What lowers the top number, in points
Average drops in the top number (the first number on your reading), from mostly short trials in people with high blood pressure. Your own drop may be bigger or smaller.
Good to know: don’t add the numbers together. They overlap, so combined they add up to less. Doing more than one still helps.
| What you change | Average drop |
|---|---|
| Eat the DASH way (more vegetables, fruit, whole grains) | 5 to 8 points |
| Less salt (sodium) | 6 to 8 points |
| More potassium, from food | about 6 points |
| Lose weight | about 1 point per 2 lb |
| Cardio, 90 to 150 minutes a week | 4 to 8 points |
| Hand grips or wall sits | 5 to 10 points |
| Drink less, if you have 3 or more drinks a day (about 1 point at 3 a day) | up to 4 to 6 points |
| Sleep enough | linked; no clear number |
Sources: 2025 AHA/ACC guideline, lifestyle table, column for people with high blood pressure; Neter 2003; Roerecke 2017; Appel 2003 (PREMIER); Sacks 2001 (DASH-Sodium). My September post used some figures that mixed people with and without high blood pressure (salt 2 to 6, potassium 2 to 5).
How to do each one
Important. If you take blood pressure medicine, these changes go alongside it. They don’t replace it. Don’t stop or lower a medicine on your own. If your numbers come down, or you feel dizzy, tell your doctor. Your doctor decides what changes.
Eat the DASH way
The National Heart, Lung, and Blood Institute’s plan:
- Eat more: vegetables, fruits and whole grains.
- Include: fat-free or low-fat dairy, fish, poultry, beans, nuts and vegetable oils.
- Limit: fatty meats, full-fat dairy, sweets and sugary drinks.
Cut the salt you don’t see
Most salt isn’t from the shaker. About 70% of the sodium Americans eat is added before the food reaches home: restaurant food and packaged food. Check the sodium line on food labels. The goal is under 2,300 mg a day. Under 1,500 mg lowers blood pressure more.
Get potassium from food
Beans, lentils, potatoes, bananas, spinach and yogurt are good sources; so are the DASH foods. Take potassium pills only if your doctor prescribes them. Ask your doctor before you eat a lot more potassium, or use a salt substitute (most are made with potassium), if you have kidney disease or take a medicine that raises potassium. Some blood pressure pills do, such as the “-prils”, the “-sartans” and spironolactone.
Lose a little weight, if you have it to lose
About 1 point for every 2 pounds, in trials where people lost about 10 pounds; less per pound with bigger losses. Losing 5% of your weight is a good first goal: 10 pounds if you weigh 200.
Caution. If your blood pressure is 180/110 or higher, hold off on new exercise and see your doctor first.
Cardio: 90 to 150 minutes a week
Brisk walking, cycling, swimming. Go brisk enough that you can talk in short sentences, but not sing. 90 to 150 minutes a week is about 15 to 20 minutes a day.
Hand grips and wall sits
Hand grip
Squeeze a hand grip at about a third of your hardest squeeze. Hold 2 minutes, rest 1 minute. Do 4 holds, 3 times a week.
Wall sit
Back flat against a wall, knees bent, hold. Do 4 holds of 2 minutes, resting 2 minutes between, 3 times a week. Bend your knees only as far as you can hold for the full 2 minutes, and stop if your knees hurt.
Breathe normally during every hold; don’t hold your breath. The trials behind these are small, so hold the number loosely. They add to cardio; they don’t replace it.
Drink less
If you have more than 2 drinks a day, aim to cut that at least in half. The more you drink now, the bigger the drop. The guideline’s limit: 1 a day for women, 2 for men. For your health overall, it says none is best.
Sleep
Short sleep is linked with higher blood pressure. Aim for 7 to 9 hours a night, the American Heart Association’s goal.
Sources: 2025 AHA/ACC guideline; NHLBI, DASH Eating Plan; Harnack 2017; NIH ODS, Potassium; Neter 2003; Ghadieh and Saab 2015; CDC, activity intensity; Edwards 2023; Wiles 2017; Roerecke 2017; AHA, Life’s Essential 8 (2022).
Your 14-day home check
Pick 2 rows. Measure for 14 days before you start, then for the 14 days you do them. Compare the 2 averages to see whether they’re starting to work.
- Already measured? A recent 14-day home average can be your “before”.
- Give it time: weight and fitness changes keep adding up after 14 days. With 2 at once, you won’t know which one helped, and that’s fine.
- Home to home: compare home readings with home readings, not the office number.
My 2 rows: ______________ and ______________
Before average: ______ / ______ After average: ______ / ______
How to measure
- Cuff: a validated automatic cuff that goes on your upper arm, in your arm’s size. Not a wrist cuff. Check yours at validatebp.org.
- Before: no caffeine, exercise or smoking for 30 minutes, and empty your bladder. Sit quietly for at least 5 minutes, back supported, feet flat, legs uncrossed.
- Arm: cuff on a bare arm, resting on a table, upper arm at heart level.
- During: don’t talk or text.
- Readings: take 2 readings, 1 minute apart, every morning before medicines and every evening before supper.
- At the end: average all the top numbers, then all the bottom numbers.
- Very high? If a reading is 180/120 or higher, rest a minute and check again. Still that high? Call your doctor. With chest pain, shortness of breath, weakness, or a change in vision or speech, call 911.
Guidelines ask for at least 3 days of readings and prefer 7 or more. 14 days is my protocol: it gives a steadier average.
Sources: Muntner, Hypertension 2019 (AHA); 2025 AHA/ACC guideline; AMA, US Validated Device Listing.
My 14-day log
| Day (write both readings in each box) | Before, morning | Before, evening | After, morning | After, evening |
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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 9. 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.