It depends. Blood pressure response to different medications varied considerably between individuals, between treatments and even within patients taking the same treatment at different times.

Many different antihypertensives are available on the market, and it is not always clear which agent might offer the best blood pressure (BP) lowering for a given patient. To deter­mine whether individuals responded better to one antihypertensive mono­therapy versus another, investigators performed a randomised, double­-blind, repeated crossover trial in low­-risk patients with hypertension recruited from an outpatient research clinic in Sweden (NCT02774460; the Precision Hypertension Care Study [PHYSIC]).

A total of 280 patients (mean age, 64 years; 54% men; mean office BP, 154/89 mmHg) were randomised to sequential treatment with four different classes of single, once­-daily, blood pressure­-lowering medications, two of which were repeated to see if BP response changed. The agents were lisinopril 20mg, an ACE inhibitor; candesartan 16 mg, an angiotensin­-receptor blocker; hydrochlorothiazide 25mg, a thiazide diuretic; and amlodipine 10mg, a calcium channel blocker.

The blood pressure response to different medications varied considerably between individuals, between treatments and even within participants taking the same treatment during different periods. In this entirely white European popula­tion, in general, BP was higher when participants were taking hydrochlorothia­ zide than the other treatments, but little difference was seen when patients were taking candesartan versus lisinopril or amlodipine versus hydrochlorothiazide. Personalised treatment had the potential to reduce systolic BP by an additional 4.4mmHg for an individual patient.

Comment: This small, well­designed trial reminds us how variable and individual hypertension is for any given patient. Although some patients may respond better to some classes of medications than others, it is difficult to tell for a given patient which medication they will respond to best. The approach I take is to individualise therapy based on clinical characteristics (such as age and race), lifestyle characteristics (for instance, patients with very high salt intake often need a thiazide diuretic for control) and patient preference.

Karol E. Watson, MD, PhD, FACC, John C. Mazziotta, MD, PhD, Term Endowed Chair and Professor of Medicine/Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, USA.

Sundström J, et al. Heterogeneity in blood pressure response to 4 antihypertensive drugs: a randomized clinical trial. JAMA 2023; 329: 1160-1169.

This summary is taken from the following Journal Watch titles: Cardiology, Ambulatory Medicine, General Medicine.