High blood pressure is one of the most common health conditions worldwide and a leading cause of heart attacks, strokes, and early death. Many people live with high blood pressure for years without noticeable symptoms, which is why it is often called a “silent killer.”
Because of its serious long-term risks, doctors usually begin treatment as soon as high blood pressure is diagnosed, often with medication.
There are several types of drugs available to lower blood pressure, and doctors typically choose from five main groups. These include thiazide diuretics, ACE inhibitors, angiotensin II receptor blockers, and two types of calcium channel blockers.
For years, ACE inhibitors have been one of the most commonly prescribed first treatments. They are familiar to doctors, widely used, and recommended in many guidelines.
However, a large new study from Columbia University suggests that ACE inhibitors may not be the best option to start with for many patients. The research found that another older and less frequently prescribed drug type, thiazide diuretics, may work better and cause fewer side effects.
Choosing the right first medication for high blood pressure is not always easy. Clinical guidelines often rely on expert opinion rather than direct comparisons between drugs. This is because large head-to-head studies are expensive and difficult to conduct.
As a result, doctors may continue prescribing medications based on habit, training, or tradition rather than strong evidence.
To address this gap, researchers led by George Hripcsak examined health records and insurance claims from nearly five million people who were starting blood pressure treatment for the first time. These patients came from a wide range of backgrounds, making the results more relevant to real-world medical care.
The researchers found that almost half of the patients, about 48 percent, were prescribed ACE inhibitors as their first treatment. In contrast, only 17 percent started with thiazide diuretics. This difference stood out, especially given what the researchers discovered next.
Patients who began treatment with thiazide diuretics had better overall outcomes. They experienced about a 15 percent lower risk of major heart-related events compared to those who started with ACE inhibitors. These serious events included heart attacks, strokes, and heart failure. Even a reduction of this size can have a major impact when millions of people are affected.
The study also looked closely at side effects, which are an important part of any long-term treatment. ACE inhibitors were linked to a higher rate of problems. Patients taking these drugs experienced more side effects across 19 different categories.
Some of the most common issues included a persistent dry cough and dangerously high potassium levels, both of which can lead patients to stop taking the medication.
In contrast, people who took thiazide diuretics generally reported fewer side effects. This made the drug easier to tolerate over time, which is important because blood pressure medication is usually taken for life. When patients feel better on a medication, they are more likely to take it consistently, improving long-term outcomes.
The researchers also estimated the potential impact of changing prescribing habits. They calculated that if all patients who were initially given ACE inhibitors had instead started with thiazide diuretics, more than 3,100 major heart-related events might have been prevented. This finding highlights how powerful medication choices can be on a population level.
Thiazide diuretics are not new drugs. They have been used for decades and are relatively inexpensive. They work by helping the body remove excess salt and water, which reduces pressure inside blood vessels. Despite their long history, they have often been overlooked in favor of newer medications.
The study, published in The Lancet, does not suggest that ACE inhibitors should never be used. These drugs can still be very helpful for certain patients, especially those with specific medical conditions. However, the findings strongly suggest that thiazide diuretics may be a better first option for many people starting blood pressure treatment.
This research offers clearer guidance for doctors and highlights the importance of using real-world data to guide treatment decisions. By choosing medications that are both effective and well tolerated, doctors can reduce the risk of heart disease and improve patients’ quality of life.
For patients, the study is a reminder that it is reasonable to ask questions about treatment options. Blood pressure control is a long-term commitment, and starting with the right medication can make a meaningful difference. As more research like this emerges, treatment guidelines may continue to evolve toward safer and more effective care.
If you care about high blood pressure, please read studies about unhealthy habits that may increase high blood pressure risk, and drinking green tea could help lower blood pressure.
For more information about high blood pressure, please see recent studies about what to eat or to avoid for high blood pressure, and 12 foods that lower blood pressure.
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