What is the recommended initial antihypertensive therapy for African Americans with hypertension?

Initial Antihypertensive Therapy for African Americans with Hypertension

In black adults with hypertension but without heart failure or chronic kidney disease, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic or calcium channel blocker (CCB). 1

First-Line Therapy Recommendations

• Thiazide-type diuretics or CCBs are more effective in lowering blood pressure in African Americans than renin-angiotensin system (RAS) inhibitors (ACE inhibitors, ARBs) or beta blockers 1
• These agents are also more effective in reducing cardiovascular disease events than RAS inhibitors or alpha blockers in this population 1
• For optimal endpoint protection, chlorthalidone should be administered at a dose of 12.5 to 25 mg/day (or hydrochlorothiazide 25-50 mg/day) 1
• The CCB amlodipine is as effective as chlorthalidone and more effective than lisinopril in reducing BP, CVD, and stroke events in African Americans, though less effective in preventing heart failure 1

Combination Therapy Considerations

• Two or more antihypertensive medications are recommended to achieve a BP target of less than 130/80 mm Hg in most adults with hypertension, especially in black adults 1
• When BP is >15/10 mmHg above goal levels, combination therapy should be initiated rather than monotherapy 2, 3
• A single-tablet combination that includes either a diuretic or a CCB may be particularly effective in achieving BP control in African Americans 1
• The 2020 International Society of Hypertension guidelines recommend for black patients:
  • Initial therapy with low dose ARB + dihydropyridine CCB or dihydropyridine CCB + thiazide-like diuretic 1
  • Then increase to full dose, followed by adding a diuretic or ACE/ARB if not already included 1

Special Clinical Scenarios

• For African Americans with chronic kidney disease and proteinuria, ACE inhibitors or ARBs are recommended as components of multidrug antihypertensive regimens 1, 4
• For those with heart failure, beta blockers should be added to the regimen 1
• For patients with coronary heart disease who have had a myocardial infarction, beta blockers are recommended 1
• African Americans have a greater risk of angioedema with ACE inhibitors, which should be considered when selecting therapy 1

Practical Considerations

• Most African American patients with hypertension will require combination antihypertensive therapy to maintain BP consistently below target levels 1, 2
• Lifestyle modifications (weight reduction, dietary modification, increased physical activity, sodium restriction) are particularly important in African Americans but may be challenging due to socioeconomic factors 1
• Hypertension control rates are lower in African Americans, especially men, than in other racial/ethnic groups, highlighting the need for more aggressive management 2, 5
• Recent perspectives suggest moving toward race-agnostic drug therapy algorithms coupled with greater emphasis on diet/lifestyle modifications for Black patients 5

Treatment Algorithm for African Americans with Hypertension

1. Initial therapy: Thiazide-type diuretic or CCB as monotherapy if BP is <15/10 mmHg above goal 1
2. If BP is >15/10 mmHg above goal: Start with combination therapy of a CCB plus a thiazide diuretic, or a CCB plus an ARB 1, 3
3. If BP remains uncontrolled: Progress to triple therapy with CCB + thiazide diuretic + ARB/ACE inhibitor 1
4. For resistant hypertension: Add spironolactone or, if not tolerated, other agents such as eplerenone, amiloride, doxazosin, or a beta-blocker 1