What are the preferred initial medications for managing Hypertension (HTN) in African Americans according to the latest American College of Cardiology (ACC)/American Heart Association (AHA) guidelines?

Preferred Drugs for Managing Hypertension in African Americans According to Latest ACC/AHA Guidelines

According to the latest ACC/AHA guidelines, thiazide-type diuretics and calcium channel blockers (CCBs) are the preferred initial medications for managing hypertension in African Americans. 1, 2

First-Line Therapy Options

• Thiazide-type diuretics: Recommended as first-line therapy for African American patients with hypertension
• Calcium Channel Blockers (CCBs): Equally recommended as first-line therapy

These recommendations are based on the pathophysiology of hypertension in African Americans, who often have lower renin levels and greater salt sensitivity compared to other populations 2.

Combination Therapy Approach

Most African American patients with hypertension will require combination therapy to achieve adequate blood pressure control:

1. Initial monotherapy: If BP is <15/10 mmHg above target

   • Thiazide-type diuretic OR
   • Calcium channel blocker

2. Initial combination therapy: If BP is ≥15/10 mmHg above target

   • CCB + ARB (preferred combination) OR
   • Thiazide-type diuretic + ARB (especially in edematous or volume overload states) 1, 2

3. Triple therapy: If target BP not achieved with dual therapy

   • ARB + CCB + Thiazide-like diuretic (preferably chlorthalidone 12.5-25 mg daily or indapamide 1.5-2.5 mg daily) 2

4. Quadruple therapy: If triple therapy insufficient

   • Consider adding spironolactone, amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 2

Important Considerations

• ARBs are preferred over ACE inhibitors in African American patients due to lower risk of angioedema 2
• Single-pill combinations improve adherence and are strongly recommended when available 1, 2
• Target BP according to ACC/AHA guidelines is <130/80 mmHg 2
• Avoid simultaneous use of ACE inhibitors and ARBs as this combination is potentially harmful 1
• Monitor serum sodium, potassium, and renal function within 1 month of starting or increasing diuretic dose 2

Special Circumstances

• For African Americans with CKD: Include an ARB or ACE inhibitor in the regimen, particularly if proteinuria is present 1, 2
• For African Americans with diabetes: Thiazide-type diuretics and CCBs are particularly effective and kidney-protective 2
• For African Americans with heart failure or CAD: Beta-blockers may be indicated as part of the regimen 2

Lifestyle Modifications

Alongside pharmacological therapy, the ACC/AHA guidelines emphasize the importance of lifestyle modifications, which are particularly effective in African Americans:

• DASH diet (rich in fruits, vegetables, and low-fat dairy)
• Sodium reduction (<2,300 mg/day)
• Weight loss
• Regular physical activity
• Limited alcohol consumption 2

These non-pharmacological approaches should be implemented in all African American patients with BP ≥115/75 mmHg 2.