Ventralink- •Three main drug classes are used first: ACE inhibitors/ARBs, calcium channel blockers, and thiazide diuretics. All are effective and well-studied.
- •Most people need 2+ medications to reach goal. Each drug typically lowers BP by 10-15 mmHg—often not enough alone.
- •Starting with two drugs (often in a single pill) is increasingly standard and gets to goal faster.
- •Resistant hypertension (BP still high on 3 drugs) affects about 10-15% of treated patients. Adding spironolactone often helps.
- •Consistency matters most. Taking medication at the same time daily beats perfect timing with frequent misses.
If lifestyle changes aren't enough—or if your blood pressure is high enough that medication is recommended from the start—you'll encounter drugs from a few well-established classes. This article explains what they do and what to expect.
The Three First-Line Classes
Guidelines recommend starting with one of three main drug classes. All have decades of evidence showing they lower blood pressure and reduce heart attacks, strokes, and death.
💊 ACE Inhibitors & ARBs
These block a hormone system that constricts blood vessels and retains salt. Less constriction = lower pressure.
Common names: lisinopril, losartan, valsartan
Good to know: ACE inhibitors can cause a dry cough in ~10% of people—switching to an ARB usually fixes this. Both protect the kidneys, making them a top choice with diabetes or kidney disease.
💊 Calcium Channel Blockers
These relax blood vessel walls directly. More relaxed vessels = lower resistance = lower pressure.
Common names: amlodipine, nifedipine
Good to know: Amlodipine is one of the most prescribed BP drugs. Ankle swelling is the main side effect (~10%). Works well in older adults and regardless of salt intake.
💊 Thiazide Diuretics
These help the kidneys remove more sodium and water, reducing blood volume and relaxing vessels over time.
Common names: chlorthalidone, hydrochlorothiazide (HCTZ)
Good to know: Old, inexpensive, and highly effective. Increases urination, especially initially. Periodic blood tests check potassium, sodium, and blood sugar.
💡 What About Beta-Blockers?
Beta-blockers (metoprolol, atenolol) are no longer first-line for high blood pressure alone. But they're still used if you have heart failure, have had a heart attack, or have certain heart rhythm problems—in which case they help with BP too.
Why Most People Need More Than One Drug
Each blood pressure medication typically lowers systolic BP by about 10-15 mmHg. That's meaningful—but often not enough to reach goal.
📐 The Math
Starting BP: 160/95 mmHg
Goal: under 130/80 mmHg
Gap to close: 30+ mmHg
One drug (10-15 mmHg) won't get there.
This is why guidelines often recommend starting with two medications for stage 2 hypertension (≥140/90).
Different drug classes also work through different mechanisms—so combining them often works better than doubling the dose of one.
Starting With Two: The Modern Approach
Older guidelines had doctors start with one drug, slowly increase it, then add a second. This took months while elevated pressure continued causing damage.
Current guidelines encourage starting with two drugs for most patients with stage 2 hypertension—often combined in a single pill.
❌ Old Approach
One drug → wait → increase → wait → add second → wait...
Months to goal
✓ Current Approach
Start two drugs together → reach goal faster → adjust as needed
Weeks to goal
Single-pill combinations (like amlodipine + lisinopril) also improve adherence—one pill is easier to remember than two.
When Three Drugs Aren't Enough
About 10-15% of treated patients have "resistant" hypertension: BP stays above goal despite three medications (including a diuretic).
Before assuming true resistance, doctors check for adherence issues (studies find about half of apparent resistant cases involve missed doses), white coat effect (high in office but normal at home), or secondary causes like sleep apnea.
For true resistant hypertension, adding spironolactone as a fourth medication often works—it can lower systolic BP by another 8-10 mmHg by blocking a hormone that promotes salt retention.
Practical Tips
⏰ Timing
Most BP medications can be taken morning or evening. What matters most is consistency—taking it when you'll actually remember beats perfect timing with frequent misses.
⚠️ Don't Stop Suddenly
Talk to your doctor before stopping or changing medications. Stopping some BP drugs abruptly can cause rebound spikes. Tapering is safer.
The Bottom Line
Blood pressure medications are among the most effective drugs in medicine. The three main first-line classes—ACE inhibitors/ARBs, calcium channel blockers, and thiazides—all work well. Most people need two or more to reach goal, and starting combination therapy early is increasingly standard. For resistant cases, spironolactone often helps as a fourth agent. The key is finding a regimen you can take consistently—because medications only work if you take them.