What is the initial treatment approach for hypertension (HTN) in African American males?

Initial Hypertension Treatment for African American Males

For African American males with hypertension, initial antihypertensive treatment should include a thiazide-type diuretic or calcium channel blocker (CCB) as first-line therapy. 1, 2

First-Line Medication Options

Preferred First-Line Agents:

• Thiazide-type diuretics:

  • Chlorthalidone (12.5-25 mg daily) - preferred for optimal endpoint protection 2
  • Hydrochlorothiazide (25-50 mg daily) - alternative option 2

• Calcium Channel Blockers (CCBs):

  • Amlodipine - as effective as chlorthalidone for BP reduction and more effective than ACE inhibitors in African Americans 2

Treatment Algorithm

1. For mild hypertension (less than 15/10 mmHg above target):

   • Start with either a thiazide-type diuretic or CCB as monotherapy
   • Target BP: <130/80 mmHg 1, 2

2. For moderate to severe hypertension (≥15/10 mmHg above target):

   • Begin with combination therapy including either:
     • CCB + ARB
     • Thiazide-type diuretic + ARB 2, 3
   • Single-pill combinations are strongly recommended when available to improve adherence 2

3. Most African American patients will require ≥2 antihypertensive medications to achieve adequate blood pressure control 1, 2

Special Considerations

For African American patients with comorbidities:

• Chronic Kidney Disease (CKD):

  • Add an ARB (preferred over ACE inhibitor due to lower risk of angioedema in African Americans) 2
  • Target BP: <140/90 mmHg 2

• Diabetes with nephropathy:

  • Consider losartan for treatment of diabetic nephropathy with elevated serum creatinine and proteinuria 4
  • Both thiazide-type diuretics and CCBs are kidney protective in diabetic African American males 2

• Heart Failure:

  • Include a thiazide diuretic plus beta-blocker in the regimen 2

• Post-MI or Coronary Heart Disease:

  • Add a beta-blocker to the treatment regimen 2

Important Clinical Considerations

• African Americans have higher prevalence of hypertension and lower control rates compared to other racial groups 1, 5
• African Americans typically show less response to monotherapy with ACE inhibitors, ARBs, or beta-blockers 6, 7
• The DASH diet and sodium restriction are particularly effective in African Americans, who often have greater salt sensitivity 2
• Monitor for side effects and check blood pressure within 2-4 weeks of treatment initiation 2
• Check serum sodium, potassium, and renal function within 1 month of starting or increasing diuretic dose 2

Common Pitfalls to Avoid

• Using ACE inhibitors or ARBs as monotherapy in African American patients without specific indications (like CKD with proteinuria) 2
• Inadequate dosing of thiazide diuretics 2
• Neglecting lifestyle modifications, which are particularly effective in African Americans 2
• Failing to recognize the need for combination therapy early in treatment 2, 5
• Simultaneous use of ACE inhibitors and ARBs, which is potentially harmful 2

Recent evidence suggests that a race-agnostic therapeutic algorithm with adequate intensity can achieve high control rates with minimal racial disparity, especially when coupled with greater emphasis on diet/lifestyle modifications for Black patients 5.