Blood Pressure
Elizabeth Briand
Despite the myriad medications currently available to lower BP, millions of Americans still live with uncontrolled hypertension. A study published in the August 2025 issue of The Lancet analyzed antihypertensive medications from five major drug classes to obtain estimates of their expected BP-lowering effect, classifying their efficacy into low, moderate, and high intensity levels.
“Our goal was simple: to give clinicians a practical, evidence-based way to choose the right blood pressure lowering regimen upfront, based on how much blood pressure needs to come down,” said the study’s lead author Nelson Wang, MD, an academic cardiologist at Brigham and Women’s Hospital in Boston.
The team also developed a calculator to help clinicians and pharmacists estimate the mean expected reduction in BP for any permutation of antihypertensive medications and doses, according to baseline BP.
“High blood pressure is the leading modifiable risk factor for death and disability,” said Wang. “Our current approach to the treatment of blood pressure has been to titrate the treatment using repeated blood pressure measurements before and after treatment.”
The study supports the idea that rather than using the highly variable results of one patient’s BP readings over time, the better method of measuring the efficacy of a particular medication is to analyze the collective readings from thousands of patients gathered over time and incorporating placebo-controlled trials.
Calculating effectiveness
Wang and his colleagues conducted a systematic review and meta-analysis of 484 randomized, double-blind, placebo-controlled trials involving more than 104,000 adult participants. These individuals were randomly assigned to receive ACEs, ARBs, b-blockers, calcium channel blockers, or diuretics.
These trials reported the drug-specific and dose-specific short-term BP reduction for the antihypertensive drugs and various combinations. Drug regimens were categorized into low, moderate, and high intensity according to systolic BP-lowering efficacies ranging from less than 10 mm Hg to greater than 20 mm Hg.
From the start
The BP reduction data could be of vital importance, as the study noted, given that “each mm Hg reduction in systolic BP confers an approximately 2% reduction in the risk of major cardiovascular events. Thus, a therapy with increased efficacy of only a few mm Hg in comparison with an alternative would still be expected to confer clinically important additional reductions in cardiovascular events.”
Prescribing medications based on the reduction needed for a patient to achieve a healthy BP would allow physicians to treat hypertension the way other chronic diseases are treated. For example, the study cites the fact that lipid-lowering regimens for dyslipidemia are already categorized according to expected LDL cholesterol reductions.
“Clinicians can now be intentional with which treatment regimens they want to use to treat high blood pressure,” said Wang.
In addition, this information can be used to fine-tune decision making in the future.
“Researchers and policymakers will also be able to use this tool to quantify the efficacy of blood pressure lowering treatments,” Wang said. “For example, we can quantify how effective or ineffective the prescribed treatment regimens are, according to geographical location, health care system, or across different patient populations.”
The study also unearthed an unexpected finding regarding the dosing of antihypertensive medications. Wang and his colleagues found that “there is little additional blood pressure lowering reduction with escalating the dose of a drug. Instead, there is much more additional blood pressure lowering by adding a second or third drug class.”
With these vetted measurements and calculations now available, Wang hopes that the results of the study “will help shift the treatment paradigm for hypertension, away from the ‘trial-and-error, start low go slow’ approach, and move towards an evidence-informed prescribing approach, where clinicians choose the desired treatment regimen upfront.” ■