What is a reasonable initial antihypertensive medication for an African American female with severe hypertension?

From the Guidelines

For an African American female with severe hypertension, a calcium channel blocker (such as amlodipine 5-10 mg daily) or a thiazide diuretic (such as hydrochlorothiazide 12.5-25 mg daily or chlorthalidone 12.5-25 mg daily) would be a reasonable initial antihypertensive medication. These medications are particularly effective in African American patients due to their physiological characteristics, including higher vascular reactivity and lower renin levels compared to other populations 1.

When treating severe hypertension, combination therapy may be necessary from the start, potentially adding a second agent like an ACE inhibitor (such as lisinopril 10-40 mg daily) or an ARB (such as losartan 50-100 mg daily) 1. Blood pressure should be monitored closely after initiating therapy, with follow-up within 2-4 weeks to assess efficacy and adjust dosing if needed.

Some key points to consider:

• Lifestyle modifications including sodium restriction, weight management, regular physical activity, and limiting alcohol consumption should accompany pharmacological treatment 1.
• If blood pressure remains uncontrolled on two medications, a third agent from a different class may be added, with consideration for specialist referral if hypertension remains resistant to treatment 1.
• The choice of initial antihypertensive medication should be based on the individual patient's characteristics, including comorbid conditions and potential side effects 1.

Overall, the goal of treatment is to reduce blood pressure to a target level, while minimizing adverse effects and improving quality of life 1.

From the FDA Drug Label

Some antihypertensive drugs have smaller blood pressure effects (as monotherapy) in black patients, and many antihypertensive drugs have additional approved indications and effects (e.g., on angina, heart failure, or diabetic kidney disease). These considerations may guide selection of therapy. Amlodipine besylate tablets may be used alone or in combination with other antihypertensive agents.

For an African American female with a systolic pressure of 200, Amlodipine may not be the most effective initial antihypertensive medication due to its potentially smaller blood pressure effects in black patients. However, it can still be considered as part of a comprehensive treatment plan, possibly in combination with other antihypertensive agents. The choice of initial medication should be guided by published guidelines and individual patient factors, such as the presence of other health conditions like diabetes or hyperlipidemia 2.

• Key considerations for selecting an initial antihypertensive medication include the patient's demographic characteristics, such as African American ethnicity, and the presence of other health conditions.
• Treatment goals should be based on published guidelines, such as those of the National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC).
• Combination therapy may be necessary to achieve blood pressure goals, and Amlodipine can be used in combination with other antihypertensive agents.

From the Research

Initial Antihypertensive Medication for African American Females

For an African American female with a systolic pressure of 200, the choice of initial antihypertensive medication is crucial. Considering the severe hypertension, the following options are recommended:

• Thiazide or thiazide-like diuretics, such as hydrochlorothiazide or chlorthalidone, as first-line therapy 3, 4
• Calcium channel blockers, such as amlodipine, as an alternative option 3, 5, 4
• Angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) may also be considered, but ACEIs and ARBs should not be used simultaneously 5

Considerations for African American Population

In the African American population, at least one agent should be a thiazide diuretic or a calcium channel blocker 5. The International Society of Hypertension in Blacks recommends initiating dietary intervention for values of systolic/diastolic arterial blood pressure above 115/75 mmHg and maintaining arterial blood pressure below 135/85 mmHg using appropriate antihypertensive medication 6.

Study Findings

The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) found that thiazide-type diuretics are superior in preventing one or more major forms of cardiovascular disease and are less expensive, making them a preferred choice for first-step antihypertensive therapy 4. Additionally, a study on hypertension stigma among Black women highlighted the importance of addressing psychological factors that may influence adherence to treatment regimens 7.