A few weeks ago I reported on aggressive treatment of high blood pressure of patients who also had diabetes and/or a past history of a stroke, with results from the ESPRIT trial. Now we have results from ALLHAT, the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (JAMA Netw Open, Dec 4, 2023;6(12):e2344998). ALLHAT followed 32,804 people who were treated for high blood pressure, average age 66.9 years, for up to 23.9 years.
The rate of suffering from and dying from heart attacks was the same for those who took:
• calcium channel blockers (amlodipine)
• angiotensin-converting enzyme inhibitors called ACE inhibitors (lisinopril)
• thiazide-type diuretics (chlorthalidone)
Those who took ACE inhibitors had an 11 percent increased risk for fatal and non-fatal strokes, compared to those taking diuretics. Those who took amlodipine (a calcium channel blocker) had an insignificant minimal higher rate of heart failure. However, the differences were so small that all three of these medications offer close to the same protection and side effects. A group taking alpha-blockers (doxazosin) was removed early from the study because they were associated with a much higher rate of heart attacks.
Summary of Drugs to Lower Blood Pressure and Their Side Effects
There are more than 15 different classes of drugs that are used to help lower high blood pressure, and your doctor will work with you to decide which ones are best for you. The most commonly used medications include diuretics, Calcium Channel Blockers (CCBs), Angiotensin Receptor Blockers (ARBs) or Angiotensin Converter Enzyme inhibitors (ACE inhibitors), and Beta Blockers.
• Diuretics: Diuretics lower blood pressure mainly by causing the kidneys to excrete excess sodium and water, to reduce blood volume. Examples include thiazides such as chlorthalidone, hydrochlorothiazide, and indapamide. Side effects can include potassium deficiency. Diuretics are often recommended for people with osteoporosis because they help the kidneys to retain calcium and not lose so much calcium from bones. Diuretics can cause muscle cramps and weakness, gout, and reversible erectile dysfunction.
• Angiotensin-converting enzyme (ACE) inhibitors block angiotensin II, a hormone that constricts blood vessels to raise blood pressure. ACE inhibitors include benazepril, captopril, enalapril, fosinopril, lisinopril, moexipril, perindopril, quinapril, ramipril, and trandolapril. Potential side effects include swelling of the ankles, lips or throat, a dry cough, dry mouth, nausea, rash, muscle pain, and high blood potassium.
• Angiotensin receptor blockers (ARB) widen blood vessels to reduce high blood pressure. They include azilsartan, candesartan, irbesartan, losartan, olmesartan, telmisartan, and valsartan. Potential side effects include headache, nausea, dry mouth, abdominal pain, or sudden swelling in the body.
• Calcium channel blockers (CCB) widen blood vessels to lower high blood pressure. Potential side effects include slow heart rate, constipation, headache, flushing, nausea, overgrowth of the gums, swelling of legs, headache and nausea.
• Beta blockers (BB) lower high blood pressure by lowering rate and force of heart contractions. They include acebutolol, atenolol, betaxolol, bisoprolol, metoprolol, nadolol, nebivolol, pindolol, propranolol, timolol, labetalol and carvedilol. Potential side effects include shortness of breath, particularly in peole with asthma. They slow heart rate, so they should not be given to people with peripheral artery disease. They mask low blood sugar, so they usually are not given to people with diabetes. They also can cause fatigue, insomnia, nightmares, decreased exercise tolerance, rashes, and cold hands and feet due to reduced blood flow.
Lifestyle Changes to Lower Blood Pressure
The primary treatment for high blood pressure should be lifestyle changes, whether or not you are taking any of the blood pressure drugs. Everyone can help to prevent and control high blood pressure by:
• Eating a plant-based diet that is heavy in fruits, vegetables, whole grains, beans, nuts and other seeds. Restrict mammal meat and processed meats, sugar-added foods and drinks, and fried foods.
• Making sure that you are not using extra salt. Limit use of a salt shaker and restrict processed foods because they often have added salt and sugar.
• Exercising. Try to do aerobic and resistance exercise for at least 30 minutes daily. If you have heart-attack risk factors, check with your doctor.
• Trying to get 7-8 hours of sleep every night.
• Trying to avoid habits and exposure to everything that increases cell damage such a smoke, alcohol, recreational drugs, herbicides, insecticides, air pollution, and so forth.
My Recommendations
I recommend buying a blood pressure cuff (arm, not wrist) and take your own blood pressure. You can buy one at your drugstore or on Amazon or ebay for about $25. If it repeatedly shows that your blood pressure is above 120/80, check with your doctor. You and your doctor together will decide whether you need to take medication. Meanwhile, you may be able to control your blood pressure by following the lifestyle guidelines.
Dr. Gabe Mirkin is a Villager. Learn more at www.drmirkin.com
