2 Antihypertensive Medications

Recognizing blood-pressure categories

Under the 2025 U.S. guideline, an average blood pressure of $134/84\ \text{mm Hg}$ falls into Stage 1 hypertension. This category includes systolic pressure from $130$ to $139\ \text{mm Hg}$ or diastolic pressure from $80$ to $89\ \text{mm Hg}$; either range can qualify.

Blood pressure should be measured properly and confirmed as appropriate. A single reading does not establish a diagnosis.

Choosing initial treatment

Commonly recommended first-line options are ACE inhibitors, ARBs, thiazide or thiazide-like diuretics, and long-acting dihydropyridine calcium-channel blockers. For uncomplicated hypertension without a condition favoring a particular class, these are common options.

Beta blockers may be appropriate for specific indications, such as certain cardiac conditions, but are not generally the default choice for uncomplicated hypertension. Medication selection depends on comorbidities, contraindications, and patient preferences, and individual choices require clinical assessment.

Applying treatment thresholds

For adults with average blood pressure of at least $140/90\ \text{mm Hg}$, medication in addition to lifestyle measures is generally recommended. For Stage 2 hypertension, starting two first-line agents from different classes is preferred when appropriate; the agents are often provided in one combination pill.

Treatment decisions should account for the person’s other conditions, pregnancy status, kidney function, potassium level, adverse-effect risks, and preferences.

Using ACE inhibitors and ARBs safely

ACE inhibitors or ARBs may be especially useful for a person with hypertension and chronic kidney disease with albuminuria. Do not combine an ACE inhibitor with an ARB for routine hypertension treatment.

ACE inhibitors can cause persistent dry cough, elevated potassium, changes in kidney function, and dizziness; angioedema is rare. Swelling of the face, lips, tongue, or throat—especially with trouble breathing—requires emergency care.

ACE inhibitors and ARBs can cause fetal harm and are not used during pregnancy. A patient taking either class who has a positive pregnancy test should contact the prescribing clinician promptly so the treatment plan can be reviewed. Medication changes should be guided by the care team.

Monitoring treatment

After an ACE inhibitor is started or its dose is changed, clinicians commonly assess kidney function and serum potassium. These medicines can raise potassium and affect kidney function; monitoring timing and plans depend on the patient’s risk factors and clinical situation.

For thiazide-type diuretics, monitor blood pressure and consider electrolytes and kidney function. Because diuretics can alter fluid balance and electrolytes, follow-up is individualized; ask the prescriber or pharmacist which symptoms and laboratory checks are relevant to the specific drug and patient.

Supporting safe follow-up

When advised, use a validated upper-arm cuff, measure consistently, record readings as instructed, and share them with the care team. Home monitoring can help assess treatment response when it uses a validated device and a consistent technique.

Do not change a dose because of one high reading or stop medication when readings improve without consulting the care team. Take medicines as prescribed and report concerning adverse effects.

Follow-up is important. For adults whose hypertension remains uncontrolled after treatment is started or intensified, the 2025 U.S. guideline recommends monthly evaluation of adherence and response until control is achieved.

• Home blood-pressure monitoring