What is a suitable first-line antihypertensive medication for a 75-year-old African-American patient with hypertension?

First-Line Antihypertensive Medication for 75-Year-Old African-American

For a 75-year-old African-American patient with hypertension, a calcium channel blocker (CCB) such as amlodipine is the recommended first-line antihypertensive medication. 1

Rationale for Recommendation

Race-Specific Considerations

• The 2020 International Society of Hypertension (ISH) guidelines specifically recommend different first-line agents based on race, with Black patients benefiting most from:

  • Calcium channel blockers (CCBs)
  • Thiazide/thiazide-like diuretics 1

• These recommendations are supported by evidence showing that in Black patients:

  • CCBs and thiazide diuretics are more effective in lowering BP than RAS inhibitors (ACEIs/ARBs) or beta-blockers
  • CCBs and thiazide diuretics are more effective in reducing cardiovascular disease events than RAS inhibitors or alpha-blockers 1

Age-Specific Considerations

• For elderly patients (75 years old):
  • Treatment should aim for a target BP of <140/90 mmHg 2
  • Medication should be initiated at a lower dose and titrated more gradually to avoid adverse effects 1
  • CCBs like amlodipine have demonstrated good efficacy and safety in elderly hypertensive patients 3

Treatment Algorithm

Step 1: Initial Monotherapy

• Start with amlodipine 2.5 mg daily (lower starting dose for elderly)
• Amlodipine has demonstrated:
  • Significant BP reduction in African Americans 4, 5
  • Good tolerability in elderly patients 3
  • Once-daily dosing for better adherence 6

Step 2: Dose Titration

• After 2-4 weeks, if BP remains ≥140/90 mmHg:
  • Increase to amlodipine 5 mg daily
  • Allow 2-4 weeks to assess full effect 1

Step 3: Combination Therapy (if needed)

• If BP control is inadequate with maximum amlodipine dose:
  • Add a thiazide/thiazide-like diuretic 1
  • Consider single-pill combinations to improve adherence 7

Evidence Supporting CCBs in African Americans

• Clinical trials have consistently shown that CCBs like amlodipine are particularly effective in African American patients:
  • Comparable efficacy to other dihydropyridine CCBs with good tolerability 4
  • Significant reductions in both systolic and diastolic BP in African Americans 5
  • Strong evidence for cardiovascular event reduction 8

Potential Adverse Effects and Monitoring

• Common adverse effects of amlodipine:

  • Peripheral edema (10-15%)
  • Headache (5-10%)
  • Dizziness (3-5%) 5

• Monitoring recommendations:

  • Assess BP control within 2-4 weeks of initiation
  • Monitor for orthostatic hypotension, especially in elderly patients
  • Target BP should be achieved within 3 months 1

Cautions and Considerations

• Starting with a lower dose (2.5 mg) in elderly patients reduces the risk of adverse effects
• Avoid rapid dose escalation in elderly patients
• Monitor for orthostatic hypotension which can increase fall risk
• Consider simplified regimen (once-daily dosing) to improve adherence 2

In summary, based on the most recent guidelines, a calcium channel blocker like amlodipine represents the optimal first-line choice for a 75-year-old African-American patient with hypertension, balancing efficacy, safety, and tolerability considerations specific to both age and race.