What is a suitable antihypertensive medication for African American women with hypertension?

Recommended Blood Pressure Medications for African American Women

For African American women with hypertension, initial treatment should be a thiazide-type diuretic (specifically chlorthalidone 12.5-25 mg daily or hydrochlorothiazide 25-50 mg daily) or a calcium channel blocker (such as amlodipine), as these are the most effective first-line agents for blood pressure control and cardiovascular event reduction in this population. 1

First-Line Monotherapy Options

Thiazide-Type Diuretics (Preferred)

• Chlorthalidone is the superior thiazide choice due to more cardiovascular disease risk reduction data and a longer therapeutic half-life compared to hydrochlorothiazide 2
• Dosing: Chlorthalidone 12.5-25 mg daily or hydrochlorothiazide 25-50 mg daily 1, 2
• These agents are more effective than ACE inhibitors or ARBs at lowering blood pressure in African Americans 1
• They reduce cardiovascular events more effectively than RAS inhibitors or alpha blockers in this population 1, 2

Calcium Channel Blockers (Equally Effective Alternative)

• Amlodipine is the preferred CCB, as it is as effective as chlorthalidone and more effective than lisinopril in reducing blood pressure, cardiovascular disease, and stroke events in African Americans 1, 2, 3
• All dihydropyridine CCBs (amlodipine, nifedipine) show equivalent efficacy, safety, and tolerability in African American patients 4

Why NOT ACE Inhibitors or ARBs as Monotherapy

• ACE inhibitors and ARBs are less effective as monotherapy in African Americans compared to thiazides or CCBs for blood pressure reduction 1, 5
• African American women have a greater risk of angioedema with ACE inhibitors compared to other populations 1, 2
• In the ALLHAT trial, lisinopril was associated with increased stroke risk specifically in African American patients compared to chlorthalidone 6, 7

When Combination Therapy is Needed

Most African American women will require two or more medications to achieve blood pressure control below 130/80 mmHg 1, 2

Recommended Combination Approaches:

• Start with combination therapy if blood pressure is >15/10 mmHg above goal 2, 3
• Preferred combinations:
  • CCB + thiazide diuretic 1, 2
  • ARB + CCB (ARBs preferred over ACE inhibitors due to lower angioedema risk) 2, 3
  • ARB + thiazide diuretic 2, 8
• Single-tablet combinations containing a diuretic or CCB are particularly effective for achieving blood pressure control 1

Triple Therapy for Resistant Hypertension:

• If blood pressure remains uncontrolled on dual therapy, progress to: CCB + thiazide diuretic + ARB/ACE inhibitor 2, 3

Special Clinical Scenarios

Chronic Kidney Disease with Proteinuria

• Add an ACE inhibitor or ARB to the regimen (in combination with other agents) for African American women with CKD and proteinuria 1, 2
• These agents are specifically indicated for renal protection in this context 9

Heart Failure

• Add a beta blocker to the antihypertensive regimen 1, 2

Post-Myocardial Infarction

• Beta blockers are recommended for coronary heart disease patients who have had an MI 1, 2

Important Clinical Considerations

Blood Pressure Target

• Goal: <130/80 mmHg 2, 3, 8
• Aim to reduce blood pressure by at least 20/10 mmHg from baseline 3, 8

Monitoring

• Achieve target blood pressure within 3 months 3, 8
• If uncontrolled on optimized triple therapy, refer to a hypertension specialist 3

Critical Pitfall to Avoid

• Do not use ACE inhibitors or ARBs as monotherapy in African American women without compelling indications (such as CKD with proteinuria, heart failure, or diabetes with nephropathy), as they are less effective for blood pressure control and cardiovascular protection compared to thiazides or CCBs in this population 1, 6, 7