What is the next step for an African American patient with uncontrolled hypertension on Lisinopril (angiotensin-converting enzyme inhibitor)?

Next Step for African American Patient with Uncontrolled Hypertension on Lisinopril

For an African American patient with uncontrolled hypertension on lisinopril, the next step should be adding a calcium channel blocker (CCB), specifically a dihydropyridine CCB such as amlodipine. 1

Rationale for Treatment Selection

African American patients respond differently to antihypertensive medications compared to non-Black patients:

• ACE inhibitors like lisinopril are less effective as monotherapy in Black patients, with studies showing less BP lowering compared to diuretics or CCBs 1, 2
• Stroke incidence is greater with lisinopril than chlorthalidone therapy in Black patients 1, 2
• Black patients tend to have a better response to calcium channel blockers and diuretics 1

Treatment Algorithm for African American Patients

The 2020 International Society of Hypertension guidelines provide a specific treatment pathway for Black patients with hypertension:

1. Initial therapy: Low-dose ARB + dihydropyridine CCB or dihydropyridine CCB + thiazide/thiazide-like diuretic 1
2. Increase to full dose of initial medications 1
3. Add diuretic (if not already included) or ACE inhibitor/ARB 1
4. Add spironolactone or, if not tolerated, consider amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 1

Specific Recommendation for This Patient

Since the patient is already on lisinopril (ACE inhibitor) with uncontrolled hypertension:

• Add amlodipine 5-10 mg daily as the next step 1
• Amlodipine has demonstrated efficacy in Black patients and can be given once daily 1, 3
• The combination of an ACE inhibitor and CCB provides complementary mechanisms of action 3

If blood pressure remains uncontrolled after adding amlodipine:

• Add a thiazide-like diuretic (chlorthalidone 12.5-25 mg or indapamide 1.5-2.5 mg) 1

Important Considerations

• Monitor blood pressure response within 4-6 weeks of medication adjustment 1
• Target blood pressure should be <130/80 mmHg 1
• Fixed-dose combination pills (e.g., lisinopril-amlodipine) can improve adherence 1
• If BP remains uncontrolled on triple therapy (ACE inhibitor + CCB + diuretic), consider adding spironolactone as a fourth agent 1

Potential Pitfalls

• Avoid using beta-blockers as second-line agents in Black patients unless there are specific indications (e.g., coronary artery disease) 1
• Be aware that ACE inhibitors have a higher incidence of angioedema in Black patients 1
• Ensure medication adherence is assessed before adding new medications 1
• Consider home blood pressure monitoring to confirm uncontrolled hypertension and monitor treatment response 1

The evidence strongly supports adding a CCB like amlodipine as the most effective next step for an African American patient with uncontrolled hypertension on lisinopril, with subsequent addition of a thiazide-like diuretic if needed for further BP control 1, 2.