C, A+C, A+C+D approach as follows:
- If you are less than 55 years old and are not of black African or Caribbean origin then initial treatment should be with ‘A’ (an ACE inhibitor, or an angiotensin receptor blocker if an ACE inhibitor causes problems or side-effects).
- If you are 55 years or older, or are of black African or Caribbean origin then initial treatment should be with ‘C’ (a calcium-channel blocker).
- Then, if the target blood pressure is not reached, combine ‘A’ with ‘C’ (an ACE inhibitor or an angiotensin receptor blocker plus a calcium-channel blocker).
- Then, if target blood pressure is still not reached, combine ‘A’ with ‘C’ and ‘D’ (an ACE inhibitor or an angiotensin receptor blocker, and a calcium-channel blocker, and a diuretic).
- If a fourth medicine is needed to achieve the target blood pressure, consider adding of one of the following:
- A beta-blocker
- Another diuretic
- An alpha-blocker
However, individuals can vary. Sometimes, if one medicine does not work so well or causes side-effects, a switch to a different class of medicine may work fine.
How long is medication for high blood pressure needed for?
In most cases, medication is needed for life. However, in some people whose blood pressure has been well-controlled for three years or more, medication may be able to be stopped. In particular, in people who have made significant changes to lifestyle which can affect blood pressure (such as lost a lot of weight, or stopped heavy drinking, etc). Your doctor can advise. If you stop medication, you need regular blood pressure checks. In some cases, the blood pressure remains normal. However, in others it starts to rise again. Medication can then be started again.
Further help and information
Blood Pressure Association
60 Cranmer Terrace, London, SW17 0QS
Tel: 020 8772 4994
References and Disclaimer | Provide feedback
- Hypertension: management of hypertension in adults in primary care, NICE Clinical Guideline (August 2011)
- Turnbull F, Neal B, Ninomiya T, et al; Effects of different regimens to lower blood pressure on major cardiovascular events in older and younger adults: meta-analysis of randomised trials. BMJ. 2008 May 17;336(7653):1121-3. Epub 2008 May 14. [abstract]
- Staessen JA, Richart T, Verdecchia P; Reducing blood pressure in people of different ages. BMJ. 2008 May 17;336(7653):1080-1. Epub 2008 May 14.
- Nelson MR, Reid CM, Krum H, et al; Predictors of normotension on withdrawal of antihypertensive drugs in elderly patients: prospective study in second Australian national blood pressure study cohort. BMJ. 2002 Oct 12;325(7368):815. [abstract]
- Aylett M, Creighton P, Jachuck S, et al; Stopping drug treatment of hypertension: experience in 18 British general practices. Br J Gen Pract. 1999 Dec;49(449):977-80. [abstract]