What is the next step for an African American male with uncontrolled hypertension on lisinopril (Angiotensin-Converting Enzyme Inhibitor) 10 mg and an Atherosclerotic Cardiovascular Disease (ASCVD) risk of 7.5%?

Management of Uncontrolled Hypertension in African American Male on Lisinopril

For an African American male with uncontrolled blood pressure on lisinopril 10 mg and an ASCVD risk of 7.5%, the next step should be adding a thiazide-type diuretic (preferably chlorthalidone 12.5-25 mg daily) or a calcium channel blocker (amlodipine 5-10 mg daily). 1

Rationale for Treatment Selection

Race-Specific Considerations

• The 2017 ACC/AHA hypertension guidelines specifically recommend that in black adults with hypertension, initial antihypertensive treatment should include a thiazide-type diuretic or calcium channel blocker (CCB) 1
• African Americans typically have lower renin levels and respond less effectively to ACE inhibitors like lisinopril when used as monotherapy 1, 2
• In the ALLHAT trial, chlorthalidone (a thiazide-type diuretic) demonstrated greater blood pressure reduction and better stroke prevention in African Americans compared to lisinopril 2
• The current regimen of lisinopril monotherapy is suboptimal for this demographic group

Medication Options

Option 1: Add a Thiazide-Type Diuretic

• Chlorthalidone (12.5-25 mg daily) is preferred over hydrochlorothiazide due to superior outcomes in clinical trials 1, 3
• Benefits:
  • Proven efficacy in reducing cardiovascular events in African Americans
  • Synergistic effect when combined with ACE inhibitors
  • Cost-effective option
  • Longer duration of action than hydrochlorothiazide

Option 2: Add a Calcium Channel Blocker

• Amlodipine (5-10 mg daily) is an appropriate choice 1, 4
• Benefits:
  • Effective blood pressure lowering in African Americans
  • Once-daily dosing improves adherence
  • Minimal metabolic side effects
  • Complementary mechanism to ACE inhibitors

Treatment Algorithm

1. Initial Addition:

   • Add either chlorthalidone 12.5 mg daily OR amlodipine 5 mg daily to current lisinopril 10 mg
   • Consider a single-pill combination to improve adherence if available

2. Follow-up Evaluation:

   • Reassess blood pressure, electrolytes, and renal function within 2-4 weeks 3
   • Target blood pressure should be <130/80 mm Hg 1

3. Dose Titration:

   • If blood pressure remains uncontrolled, increase the dose of the added medication:
     • Chlorthalidone: Increase to 25 mg daily
     • Amlodipine: Increase to 10 mg daily

4. Further Intensification:

   • If blood pressure remains uncontrolled on dual therapy, add the third agent (complete the trio of ACE inhibitor, thiazide-type diuretic, and CCB) 1
   • Consider evaluating for resistant hypertension if triple therapy fails

Monitoring and Follow-up

• Monitor for electrolyte abnormalities, particularly potassium and sodium levels
• Check renal function within 2-4 weeks of medication changes 3
• Aim to achieve target blood pressure within 3 months 3
• Assess medication adherence at each visit
• Consider 24-hour ambulatory blood pressure monitoring if office readings remain elevated despite adequate therapy

Important Considerations

• The patient's ASCVD risk of 7.5% indicates moderate cardiovascular risk, supporting the need for effective blood pressure control
• Two or more antihypertensive medications are often required to achieve target blood pressure in African Americans 1
• Lifestyle modifications should be emphasized alongside pharmacotherapy (sodium restriction, weight management, physical activity)
• If the patient develops adverse effects from lisinopril (such as cough), consider replacing it with an ARB, though this would still require combination with a thiazide-type diuretic or CCB

By implementing this evidence-based approach, blood pressure control should improve, reducing the patient's risk of cardiovascular events, stroke, heart failure, and kidney disease.