What is the best blood pressure (BP) medication for an African American patient with diastolic dysfunction and a normal ejection fraction (EF)?

Best Antihypertensive Medications for African American Patients with Diastolic Dysfunction

For African American patients with diastolic dysfunction and preserved ejection fraction (EF 67%), a thiazide-type diuretic or calcium channel blocker (CCB) should be used as first-line therapy, with combination therapy often required to achieve adequate blood pressure control. 1, 2

First-Line Therapy Options

• Thiazide-type diuretics (particularly chlorthalidone 12.5-25 mg/day or hydrochlorothiazide 25-50 mg/day) are more effective in lowering blood pressure and reducing cardiovascular disease events in African Americans than renin-angiotensin system (RAS) inhibitors 1, 2
• Calcium channel blockers (particularly amlodipine) are as effective as chlorthalidone in reducing BP, cardiovascular disease, and stroke events in African Americans 1, 2
• For optimal endpoint protection, chlorthalidone should be administered at 12.5-25 mg/day (or hydrochlorothiazide 25-50 mg/day) as lower doses are less effective in clinical outcome trials 1

Combination Therapy Approach

• Most African American patients with hypertension will require two or more antihypertensive medications to achieve adequate BP control 1, 2
• A single-tablet combination that includes either a diuretic or a CCB may be particularly effective in achieving BP control in African Americans 1, 2
• For patients with BP >15/10 mmHg above goal, consider starting with combination therapy of a CCB plus a thiazide diuretic 2, 3

Special Considerations for Diastolic Dysfunction

• Beta-blockers, ACE inhibitors, ARBs, or CCBs may be effective to minimize symptoms of heart failure in patients with preserved ejection fraction and hypertension (Class IIb; Level of Evidence C) 1
• ACE inhibitors and ARBs have shown improvement in measures of diastolic function and are recommended for patients with diastolic heart failure, though their efficacy may be reduced when used as monotherapy in African Americans 4, 5
• Aldosterone receptor antagonists (spironolactone, eplerenone) should be considered for patients with resistant hypertension, particularly when combined with a thiazide diuretic 1

Important Cautions and Contraindications

• African Americans have a greater risk of angioedema with ACE inhibitors compared to other racial groups 1, 2
• Non-dihydropyridine CCBs (verapamil, diltiazem), clonidine, moxonidine, and hydralazine without a nitrate should be avoided in patients with heart failure with reduced ejection fraction (Class III Harm; Level of Evidence B) 1
• Hydralazine plus isosorbide dinitrate should be added to the regimen in African American patients with NYHA class III or IV heart failure with reduced ejection fraction (Class I; Level of Evidence A), but this recommendation is specifically for reduced EF, not preserved EF 1

Treatment Algorithm for African Americans with Diastolic Dysfunction

1. Initial therapy: Start with a thiazide-type diuretic (preferably chlorthalidone 12.5-25 mg/day) or CCB (amlodipine) 1, 2
2. If BP remains uncontrolled: Progress to combination therapy with CCB + thiazide diuretic 2, 3
3. If further BP lowering needed: Add an ACE inhibitor or ARB (recognizing they may be less effective as monotherapy but work well in combination) 1, 5
4. For resistant hypertension: Consider adding spironolactone or eplerenone, particularly in combination with a thiazide diuretic 1, 2

Target Blood Pressure Goals

• Target BP is <140/90 mm Hg, but consideration can be given to lowering BP even further to <130/80 mm Hg 1
• In older hypertensive individuals with wide pulse pressures, monitor for very low DBP values (<60 mm Hg) which may cause myocardial ischemia and worsening heart failure 1