What is the initial antihypertensive medication for a black male with newly diagnosed hypertension?

Initial Antihypertensive Medication for Black Males

For a black male with newly diagnosed hypertension, start with either a thiazide-type diuretic (chlorthalidone 12.5-25 mg daily or hydrochlorothiazide 25-50 mg daily) or a calcium channel blocker (amlodipine 5-10 mg daily) as first-line monotherapy. 1, 2

First-Line Monotherapy Options

The evidence strongly supports two equally effective initial choices for black patients:

Thiazide-Type Diuretics

• Chlorthalidone is the preferred thiazide due to superior cardiovascular outcome data and longer half-life compared to hydrochlorothiazide 1
• Start chlorthalidone at 12.5-25 mg daily 1
• If using hydrochlorothiazide instead, use 25-50 mg daily (higher doses are more effective in black patients) 1, 2
• Thiazide diuretics are more effective than ACE inhibitors or ARBs at lowering blood pressure in black patients 1, 3
• In the landmark ALLHAT trial, chlorthalidone reduced stroke, heart failure, and combined cardiovascular events more effectively than lisinopril in black patients 4

Calcium Channel Blockers

• Amlodipine is equally effective as chlorthalidone for blood pressure reduction and cardiovascular outcomes in black patients 1
• Start amlodipine at 5 mg daily, can increase to 10 mg 5
• In black South African patients, nifedipine achieved blood pressure control in 63% as monotherapy compared to only 40% with hydrochlorothiazide and 21% with enalapril 3
• The CREOLE trial in sub-Saharan Africa confirmed amlodipine-based combinations were superior to ACE inhibitor-based regimens 6

When to Use Combination Therapy Initially

If blood pressure is >15/10 mmHg above goal, start with combination therapy immediately rather than monotherapy 1:

• Preferred initial combinations for black patients:
  • Amlodipine + hydrochlorothiazide 7, 1
  • Amlodipine + ARB (low-dose) 7, 1
• Most black patients will require two or more medications to achieve target BP <130/80 mmHg 1, 2

Critical Pitfalls to Avoid

Do NOT Use ACE Inhibitors or ARBs as Monotherapy

• ACE inhibitors and ARBs are significantly less effective as monotherapy in black patients 1, 3
• In one trial, enalapril monotherapy controlled BP in only 21% of black patients at 2 months, and only 3% remained on monotherapy at 13 months 3
• Black patients have a greater risk of angioedema with ACE inhibitors 1, 2
• However, ACE inhibitors/ARBs should be included as part of combination therapy when needed, and are specifically indicated for black patients with chronic kidney disease with proteinuria or heart failure 1

Age Considerations

• Patients ≥65 years have reduced responses to ARB monotherapy compared to younger patients, but respond similarly to combination therapy with thiazides 8
• The age cutoff of 55 years suggested in some older guidelines is not supported by current evidence for determining initial therapy choice 8

Titration Algorithm

1. Start with monotherapy (thiazide or CCB) if BP is <15/10 mmHg above goal 1
2. Increase to full dose after 2-4 weeks if target not achieved 7
3. Add second agent (the other first-line class not initially chosen) if BP remains uncontrolled 7, 1
4. Add third agent (ARB or ACE inhibitor) if still uncontrolled on dual therapy 7, 1
5. For resistant hypertension, add spironolactone or alternatives (amiloride, doxazosin, eplerenone) 7, 1

Target Blood Pressure and Monitoring

• Target BP is <130/80 mmHg with goal to reduce BP by at least 20/10 mmHg 7, 1
• Achieve target within 3 months of initiating therapy 7, 2
• Confirm diagnosis and monitor with home BP monitoring (target <135/85 mmHg) or 24-hour ambulatory monitoring (target <130/80 mmHg) 7

Special Clinical Scenarios

• Chronic kidney disease with proteinuria: Include ACE inhibitor or ARB as part of multidrug regimen 1
• Heart failure: Add beta-blocker to the regimen 1
• Post-myocardial infarction: Include beta-blocker 1
• Diabetes: Same first-line recommendations apply (thiazide or CCB) 1