What is the first-line treatment for hypertension in African Americans?

First-Line Blood Pressure Treatment for African Americans

For African Americans with hypertension, first-line treatment should be either a thiazide-type diuretic (preferably chlorthalidone at 12.5-25 mg/day) or a calcium channel blocker (CCB) such as amlodipine. 1

Rationale for First-Line Therapy Recommendations

Evidence-Based Recommendations

• The American College of Cardiology/American Heart Association (ACC/AHA) guidelines specifically recommend thiazide-type diuretics or CCBs as initial antihypertensive therapy for Black adults with hypertension 2
• Chlorthalidone is the preferred thiazide diuretic due to its longer half-life and more robust cardiovascular disease (CVD) risk reduction data compared to hydrochlorothiazide 2, 1
• Amlodipine has been shown to be as effective as chlorthalidone for reducing blood pressure and cardiovascular events in African Americans 1, 3

Physiological Considerations

• African Americans tend to have lower renin levels and are more salt-sensitive, making diuretics particularly effective
• CCBs are also highly effective in this population due to their mechanism of action that is less dependent on renin-angiotensin system activity

Treatment Algorithm

Step 1: Initial Monotherapy for Stage 1 Hypertension

• For BP 130-139/80-89 mmHg with target <130/80 mmHg:
  • Start with either chlorthalidone 12.5 mg daily OR amlodipine 5 mg daily
  • For patients with heart failure risk: Prefer chlorthalidone over CCBs 1

Step 2: Combination Therapy for Stage 2 Hypertension

• For BP ≥140/90 mmHg or >20/10 mmHg above target:
  • Initiate with two first-line agents, preferably as a fixed-dose combination 2, 1
  • Recommended combinations:
    • Thiazide diuretic + CCB
    • If comorbidities like proteinuria or diabetes exist: Add ACE inhibitor or ARB

Special Considerations

Comorbid Conditions

• Heart Failure: Prioritize thiazide diuretics over CCBs due to lower risk of heart failure with diuretics 1, 3
• Chronic Kidney Disease with Proteinuria: Add an ACE inhibitor or ARB to the regimen (not as monotherapy) 1
• Diabetes: Thiazide diuretic + CCB combination is particularly effective 1

Important Cautions

• ACE inhibitors or ARBs as monotherapy are less effective in African Americans 1
• African Americans have a 3x higher risk of angioedema with ACE inhibitors; ARBs may be preferred when renin-angiotensin system blockade is needed 1
• Beta-blockers are not recommended as first-line therapy unless specific indications exist (e.g., coronary artery disease, heart failure) 2

Blood Pressure Targets

• Target BP for most African Americans with hypertension: <130/80 mmHg 2, 1
• Most patients will require at least two medications to achieve target BP 1, 4

Common Pitfalls to Avoid

1. Underdosing thiazide diuretics: Use adequate doses (chlorthalidone 12.5-25 mg/day) 1
2. Starting with ACE inhibitors/ARBs as monotherapy: Less effective in African Americans when used alone 1
3. Failing to intensify therapy: Most patients need multiple agents to reach target BP 1, 4
4. Simultaneous use of ACE inhibitors and ARBs: Not recommended and potentially harmful 1
5. Inadequate follow-up: If BP remains above goal after 4-8 weeks, increase to maximum doses or add a third agent 1

The ALLHAT trial, one of the largest hypertension trials that included a significant number of African American participants, demonstrated that thiazide diuretics were at least as effective as—and in some cases superior to—other antihypertensive medications in preventing cardiovascular outcomes in this population 3.