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

First-Line Treatment Options for Hypertension in African Americans

For African American patients with hypertension, a thiazide-type diuretic or calcium channel blocker (CCB) should be used as first-line therapy, with a target blood pressure of <130/80 mmHg. 1

Initial Treatment Approach

Mild Hypertension (< 15/10 mmHg above target)

• Start with monotherapy using either:
  • Thiazide-type diuretic (e.g., chlorthalidone) OR
  • Calcium channel blocker (e.g., amlodipine)
• Target blood pressure: <130/80 mmHg 1

Moderate to Severe Hypertension (≥ 15/10 mmHg above target)

• Begin with combination therapy:
  • CCB + ARB OR
  • Thiazide-type diuretic + ARB
• Single-pill combinations are strongly recommended to improve adherence 1
• Most African American patients will require ≥2 antihypertensive medications to achieve adequate control 1, 2

Medication Efficacy in African Americans

African Americans typically show:

• Better response to thiazide diuretics and CCBs as monotherapy
• Less response to ACE inhibitors, ARBs, or beta-blockers when used alone 1, 2

The ALLHAT study demonstrated that chlorthalidone (a thiazide diuretic) was superior to lisinopril (an ACE inhibitor) in preventing stroke and combined cardiovascular disease outcomes in African Americans 3. Additionally, diuretic-based treatment resulted in the lowest risk of heart failure compared to both amlodipine and lisinopril 3.

Special Considerations

For Patients with Comorbidities:

1. Diabetes with nephropathy:

   • Consider adding an ARB (preferably losartan) for patients with elevated serum creatinine and proteinuria 1
   • Thiazide-type diuretics and CCBs are kidney-protective in diabetic African American patients 1

2. Chronic Kidney Disease:

   • Add an ARB (preferred over ACE inhibitors due to lower risk of angioedema in African Americans)
   • Target blood pressure: <140/90 mmHg 1

3. Heart Failure:

   • Include a thiazide diuretic plus beta-blocker in the regimen 1

4. Post-MI or Coronary Heart Disease:

   • Add a beta-blocker to the treatment regimen 1

Lifestyle Modifications

All African American patients with hypertension should receive counseling on:

• DASH diet (particularly effective in African Americans)
• Sodium restriction (<2,300 mg/day) - especially important due to greater salt sensitivity in African Americans
• Regular physical activity
• Weight loss if overweight/obese
• Limited alcohol consumption 1

Monitoring and Follow-up

• Check blood pressure within 2-4 weeks of treatment initiation
• Monitor for side effects
• Check serum sodium, potassium, and renal function within 1 month of starting or increasing diuretic dose
• Aim to achieve target blood pressure within 3 months 1

Common Pitfalls to Avoid

1. Using ACE inhibitors or ARBs as monotherapy without specific indications
2. Inadequate dosing of thiazide diuretics
3. Neglecting lifestyle modifications
4. Failing to recognize the need for early combination therapy
5. Simultaneous use of ACE inhibitors and ARBs (potentially harmful) 1

While some research suggests that RAS inhibitors (ACE inhibitors and ARBs) can improve clinical outcomes in African Americans with hypertension and cardiovascular risk factors 4, the most recent guidelines still recommend thiazide diuretics or CCBs as first-line therapy, with RAS inhibitors added for specific indications or as part of combination therapy.