The 4 usual first picks
Safety first. Don’t stop or change any blood pressure medicine on your own. Some, like clonidine, can make your pressure jump if they’re stopped suddenly. Beta blockers such as atenolol also carry a warning against stopping suddenly. Bring this guide and your bottles to your doctor or pharmacist instead.
For most people with plain high blood pressure, the 2025 US blood pressure guideline starts with 1 of 4 groups of medicine. For many people, it recommends starting with 2 of them combined in one pill.
The 4 usual first picks
Check the generic name on your label; brand names don’t follow these patterns.
| Group | How to spot it |
|---|---|
| Thiazide-type water pill | One of these 3 names: chlorthalidone, hydrochlorothiazide, indapamide. Hydrochlorothiazide is often shortened to HCTZ. Not every water pill is this kind. |
| ACE inhibitor | Generic name ends in “-pril”. Examples: lisinopril, enalapril, ramipril. |
| ARB | Generic name ends in “-sartan”. Examples: losartan, valsartan, olmesartan. |
| Long-acting calcium channel blocker | Generic name ends in “-dipine”. Examples: amlodipine, long-acting nifedipine. Amlodipine lasts all day on its own. Long-acting nifedipine usually says ER, XL or CC. Not sure? Ask your pharmacist. |
Not on this table doesn’t mean wrong. Plenty of people need a different medicine, or an extra one, for a good reason. This is about where most people start.
Sources: Jones et al., 2025 AHA/ACC high blood pressure guideline, Hypertension 2025 (§5.2.3, §5.2.4, Table 13).
5 blood pressure medicines I wouldn’t start with
These are my picks, not an official ranking. Most of them are the right medicine for somebody.
Before you read: don’t stop or change any of these on your own. If you’re on one as an add-on, or for a reason other than starting treatment for high blood pressure, that can be exactly how it’s meant to be used. This page is about which pill to start with.
1. Taking a “-pril” and a “-sartan” at the same time (an ACE inhibitor plus an ARB)
Why I wouldn’t start with it: Big trials in high-risk adults found no extra protection, and more kidney problems and high potassium. Guidelines say not to take these 2 together.
Who it can be right for: Taking just one of them is fine; each is a first pick on page 3. Being on 2 or 3 blood pressure medicines is normal. This is one specific pair.
2. Short-acting nifedipine (immediate-release capsule)
Why I wouldn’t start with it: Its label says it isn’t meant for everyday high blood pressure.
Who it can be right for: Doctors use it in the hospital for severe high blood pressure in pregnancy. The long-acting version is a first pick. Not sure which one you have? Ask your pharmacist.
3. Clonidine
Why I wouldn’t start with it: Guidelines keep it as a later choice, mainly for side effects like drowsiness, dry mouth and dizziness, especially in older adults. Never stop it suddenly.
Who it can be right for: A later choice, after other medicines.
4. Hydralazine
Why I wouldn’t start with it: On its own it can make your heart race and your body hold on to salt and water, so it’s usually paired with a water pill and a beta blocker. Usually taken 2 to 4 times a day.
Who it can be right for: An add-on when other medicines haven’t been enough; some kinds of heart failure, paired with a nitrate; in the hospital in pregnancy.
5. Atenolol
Why I wouldn’t start with it: Beta blockers aren’t a first pick for plain high blood pressure. In a trial of people with a thickened heart muscle, losartan prevented more strokes than atenolol. In another, plans built on amlodipine prevented more strokes than plans built on atenolol. Never stop it suddenly.
Who it can be right for: Beta blockers can be right for people who also have heart disease, including a past heart attack. In heart failure, doctors usually pick a different beta blocker. Ask which reason applies to you.
My suggestion: if one of your medicines is on this page, it doesn’t mean it’s wrong for you. Don’t stop or change it on your own. Bring the bottle and ask why you’re on it.
Sources: 2025 AHA/ACC guideline (Table 13; §5.2.4); Yusuf et al., NEJM 2008 (ONTARGET); Fried et al., NEJM 2013 (VA NEPHRON-D); nifedipine immediate-release capsule label; clonidine label; hydralazine label; Dahlöf et al., Lancet 2002 (LIFE); Dahlöf et al., Lancet 2005 (ASCOT-BPLA).
My medicines
Write down every medicine you take, including anything you buy without a prescription. Better yet, bring the bottles.
| Medicine name | Dose | Times a day | Year I started | Why I take it |
|---|---|---|---|---|
This page is for you and your care team. Please don’t post it or send it to me; I can’t review personal medicine lists.
Questions to bring
Ask about each blood pressure medicine:
- Why am I on this one, and is it still the best choice for me?
- Is this the short-acting or the long-acting version?
- Am I taking an ACE inhibitor and an ARB at the same time?
- How many times a day is this one meant to be taken, and what should I do if I miss a dose?
- Could any of my pills be combined into one?
- Could any of my other medicines, prescription or over the counter, be pushing my numbers up?
Good to know: some blood pressure medicines can make your pressure jump if they’re stopped suddenly. Ask before you stop or change any of them.
Sources: 2025 AHA/ACC guideline (Table 13, §5.2.3, §5.2.4); see the earlier pages.