What are the recommended initial and secondary antihypertensive medications for African American patients with hypertension?

Recommended Antihypertensive Medications for African American Patients with Hypertension

For African American patients with hypertension, initial antihypertensive treatment should include a thiazide-type diuretic or calcium channel blocker (CCB) as first-line therapy, as these agents are more effective in lowering blood pressure and reducing cardiovascular events in this population compared to renin-angiotensin system inhibitors or beta blockers. 1

Initial Therapy Recommendations

• Thiazide-type diuretics (preferably chlorthalidone 12.5-25 mg/day) or CCBs (such as amlodipine) are recommended as first-line agents for African American patients with hypertension 1, 2
• Chlorthalidone has more cardiovascular disease risk reduction data than hydrochlorothiazide (HCTZ) and has a longer therapeutic half-life, making it the preferred thiazide diuretic 3
• Amlodipine is as effective as chlorthalidone in reducing blood pressure, cardiovascular disease, and stroke events in African Americans, though less effective in preventing heart failure 1, 4
• Initial monotherapy is appropriate if blood pressure is <15/10 mmHg above goal; otherwise, combination therapy should be initiated 1, 2

Combination Therapy Approach

• Most African American patients will require two or more antihypertensive medications to achieve adequate blood pressure control 1, 2
• Recommended combination approaches include:
  • Low-dose ARB + dihydropyridine CCB 1
  • Dihydropyridine CCB + thiazide-like diuretic 1
  • Single-tablet combinations that include either a diuretic or CCB are particularly effective 1, 2
• If blood pressure remains uncontrolled, progress to triple therapy with CCB + thiazide diuretic + ARB/ACE inhibitor 1

Special Clinical Scenarios

• For African Americans with chronic kidney disease and proteinuria, ACE inhibitors or ARBs should be included as part of a multidrug regimen despite their reduced efficacy as monotherapy 1, 5
• In the AASK trial, ramipril showed better renoprotection compared to amlodipine or metoprolol in African Americans with hypertensive nephrosclerosis 5
• For patients with heart failure, beta blockers should be added to the regimen 1, 6
• For those with coronary heart disease who have had a myocardial infarction, beta blockers are recommended 1

Important Considerations and Cautions

• African Americans have a greater risk of angioedema with ACE inhibitors, which should be considered when selecting therapy 1, 2
• The target blood pressure should be <130/80 mmHg according to current guidelines 1, 6
• In resistant hypertension, consider adding spironolactone or, if not tolerated, other agents such as eplerenone, amiloride, doxazosin, or a beta-blocker 1
• The ALLHAT study demonstrated that chlorthalidone-based treatment resulted in the lowest risk of heart failure compared to amlodipine or lisinopril in both black and nonblack patients 4

Treatment Algorithm for African Americans with Hypertension

1. Initial therapy:

   • For BP <15/10 mmHg above goal: Start with thiazide-type diuretic (preferably chlorthalidone 12.5-25 mg/day) or CCB (amlodipine 5-10 mg/day) as monotherapy 1, 2
   • For BP >15/10 mmHg above goal: Start with combination therapy of a CCB plus a thiazide diuretic, or a CCB plus an ARB 1

2. If BP remains uncontrolled:

   • Progress to triple therapy with CCB + thiazide diuretic + ARB/ACE inhibitor 1
   • For resistant hypertension, add spironolactone or other fourth-line agents 1

3. For specific comorbidities:

   • Chronic kidney disease with proteinuria: Include an ACE inhibitor or ARB in the regimen 1, 5
   • Heart failure: Include a beta blocker 1, 6
   • Post-myocardial infarction: Include a beta blocker 1