The Best Blood Pressure Medications To Take and Avoid, According to a Top Cardiologist

Nearly half of U.S. adults struggle with high blood pressure—no wonder there’s a seeming sea of medications claiming to lower it. But what are the benefits and pitfalls of each, and how might you decide which one is right for you? We asked a leading cardiologist to weigh in on the most common blood pressure medications and share her thoughts and advice. It turns out one option may be a better bet than the rest, according to new research, and there’s one antihypertensive medication you may want to avoid.

The 4 major types of blood pressure medications explained

To give you the lay of the land, there are four “families” of blood pressure medications: angiotensin II receptor blockers (ARBs), angiotensin-converting enzyme inhibitors (ACE inhibitors), calcium channel blockers (CCBs) and thiazide or thiazide-like diuretics (TDIs). Here, a brief breakdown of how each of these drugs works, including their pros and cons:

ARBs

These medications work by blocking the action of angiotensin II, a hormone that normally tightens blood vessels. By preventing that hormone from attaching to its receptors, ARBs help blood vessels relax, lowering blood pressure, explains preventive cardiologist Elizabeth Klodas, MD.

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Generally speaking, ARBs are very well tolerated, though they may be slightly less effective than ACE inhibitors at lowering blood pressure, she adds.

ACE inhibitors

This class of drugs also works by curbing angiotensin, but it goes about it differently, says Dr. Klodas. “While ARBs block the hormone from attaching to its receptors, ACE inhibitors work by reducing the production of angiotensin’s active form, which is made in the lungs.”

“ACE inhibitors are also usually well tolerated, but about 20 percent of people develop a dry cough, which goes away once the medication is stopped,” she adds.

CCBs

“Calcium channel blockers do what they say they do—they block calcium from entering the smooth muscle cells that comprise artery walls,” Dr. Klodas explains, adding that this is important because calcium causes those cells to constrict, increasing blood pressure.

One downside of CCBs is that they can cause ankle swelling, she notes. “This is reversible, but not a great tradeoff for keeping blood pressure low. Some CCBs can also cause constipation.”

TDIs

These medications lower blood pressure by encouraging fluid and sodium loss through the urine, Dr. Klodas says. “Less fluid flowing through arteries means less pressure on artery walls, and therefore a reduction in blood pressure.”

However, this can lead to abnormal electrolyte levels and increased thirst, she adds. “It’s usually not just sodium that’s lost—potassium can be depleted as well, which isn’t ideal. Because potassium plays a role in insulin secretion, these medications have been shown to worsen blood sugar control.”

On the plus side, she says TDIs help the body retain calcium, which may benefit patients who are prone to osteoporosis.

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Why ARBs are the top choice for long-term heart health

So, which class of blood pressure medications is best? The answer depends in part on your individual profile and risk factors. That said, a new study in eClinicalMedicine shows that patients starting on ARBs are more likely to stick with the treatment long-term—ultimately leading to better outcomes.

That may very well come down to the drugs’ safety profile. “ARBs are often used as drugs of first choice for people with high blood pressure because they have such a favorable side effect profile: no swelling, no negative energy impacts, no increased need to go to the bathroom, no potassium loss,” explains Dr. Klodas.

“Rarely people can be allergic to these medications and can develop lip swelling, but this is truly rare,” she adds. “The main side effect is them not working! Not everyone responds to every drug.”

The common blood pressure drug you may want to avoid

“I’m not a big fan of beta blockers,” declares Dr. Klodas. “Drugs like metoprolol, atenolol—anything that ends with an ‘lol.’” These medications are effective blood pressure-lowering drugs, but they also slow down heart rates and can have a calming effect.”

She adds that slowing down the heart rate can be very advantageous if you experience heart palpitations, and a calming effect can be beneficial if you tend toward anxiety—but for most people, these effects are truly unpleasant.

“People report reduced exercise tolerance, fatigue and sometimes even depression,” she reveals. “Not everyone experiences these impacts, but they occur often enough that I typically reserve these medications more as a distant fourth choice. That is, unless someone would benefit from the calming effects or lower heart rate. Then it becomes my first choice, as I can address two problems with one drug.”

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Expert tips to boost the efficacy of your BP prescription

No matter which drug you’re on to treat high blood pressure, all medications work best when supported by healthy lifestyle choices. Here, Dr. Klodas shares a few steps that can significantly improve blood pressure control:

• Regular exercise
• Weight loss, if needed
• Quitting smoking (Discover simple ways to kick the habit)
• Reducing caffeine and alcohol intake

While all of the above steps are crucial, Dr. Klodas highlights two more key ways to lower blood pressure:

Try for more sleep

This is one change that can make a huge difference when it comes to lowering blood pressure, she promises.

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“If you snore or find yourself typically tired or dozing off during the day, you should be checked for sleep apnea,” she advises. “This is a very common condition and a big contributor to elevated blood pressure readings. It is also so treatable! I’ve seen patients stop needing blood-pressure lowering drugs once their sleep apnea was addressed.”

Reduce your sodium intake

This is an especially pervasive contributor to elevated blood pressure readings, Dr. Klodas notes. “Sodium is everywhere and in almost everything, making it nearly impossible to avoid, unless you cook everything from scratch.

“But if you decrease sodium intake while increasing your intake of fruits and vegetables—which often happens simultaneously, since we only have so much room in our stomachs—you can see the same blood pressure–lowering effect as a drug.”