What is the recommended initial therapy for hypertension (HTN) in black people?

Initial Hypertension Therapy for Black People

In black adults with hypertension but without heart failure or chronic kidney disease, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic or calcium channel blocker (CCB). 1, 2

First-Line Medication Recommendations

Preferred Initial Agents:

• Thiazide-type diuretics:
  • Chlorthalidone (12.5-25.0 mg once daily) - preferred over conventional thiazides 2
  • Indapamide (1.5 mg modified-release or 2.5 mg daily) - alternative to chlorthalidone 2
• Calcium Channel Blockers (CCBs):
  • Particularly effective in black patients due to their pathophysiology of hypertension 1, 2

Medication Selection Algorithm:

1. Start with either:
   • Thiazide-type diuretic OR
   • Calcium channel blocker
2. If BP remains above target:
   • Add the other first-line agent (CCB if started with diuretic, or diuretic if started with CCB)
3. If still not at target:
   • Consider adding an ARB (preferred over ACE inhibitor due to lower risk of angioedema) 2

Treatment Targets and Considerations

Blood Pressure Targets:

• Target BP of less than 130/80 mm Hg for most black adults with hypertension 1, 2
• Two or more antihypertensive medications are often required to achieve this target 1

Monitoring:

• Check serum sodium, potassium, and renal function within 1 month of starting or increasing diuretic dose 2
• Monitor for electrolyte imbalances, particularly with thiazide diuretics

Special Considerations

Comorbidities:

• With Diabetes: Thiazide-type diuretic or CCB remains first-line 1, 2
• With Proteinuria: Consider adding an ACE inhibitor or ARB (with ARB preferred in black patients) 2
• With Heart Failure or CKD: Different recommendations apply (not covered in this response)

Lifestyle Modifications:

• DASH Diet (Dietary Approaches to Stop Hypertension) is particularly effective in black patients 2
• Sodium reduction is especially important due to greater salt sensitivity 2
• Weight loss, increased physical activity, and alcohol restriction are also recommended 2

Evidence Strength and Rationale

The recommendation for thiazide-type diuretics or CCBs as initial therapy is supported by strong evidence from multiple guidelines and studies. The 2017 ACC/AHA guideline gives this recommendation a Class I, Level B-R rating 1, indicating strong evidence from randomized controlled trials.

Black patients typically have lower-renin hypertension, which responds better to these medication classes than to ACE inhibitors or ARBs when used as monotherapy. The ALLHAT study demonstrated that chlorthalidone (a thiazide-type diuretic) was more effective than lisinopril (an ACE inhibitor) in preventing stroke and combined cardiovascular disease outcomes in black patients 3.

Common Pitfalls to Avoid

• Pitfall #1: Using ACE inhibitors or ARBs as monotherapy in black patients

  • These are less effective as single agents in this population 1, 2

• Pitfall #2: Failing to intensify therapy when BP remains above target

  • Most black patients will require multiple agents to reach BP goals 1, 2

• Pitfall #3: Overlooking the importance of lifestyle modifications

  • The DASH diet and sodium restriction are particularly effective in black patients 2

• Pitfall #4: Not monitoring for electrolyte abnormalities with diuretic therapy

  • Regular monitoring of potassium and renal function is essential 2