When large populations are studied, the people with blood pressures of 110/70 or less have the healthiest arteries—which contributes to healthy hearts, brains, and kidneys. Heart attack prevention doctors such as Bale and Doneen, authors of “Healthy Heart, Healthy Brain,” want their patients’ blood pressures to be less than 120/80 (with the caveat that some frail, elderly people sometimes do better with somewhat higher pressures).

Regular aerobic exercise contributes to lower blood pressure. Diet contributes as well:  A plant-based, unprocessed food diet with no salt, sugar, or added oil lowers blood pressure, partly because it has been proven to be the most effective diet for attaining ideal body weight. Avoiding salt (sodium) is particularly important—intake of 1500 mg. a day or less is ideal.

 However, realistically not everyone is willing to exercise regularly and eat an ideal diet. Furthermore, a small percentage of people on a perfect diet and exercise regimen still have blood pressures above goal—often for genetic reasons. Fortunately for these people, many effective medications are now available, some with few to no side effects.

Sleep apnea is a common cause of high blood pressure, and should be treated if present–all hypertensives should be screened for it with an inexpensive, simple overnight oximetry. It is also important to determine if you are on prescriptions that can cause or contribute to hypertension, such as certain antidepressants; NSAIDS (ibuprofen, naproxen, etc.—but not aspirin); certain birth control pills; cortisone; decongestants; excessive caffeine; and excessive alcohol.

Many patients resist taking blood pressure pills because of the misconception that once you start them you can’t get off of them. Of course if people don’t change their lifestyle their hypertension will persist, but if they do, their hypertension will often resolve and they can stop their blood pressure pills. While you’re waiting for lifestyle changes to kick in, it’s important to control your BP with pills, because every day you have untreated hypertension, arterial damage is occurring.

Following is a brief overview of commonly-prescribed blood pressure medications:

• ACE (angiotensin converting enzyme) inhibitors: These prevent the kidneys of people with hypertension from making too much angiotensin—a hormone that constricts blood vessels, raising blood pressure. ACE inhibitors became available years ago, and as Bale and Doneen say, this class of drugs “show significant reductions in heart attacks, strokes, heart failure, and kidney failure,” and help prevent diabetes. People with chronic kidney disease or diabetes should be on ACEs, regardless of their blood pressures. Rare allergic reactions can occur, and 10 percent of users have a dry hacky cough—annoying but not serious. Lisinopril is most commonly prescribed, but ramipril has the best data for stabilizing arterial plaque.
• ARBs (angiotensin receptor blockers) such as losartan, came out several years after ACEs did. They prevent the constricting action of angiotensin on blood vessels. Side effects, including cough, are very rare. However, the disease-prevention data isn’t as impressive as with ACEs. Bale and Doneen recommend that doctors start hypertensive patients on an ACE inhibitor, and move to an ARB only if they develop a cough.
• Calcium channel blockers such as amlodipine lower blood pressure by causing walls of arteries to relax. Amlodipine in high doses can cause leg swelling but side effects in lower doses are rare.
• Thiazide diuretics decrease excess water and sodium in your body, resulting in lower blood pressure. High doses were used decades ago, often resulting in low potassium, elevated blood sugar, and sexual dysfunction. Low doses used these days such as 12.5 mg. of HCTZ (hydrochlorothiazide) have a low incidence of side effects. Chlorthalidone has better 24-hour coverage than HCTZ, but HCTZ is often used in combination with ACE inhibitors (e.g. lisinopril/HCTZ—2 drugs in one pill) and ARBs to improve effectiveness and to help prevent potassium loss. If blood pressure is over 150, an ACE or ARB alone is unlikely to get it to goal, whereas lisinopril/HCTZ  20/12.5 usually does. If you start a diuretic, sodium and potassium levels should be checked after 2-4 weeks and then every 6 months thereafter.
• Beta blockers: Just because a drug lowers blood pressure doesn’t necessarily mean it prevents heart attacks and strokes, and the beta blocker atenolol is an example of that. Some other beta blockers have been proven to prevent heart attacks and strokes however. Beta blockers block adrenaline, causing your heart to beat slower and less forcefully. Common side effects are tiredness, depression, low exercise tolerance, and worsening of insulin resistance/pre-diabetes. Carvedilol and nebivolol are the only 2 beta-blockers that don’t worsen insulin resistance, and are only ones that should be used in people with diabetes or pre-diabetes. Some experts argue that they are the only beta blockers that should be used to lower blood pressure.

Bottom line: To maintain healthy arteries, and in particular t prevent heart attacks and strokes, your blood pressure should be 120/80 or below. The most effective and certainly safest way to achieve this is to maintain ideal body weight; exercise regularly; avoid salt; and eat plant-based, unprocessed food. If you’re unwilling to do that, don’t hesitate to take blood pressure pills.

Dr. Greg Feinsinger is a retired family physician who started the non-profit Center For Prevention and Treatment of Disease Through Nutrition. For questions or to schedule a free consultation about nutrition or heart attack prevention contact him at gfmd41@gmail.com or 970-379-5718.