Medications for hypertension

Choices regarding drug therapy for hypertension should aim not only to decrease blood pressure levels but also to reduce cardiovascular risk in general. Among the aspects to be considered is also age because, while treatment of grade 1 hypertension has been shown to reduce cardiovascular risk, in a young person this risk at ten years is absolutely low. For grade 2 or 3 hypertension, treatment is always recommended, not only for the benefit of lowering blood pressure but also for the prevention of the damage it can cause to various organs and tissues. The time indicated by the Guidelines for achieving the systolic and diastolic blood pressure values that have been established as goals is 3 months. In the elderly, an initial level of decrease in systolic blood pressure should be established below 140 mmHg and for diastolic below 80 mmHg. Recommendations for a hypertension treatment protocol are summarized in Figure 1, starting with the first approach and continuing with subsequent steps.

Initial two-drug therapy: according to the Guidelines, this should be the usual approach for all cases of hypertension, except those in which the blood pressure value is very close to the recommended values, which can also be addressed with a single molecule.

Products available: five major classes of antihypertensive drugs have demonstrated benefits in reducing the risk of cardiovascular events:

  • Ace inhibitors
  • Angiotensin receptor blockers
  • Beta-blockers
  • Calcium antagonists
  • Thiazide or thiazide-like diuretics
  • For the choice of drugs to be used at the different levels of approach, reference can be made to Figure 1, in which it is also specified that beta-blockers should be used when there is associated pathology, such as angina, previous myocardial infarction, arrhythmia, or heart failure with reduced ejection fraction, which makes them preferable. In addition, beta-blockers may be considered as an alternative to ace inhibitor or angiotensin receptor blockers in fertile women.

Treatment-resistant hypertension: this is defined as a case of hypertension in which the goal of reducing blood pressure values is not achieved despite the administration of three or more medications, including a diuretic. Each should be taken at the optimal or maximum tolerated dose. The frequency of resistant hypertension is estimated to be less than 10 percent, and spironolactone is the most effective drug, in addition to the other therapies already used, to achieve better control. Its possible side effects should be taken into account when using this molecule. When spironolactone is not tolerated, possible alternatives are amiloride, beta-blockers, alpha-blockers, or CNS-active drugs such as clonidine.

See also in the section Hypertension

  • The causes and mechanisms of hypertension
  • How hypertension is diagnosed
  • Lifestyle changes for people with hypertension


M Volpe and S Sciarretta. Chapter 45 Hypertension. In: Handbook of Cardiovascular Diseases of the Italian Society of Cardiology.
PK Whelton 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. Hypertension. 2018;71:1269-1324.
LJ Visseren et al. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. European Heart Journal 2021;00, 1-111.

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