What is a better blood pressure (BP) medication choice for African Americans with hypertension?

Optimal Blood Pressure Medication Choice for African Americans

For African Americans with hypertension, a thiazide diuretic or calcium channel blocker (CCB) should be the first-line medication choice due to superior efficacy in this population compared to other antihypertensive classes. 1, 2

First-Line Treatment Options for African Americans

Preferred Medications:

• Thiazide-type diuretics (chlorthalidone, hydrochlorothiazide)
• Calcium channel blockers (amlodipine)

These recommendations are based on strong evidence showing that:

1. African Americans have greater BP-lowering response to these medication classes 1, 2
2. These medications demonstrate better cardiovascular outcomes in this population 3
3. Thiazide diuretics and CCBs are more effective in reducing cardiovascular disease events in African Americans than renin-angiotensin system (RAS) inhibitors or beta-blockers 1

Treatment Algorithm

Initial Therapy:

• For Stage 1 hypertension (130-139/80-89 mmHg): Start with either a thiazide diuretic or CCB as monotherapy
• For Stage 2 hypertension (≥140/90 mmHg): Begin with combination therapy using a thiazide diuretic plus CCB 1, 2

Combination Therapy:

Most African American patients will require ≥2 antihypertensive medications to achieve adequate BP control 1, 4. When adding a second agent:

• Preferred combination: Thiazide diuretic + CCB
• Alternative combination: Add an ARB (preferred over ACE inhibitor) if indicated for comorbidities

Special Clinical Scenarios

African Americans with Chronic Kidney Disease (CKD):

• Add an ARB (preferred) or ACE inhibitor to the regimen 1, 2
• ARBs are preferred over ACE inhibitors due to lower risk of angioedema in African Americans 2

African Americans with Heart Failure:

• Include a thiazide diuretic plus beta-blocker in the treatment regimen 1, 2

African Americans with Diabetes:

• For diabetic nephropathy: ARB or ACE inhibitor is recommended
• Without nephropathy: Thiazide diuretic or CCB remains first-line 1

Important Considerations

Efficacy Differences:

• ACE inhibitors, ARBs, and beta-blockers are less effective as monotherapy in African Americans 5, 4
• The ALLHAT trial showed that chlorthalidone (thiazide diuretic) was more effective than lisinopril (ACE inhibitor) in preventing stroke and combined cardiovascular disease outcomes in African Americans 3

Safety Considerations:

• African Americans have a greater risk of angioedema with ACE inhibitors 1
• ARBs have a lower risk of angioedema compared to ACE inhibitors 2
• ACE inhibitors are contraindicated during pregnancy 6

Dosing:

• Thiazide diuretics should be administered at 12.5-25 mg/day for chlorthalidone or 25-50 mg/day for hydrochlorothiazide for optimal efficacy 1

Treatment Goals

• Target BP <130/80 mmHg for most patients 2, 7
• Aim to achieve target BP within 3 months of initiating therapy 2

Monitoring

• Check serum electrolytes and renal function within 1 month of starting therapy, especially with diuretics 2
• Monitor BP within 2-4 weeks of medication initiation or adjustment 2

By following this evidence-based approach, clinicians can optimize hypertension management in African American patients and reduce the disproportionate burden of hypertension-related complications in this population.