What is the recommended initial treatment with Angiotensin-Converting Enzyme (ACE) inhibitors or Angiotensin Receptor Blockers (ARBs) for African American patients with hypertension?

From the Guidelines

For African American patients with hypertension, the initial treatment should prioritize calcium channel blockers or thiazide diuretics over ACE inhibitors or ARBs as monotherapy, due to their more effective blood pressure lowering and cardiovascular risk reduction in this population. This recommendation is based on the most recent and highest quality evidence from the 2020 International Society of Hypertension Global Hypertension Practice Guidelines 1. The guidelines suggest that first-line pharmacological therapy for African American patients should be a single pill combination including a thiazide-like diuretic plus a calcium channel blocker (CCB) or CCB plus an angiotensin receptor blocker (ARB) 1.

Key considerations for treatment include:

• The higher prevalence of low-renin, volume-dependent hypertension in African Americans, which may contribute to a less robust response to ACE inhibitors and ARBs when used alone 1.
• The importance of lifestyle modifications, including salt restriction, increased intake of vegetables and fruits, weight management, and reducing alcohol intake, as part of a comprehensive treatment plan 1.
• The potential for increased risk of angioedema with ACE inhibitors in African American patients, making ARBs a preferred choice among RAS-inhibitors in this population 1.

In cases where African American patients have certain comorbidities like diabetes, chronic kidney disease, or heart failure with reduced ejection fraction, ACE inhibitors or ARBs are still valuable components of combination therapy, typically combined with either a calcium channel blocker or a thiazide diuretic to achieve better blood pressure control 1. However, the initial approach should focus on the most effective and recommended first-line treatments for this specific patient group.

From the Research

Recommended Initial Treatment for African American Patients with Hypertension

The recommended initial treatment for African American patients with hypertension involves the use of Angiotensin-Converting Enzyme (ACE) inhibitors or Angiotensin Receptor Blockers (ARBs) as part of the treatment regimen. However, the choice of initial therapy may depend on various factors, including the patient's blood pressure level, presence of kidney disease, and other comorbidities.

Key Considerations

• The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) found that diuretics, such as chlorthalidone, were associated with greater reductions in blood pressure and a lower risk of stroke compared to ACE inhibitors, such as lisinopril, in African American patients 2.
• The African American Study of Kidney Disease and Hypertension found that ACE inhibitors, such as ramipril, were effective in reducing the progression of kidney disease in African American patients with hypertensive kidney disease 3.
• The Losartan Intervention For Endpoint reduction in hypertension (LIFE) study found that African American patients with left ventricular hypertrophy treated with atenolol had a lower risk of experiencing the primary composite endpoint (death, myocardial infarction, and stroke) compared to those treated with losartan, an ARB 2.
• A study published in the Journal of the American Medical Association (JAMA) found that diuretic-based treatment resulted in the lowest risk of heart failure in both black and nonblack hypertensive patients 4.

Combination Therapy

• Combination therapy with ACE inhibitors or ARBs and diuretics may be effective in achieving blood pressure control in African American patients 5.
• The use of combination therapy may be particularly beneficial in patients with more severe hypertension or those who are at high risk for cardiovascular events.

Important Findings

• ACE inhibitors can effectively lower blood pressure in African American patients, particularly when used at higher doses and in combination with modest reductions in dietary sodium intake 6.
• The choice of initial therapy should be individualized based on the patient's specific needs and medical history.
• Further research is needed to determine the optimal treatment strategy for African American patients with hypertension.