What is the best initial antihypertensive medication for a 72-year-old black female with stage 1 hypertension (Blood Pressure 146/80 mmHg)?

Best Initial Antihypertensive Medication for a 72-Year-Old Black Female with Stage 1 Hypertension

For a 72-year-old Black female with stage 1 hypertension (BP 146/80 mmHg), a calcium channel blocker (CCB) such as amlodipine or a thiazide/thiazide-like diuretic is the most appropriate first-line medication. 1

Rationale for Treatment Selection in Black Patients

• Black patients respond better to CCBs and thiazide/thiazide-like diuretics than to renin-angiotensin system (RAS) inhibitors when used as monotherapy 1
• The 2020 International Society of Hypertension guidelines specifically recommend starting with either:
  • Low-dose ARB + dihydropyridine CCB, or
  • Dihydropyridine CCB + thiazide/thiazide-like diuretic 1
• Black patients typically have lower-renin hypertension, making CCBs and diuretics more effective than ACE inhibitors or ARBs as initial therapy 1

Medication Options for This Patient

First Choice: Amlodipine (Calcium Channel Blocker)

• Starting dose: 5 mg once daily 2, 3
• Advantages:
  • Superior efficacy in Black patients 1
  • Once-daily dosing improves adherence 3
  • Studies show greater BP response in women and older adults (>65 years) 4
  • No dosage adjustment needed for elderly patients 2
  • Does not negatively affect glucose or lipid metabolism 3

Alternative: Thiazide/Thiazide-like Diuretic

• Chlorthalidone 12.5-25 mg daily or hydrochlorothiazide 25 mg daily 1
• Particularly effective in Black patients for BP reduction and prevention of clinical outcomes 1

Treatment Algorithm for This Patient

1. Initial therapy: Start with amlodipine 5 mg once daily 2, 3
2. Follow-up: Reassess BP within 3 months to determine if target is achieved 1
3. If BP target not achieved:
   • Increase amlodipine to 10 mg daily, OR
   • Add a thiazide/thiazide-like diuretic 1
4. If still not at target: Add an ARB or ACE inhibitor as third agent 1

BP Target for This Patient

• Target BP should be <130/80 mmHg, but individualized based on frailty status 1
• At minimum, aim to reduce BP by at least 20/10 mmHg from baseline 1

Important Considerations

• ACE inhibitors are associated with higher risk of angioedema in Black patients 1
• Combination therapy may be needed to achieve BP targets in most Black patients with hypertension 1
• Monitor for common side effects of amlodipine, particularly peripheral edema 4
• Single-pill combinations improve adherence and should be considered if multiple medications are needed 1

Monitoring Recommendations

• Assess BP control within 3 months of starting therapy 1
• Consider home BP monitoring to confirm adequate 24-hour control 1
• Monitor for potential adverse effects, particularly edema with amlodipine 4
• If BP remains uncontrolled despite optimization of therapy, consider referral to a hypertension specialist 1