Four Drug Classes for High Blood Pressure and How to Choose

Full analysis

Peter Attia outlines four first-line drug categories for primary hypertension: thiazide diuretics (which remove excess fluid), calcium channel blockers, ACE inhibitors (angiotensin-converting enzyme inhibitors, which relax blood vessels by blocking a hormone that causes tightening), and ARBs (angiotensin II receptor blockers, which work similarly but on a slightly different target). Each class typically lowers systolic pressure by 12–15 mmHg and diastolic by 9–11 mmHg; he notes that beta blockers are no longer considered first-line. His internal review found ARBs comparable or slightly superior to ACE inhibitors in both efficacy and side effects, but ACE inhibitors are older and often cheaper, and insurance may favor them. Specific cautions: calcium channel blockers should be avoided in people with heart failure or reduced ejection fraction (reduced pumping strength); ACE inhibitors and ARBs should be avoided in pregnancy or with a history of severe allergic throat swelling; thiazide diuretics may worsen gout, high triglycerides, or insulin resistance; and in people of African American heritage, thiazide diuretics or calcium channel blockers appear more effective at reducing cardiovascular events than ACE inhibitors or ARBs.