What are the recommended first-line medications for better blood pressure (BP) control in African American patients with hypertension?

First-Line Antihypertensive Medications for African American Patients

For African American patients with hypertension, initiate treatment with either a thiazide-type diuretic (chlorthalidone 12.5-25 mg/day preferred) or a calcium channel blocker (such as amlodipine), as these are more effective than ACE inhibitors or ARBs at lowering blood pressure and reducing cardiovascular events in this population. 1, 2

Primary Medication Recommendations

Thiazide-Type Diuretics

• Chlorthalidone is the preferred thiazide diuretic at doses of 12.5-25 mg/day, as it has more cardiovascular disease risk reduction data and a longer therapeutic half-life than hydrochlorothiazide 2
• Hydrochlorothiazide 25-50 mg/day is an alternative if chlorthalidone is not available 1, 2
• Thiazide diuretics are more effective than RAS inhibitors or beta blockers in both lowering BP and reducing cardiovascular events in African Americans 1, 2

Calcium Channel Blockers

• Amlodipine is as effective as chlorthalidone and more effective than lisinopril in reducing BP, cardiovascular disease, and stroke events in African Americans 1, 2
• Amlodipine is less effective than chlorthalidone in preventing heart failure, which should be considered in patients at high risk for HF 1
• All dihydropyridine calcium channel blockers (amlodipine, nifedipine) show equivalent efficacy, safety, and tolerability in African Americans 3

When to Start Combination Therapy

Most Patients Require Multiple Medications

• Most African American patients will require 2 or more antihypertensive medications to achieve BP control below 130/80 mmHg 1, 2
• If BP is >15/10 mmHg above goal, start immediately with combination therapy rather than monotherapy 2, 4
• If BP is <15/10 mmHg above goal, monotherapy with a thiazide or CCB is reasonable 2, 4

Preferred Combination Regimens

• Single-tablet combinations including either a diuretic or CCB are particularly effective in African Americans 1, 2
• First-line combinations: CCB + thiazide diuretic, or CCB + ARB 2, 4
• The combination of an ACE inhibitor or ARB with a CCB or thiazide produces similar BP lowering in African Americans as in other racial groups 1

When to Use ACE Inhibitors or ARBs

Special Clinical Scenarios Where RAS Inhibitors Are Indicated

• Chronic kidney disease with proteinuria: ACE inhibitors or ARBs are recommended as part of multidrug regimens 1, 2, 4
• Heart failure: Add beta blockers and ACE inhibitors/ARBs to the regimen 1, 2
• Post-myocardial infarction: Beta blockers are recommended 1, 2
• Diabetes with nephropathy: RAS inhibitors are appropriate 1

Important Safety Consideration

• African Americans have a greater risk of angioedema with ACE inhibitors compared to other populations, making ARBs often preferable when a RAS inhibitor is needed 1, 2, 4
• ACE inhibitors and ARBs are less effective as monotherapy in African Americans but work well when combined with diuretics or CCBs 1, 5, 6

Treatment Algorithm

Step 1: Initial Therapy

• Start with thiazide diuretic (chlorthalidone 12.5-25 mg/day) OR CCB (amlodipine 5-10 mg/day) if BP is <15/10 mmHg above goal 2, 4
• Start with combination therapy (CCB + thiazide OR CCB + ARB) if BP is ≥15/10 mmHg above goal 2, 4

Step 2: If BP Remains Uncontrolled

• Increase to full dose of initial medications 2, 4
• Add a third agent: if on CCB + thiazide, add ARB/ACE inhibitor; if on CCB + ARB, add thiazide 2, 4

Step 3: Resistant Hypertension

• Triple therapy with CCB + thiazide + ARB/ACE inhibitor 2
• If still uncontrolled, add spironolactone or alternatives (eplerenone, amiloride, doxazosin, or beta-blocker) 2

Common Pitfalls to Avoid

• Do not use ACE inhibitors or ARBs as monotherapy in African Americans without compelling indications (CKD, HF, diabetes with nephropathy), as they are less effective than diuretics or CCBs 1, 5
• Do not avoid beta blockers entirely - while less effective as monotherapy, 50% of African Americans can be controlled with them, and they are essential for post-MI and heart failure patients 7
• Do not delay combination therapy in patients with BP significantly above goal, as most will ultimately require multiple medications 1, 2, 6
• Monitor for angioedema when using ACE inhibitors in African American patients due to increased risk 1, 2

Target Blood Pressure

• Goal BP is <130/80 mmHg for most patients 2, 4
• Aim to achieve target within 3 months of initiating therapy 4
• Reduce BP by at least 20/10 mmHg from baseline 4