Before starting medications in non-emergency situations, people with concerns about their blood pressure should first, buy a good quality blood pressure cuff (an oscillometric monitor for $50 to $100) and use it to monitor their blood pressure at home.1 I suggest they then record the values several times a week and take these numbers to their private doctor for further discussion.
A sustained elevation of blood pressure to 160/100 mmHg or greater over months suggests the need for treatment with medication.2 A word of caution: If you do start blood pressure-lowering medications, avoid overly aggressive treatment. In general, reducing blood pressure below 140/90 mmHg with medication is not beneficial and actually will increase the risk of heart attacks, strokes, and death.3,4 A recent review by the well-respected Cochrane Collaboration concluded with: “Treating patients to lower than standard BP targets, ≤140-160/90-100 mmHg, does not reduce mortality or morbidity.”5
Chlorthalidone Is the Drug of Choice
Chlorthalidone is an oral diuretic (a water pill taken by mouth) with a prolonged action of 48 to 72 hours and low toxicity. Diuretics lower blood pressure by reducing fluid volume, which decreases the output of the heart causing the blood pressure to fall. Doctors and patients often believe that all diuretics have similar benefits. This is not the case, and chlorthalidone is the preferred kind of diuretic for most patients.6,7 In 1990, the Multiple Risk Factor Intervention Trial (MRFIT) reported a reduction in nonfatal cardiovascular events when the diuretic treatment was changed to replace hydrochlorothiazide (HCTZ) with chlorthalidone in men at high risk for coronary heart disease.8 Chlorthalidone is also more effective at lowering systolic blood pressure (the top number) than HCTZ. The starting dosage used was 12.5 to 25 mg daily; but the dosage can be increased to 50 to 100 mg daily. All patients receiving chlorthalidone should be checked after one month for evidence of fluid or electrolyte imbalance: namely, low sodium, low chloride, and low potassium (by blood tests). Other periodic laboratory tests should be performed to look for adverse effects from this potent diuretic. For example, blood levels of cholesterol, triglycerides and uric acid can be increased by this medication. Chlorthalidone is inexpensive; a 30-day supply is $4 and a 90-day supply is $10 for 25 or 50 mg tablets at Walmart.
Why I No Longer Routinely Prescribe Beta-blockers
For many years beta-blockers were considered one of the first line therapies for the treatment of hypertension. Current evidence suggests that beta-blockers (like Atenolol) should not be prescribed unless there is some other reason for their use (like atrial fibrillation, heart failure, or myocardial infarction).9 A recent Cochrane Collaboration concluded: “The available evidence does not support the use of beta-blockers as first-line drugs in the treatment of hypertension. This conclusion is based on the relatively weak effect of beta-blockers to reduce stroke and the absence of an effect on coronary heart disease when compared to placebo or no treatment.”10
Examples of commonly prescribed beta-blockers are: acebutolol (Sectral), atenolol (Tenormin), betaxolol (Kerlone), betaxolol (Betoptic, Betoptic S), bisoprolol fumarate (Zebeta), carteolol (Cartrol), carvedilol (Coreg), esmolol (Brevibloc), labetalol (Trandate, Normodyne), metoprolol (Lopressor, Toprol XL), nadolol (Corgard), nebivolol (Bystolic), penbutolol (Levatol), pindolol (Visken), propranolol (Inderal, InnoPran), sotalol (Betapace), and timolol (Blocadren).
I Never Prescribe Calcium Channel Blockers
Calcium channel blockers are also called “calcium antagonists” and “calcium blockers.” They may decrease the heart’s pumping strength and relax the blood vessels, and are commonly used to treat high blood pressure, angina (chest pain), and some arrhythmias (abnormal heart rhythms). However, they increase the risk of dying from heart disease and cancer (especially breast cancer), and the risk of developing open-angle glaucoma, suicide, and bleeding.11-17
Examples of commonly prescribed calcium channel blockers are: amlodipine (Norvasc), clevidipine (Cleviprex), diltiazem (Cardizem), felodipine (Plendil), isradipine (Dynacirc), nifedipine (Adalat, Procardia), nicardipine (Cardene), nimodipine (Nimotop), nisoldipine (Sular), and verapamil (Calan, Isoptin).
I Never Prescribe Angiotensin Receptor Blockers (ARBs)
Angiotensin is a hormone found in the body that causes blood vessels to constrict, resulting in higher blood pressure and extra work on the heart. Angiotensin receptor blockers (ARBs), also called angiotensin II receptor antagonists, prevent angiotensin from binding to its receptor in the walls of the blood vessels.