What blood pressure medications should be avoided in African Americans with hypertension?

Blood Pressure Medications to Avoid in African Americans

Thiazide-type diuretics or calcium channel blockers (CCBs) should be the first-line antihypertensive medications for African Americans, while ACE inhibitors, ARBs, and beta-blockers should generally be avoided as monotherapy due to reduced efficacy in this population. 1, 2

First-Line Recommendations for African Americans

• Thiazide-type diuretics (especially chlorthalidone 12.5-25 mg daily) or CCBs (like amlodipine) are more effective in lowering blood pressure and reducing cardiovascular disease events in African Americans than other antihypertensive classes 2, 3
• The American College of Cardiology/American Heart Association guidelines specifically recommend that initial antihypertensive treatment for Black adults with hypertension should include a thiazide-type diuretic or CCB 1
• Most African American patients will require two or more antihypertensive medications to achieve adequate blood pressure control, with a target of <130/80 mm Hg 1, 2

Medications to Avoid as Monotherapy in African Americans

• ACE inhibitors and ARBs should be avoided as monotherapy in African Americans without compelling indications (like chronic kidney disease with proteinuria or heart failure) due to reduced blood pressure-lowering efficacy 2, 4
• Beta-blockers should generally be avoided as initial monotherapy for uncomplicated hypertension in African Americans due to less effective blood pressure reduction compared to diuretics or CCBs 1, 5
• Alpha-blockers like doxazosin should be avoided as first-line therapy in African Americans based on evidence from the ALLHAT trial showing higher rates of heart failure compared to chlorthalidone 3
• Aliskiren (direct renin inhibitor) should be used with caution in African Americans due to the generally lower renin profile in this population 6, 7

Special Clinical Scenarios

• For African Americans with chronic kidney disease and proteinuria, ACE inhibitors or ARBs should be included as part of a multidrug antihypertensive regimen despite their reduced efficacy as monotherapy 2, 8
• For African Americans with heart failure, ACE inhibitors or ARBs plus beta-blockers should be included in the treatment regimen 1, 2
• For African Americans with coronary heart disease who have had a myocardial infarction, beta-blockers should be included in the treatment regimen despite their reduced efficacy as monotherapy 2, 5

Combination Therapy Approach

• The International Society of Hypertension recommends starting with a combination of either a CCB plus a thiazide-type diuretic or a CCB plus an ARB for African American patients 2, 9
• Single-pill combinations that include either a diuretic or a CCB may be particularly effective in achieving blood pressure control in African Americans 2, 9
• If blood pressure remains uncontrolled on dual therapy, progress to triple therapy with CCB + thiazide diuretic + ARB/ACE inhibitor 2

Important Considerations and Cautions

• African Americans have a greater risk of angioedema with ACE inhibitors compared to other racial groups 2, 8
• The combination of ACE inhibitors and ARBs should be avoided in all patients, including African Americans, due to increased risk of adverse effects without additional benefit 6
• Lifestyle modifications (weight reduction, dietary modification, increased physical activity, sodium restriction) are particularly important in African Americans 2, 4

Treatment Algorithm for African Americans with Hypertension

1. Initial therapy: Thiazide-type diuretic (preferably chlorthalidone 12.5-25 mg daily) or CCB as monotherapy if BP is <15/10 mmHg above goal 2, 3
2. If BP is >15/10 mmHg above goal: Start with combination therapy of a CCB plus a thiazide diuretic 1, 2
3. If BP remains uncontrolled: Progress to triple therapy with CCB + thiazide diuretic + ARB/ACE inhibitor 2, 9
4. For resistant hypertension: Add spironolactone or, if not tolerated, other agents such as eplerenone or amiloride 2, 10