What antihypertensive (hypertension) medications should be avoided in the African American population?

From the Guidelines

For African American patients with hypertension, it's generally recommended to avoid or use with caution ACE inhibitors, Angiotensin receptor blockers (ARBs), and Beta-blockers as initial monotherapy, as they have been shown to be less effective in lowering blood pressure and reducing cardiovascular events in this population, as noted in the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline 1. Instead, preferred first-line treatments for African American patients with hypertension are:

• Thiazide diuretics (e.g., hydrochlorothiazide 12.5-25 mg daily)
• Calcium channel blockers (e.g., amlodipine 5-10 mg daily) These recommendations are based on observed differences in treatment efficacy and outcomes in African American patients, with thiazide diuretics and calcium channel blockers demonstrating better blood pressure control and cardiovascular outcomes in this population, as seen in the ALLHAT trial 1. Key points to consider when selecting antihypertensive therapy for African American patients include:
• Individual patient factors, such as comorbidities and response to treatment
• The potential for combination therapy or medications from other classes to achieve optimal blood pressure control
• The importance of addressing common physiological factors in this population, such as salt sensitivity and vascular reactivity It's also important to note that the combination of an ACE inhibitor or ARB with a CCB or thiazide diuretic can produce similar BP lowering in blacks as in other racial or ethnic groups, as stated in the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline 1.

From the Research

Antihypertensive Medications to Avoid in African Americans

There is limited evidence to suggest specific antihypertensive medications that should be avoided in the African American population. However, some studies provide guidance on the preferred treatment options:

• The use of angiotensin-converting enzyme (ACE) inhibitors was previously thought to be less effective in African Americans, but a reinterpretation of clinical trial data suggests that they can be effective in this population, especially at higher doses and with modest reductions in dietary sodium intake 2.
• Beta-adrenoceptor antagonists are not specifically mentioned as a preferred or avoided treatment option in the provided studies, but they are listed as part of a combination therapy (beta-adrenoceptor antagonist/diuretic) in one study 3.
• There is no clear evidence to suggest that any specific antihypertensive medication should be avoided in African Americans, but rather that combination therapy and lifestyle modifications are crucial for effective blood pressure control 4, 5, 3.

Preferred Treatment Options

The preferred treatment options for hypertension in African Americans include:

• Combination therapy with a calcium antagonist/angiotensin-converting enzyme inhibitor or a thiazide diuretic/angiotensin-converting inhibitor 4.
• Thiazide diuretics and calcium-channel blockers as initial drug therapy in most African Americans, and angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in those with chronic kidney disease or heart failure 5.
• Combination antihypertensive agents, such as beta-adrenoceptor antagonist/diuretic, ACE inhibitor/diuretic, ACE inhibitor/calcium channel antagonist, and angiotensin receptor antagonist/diuretic, for individuals with blood pressure above goal levels 3.