What is the recommended treatment approach for hypertension (HTN) in African American patients?

Treatment of Hypertension in African American Patients

In African American patients with hypertension, initial antihypertensive treatment should include a thiazide-type diuretic or calcium channel blocker (CCB), as these are more effective in lowering blood pressure and reducing cardiovascular outcomes in this population. 1

First-Line Medication Selection

• Thiazide-type diuretics (particularly chlorthalidone 12.5-25 mg/day) and CCBs (such as amlodipine) are superior in lowering blood pressure when given as monotherapy or as initial agents in multi-drug regimens in African American patients 1
• These agents are more effective than drugs that inhibit the renin-angiotensin system (RAS) such as ACE inhibitors, ARBs, renin inhibitors, and beta blockers for prevention of selected clinical outcomes in African American patients 1
• The CCB amlodipine is as effective as chlorthalidone and more effective than ACE inhibitors like lisinopril in reducing blood pressure, cardiovascular disease, and stroke events in African American patients 1
• African American patients have a greater risk of angioedema with ACE inhibitors, making thiazide diuretics and CCBs safer first-line options 1

Combination Therapy Approach

• Two or more antihypertensive medications are recommended to achieve a blood pressure target of less than 130/80 mm Hg in most African American patients with hypertension 1
• When blood pressure is >15/10 mmHg above goal, combination drug therapy should be initiated immediately rather than starting with monotherapy 2
• A single-pill combination that includes either a diuretic or a CCB may be particularly effective in achieving blood pressure control in African American patients 1
• For optimal endpoint protection, the thiazide chlorthalidone should be administered at a dose of 12.5 to 25 mg/day (or 25–50 mg/d for hydrochlorothiazide) 1

Special Clinical Scenarios

• For African American patients with hypertension AND chronic kidney disease (CKD):

  • ACE inhibitors or ARBs are recommended as components of multidrug antihypertensive regimens 1
  • This is due to their renoprotective effects despite potentially less robust blood pressure lowering 1

• For African American patients with hypertension AND heart failure:

  • ACE inhibitors or ARBs plus beta blockers are recommended 1
  • The heart failure indication takes precedence over race-based recommendations 1

• For African American patients with hypertension AND diabetes without nephropathy:

  • Thiazide diuretics or CCBs remain the preferred initial agents as they offer no disadvantage compared to RAS inhibitors in this scenario 1

Lifestyle Modifications

• Lifestyle modification is particularly important in African American patients for prevention and first-line or adjunctive therapy of hypertension 1
• Key lifestyle interventions include:
  • Weight reduction 1
  • Dietary modification (including DASH diet) 3
  • Increased physical activity 3
  • Sodium restriction 3
• African American patients demonstrate robust, sometimes outsized blood pressure responses to diet/lifestyle modifications 4

Common Pitfalls and Considerations

• Monotherapy is often insufficient for blood pressure control in African American patients - most will require combination therapy 1, 4
• Social determinants of health may impede access to medications and adherence to lifestyle recommendations in African American patients 1
• Hypertension control rates are lower in African Americans, especially men, than in other racial/ethnic groups 2
• Recent evidence suggests that race-agnostic drug therapy coupled with greater emphasis on diet/lifestyle modifications may be effective in African American patients 4
• Combination of an ACE inhibitor or ARB with a CCB or thiazide diuretic produces similar blood pressure lowering in African Americans as in other racial or ethnic groups 1

By following these evidence-based recommendations, clinicians can effectively manage hypertension in African American patients and reduce the disproportionate burden of hypertension-related complications in this population.