Antihypertensive medications: relative effectiveness and adverse reactions

Thiazide diuretics may be more effective as antihypertensive agents in many subsets of patients than other medications, especially in reducing systolic blood pressure. Angiotensin converting enzyme (ACE) inhibitors and beta-blockers are less effective than calcium blockers or diuretics in black hypertensives and beta-blockers may be less effective in the elderly. Calcium blockers are equally effective in blacks, whites and the elderly but may not be as efficacious as diuretics. When used as initial monotherapy, most available antihypertensive drugs produce significant adverse subjective effects in about 8-10% of patients; centrally acting drugs, however, may produce annoying side effects in 20-30% of patients. Usually, some medication can be found that lowers blood pressure and is acceptable to the patient. Adverse metabolic effects are probably of limited long-term clinical significance except in a few patients. An approach to therapy that will prove effective in a majority of patients is outlined. Any one of the four classes of agents may appropriately be used as initial monotherapy (diuretics, beta-blockers, ACE inhibitors, calcium blockers). Diuretics are recommended as the second drug of choice if one of the other agents is used first. With this approach approximately 80% or more of patients can be controlled at normotensive levels on one or at most two drugs.