Management of Hypertension in a Black Woman with Blood Pressure 140/92 to 162/112 mmHg
For this Black woman with confirmed Grade 2 hypertension (readings 140/92 to 162/112 mmHg), initiate combination therapy immediately with a calcium channel blocker (amlodipine 5-10mg daily) plus a thiazide-like diuretic (chlorthalidone 12.5-25mg daily), targeting blood pressure <140/90 mmHg within 3 months. 1, 2
Rationale for Immediate Dual Therapy
Black patients with hypertension should start with a calcium channel blocker (CCB) or thiazide diuretic as first-line therapy, not ACE inhibitors or ARBs, as Black patients typically have a smaller response to renin-angiotensin system blockers as monotherapy 1, 3, 4.
The blood pressure readings (140/92 to 162/112 mmHg) represent Grade 2 hypertension, which requires immediate pharmacologic intervention without waiting for lifestyle modification trials 1, 2.
For Black patients specifically, the 2020 International Society of Hypertension guidelines recommend starting with either low-dose ARB plus DHP-CCB, or DHP-CCB plus thiazide/thiazide-like diuretic as initial combination therapy 1, 2.
Specific Medication Recommendations
Start amlodipine 5mg daily plus chlorthalidone 12.5-25mg daily as the preferred initial combination, as this provides complementary mechanisms (vasodilation plus volume reduction) and is particularly effective in Black patients 1, 5, 6.
Chlorthalidone is preferred over hydrochlorothiazide due to its longer duration of action and superior cardiovascular outcomes 5, 6.
Single-pill combination formulations should be used when available to improve adherence 1.
Treatment Algorithm and Escalation
If blood pressure remains uncontrolled after 2-4 weeks on optimized dual therapy:
Increase both medications to maximum tolerated doses (amlodipine 10mg, chlorthalidone 25mg) before adding a third agent 1, 5.
If still uncontrolled, add an ARB (not an ACE inhibitor) as the third agent, creating the guideline-recommended triple therapy of CCB + thiazide diuretic + ARB 1, 5, 2.
ARBs are preferred over ACE inhibitors in Black patients due to lower risk of angioedema, which occurs at higher rates in this population 1.
For resistant hypertension (uncontrolled on three drugs):
Add spironolactone 25-50mg daily as the fourth-line agent, which is the most effective option for resistant hypertension 1, 5, 7.
Monitor serum potassium closely when adding spironolactone to an ARB, as hyperkalemia risk is significant 5.
Blood Pressure Targets and Monitoring
Target blood pressure is <140/90 mmHg minimum, ideally <130/80 mmHg if well-tolerated 1, 5, 6.
Achieve target blood pressure within 3 months of initiating therapy to reduce cardiovascular risk 1, 2.
Reassess blood pressure within 2-4 weeks after any medication adjustment 5, 2.
Confirm hypertension diagnosis with home blood pressure monitoring (target <135/85 mmHg) or 24-hour ambulatory monitoring (target <130/80 mmHg) if not already done 1.
Critical Lifestyle Modifications
Sodium restriction to <2g/day provides additive blood pressure reduction of 5-10 mmHg 5, 6.
Weight loss (target BMI 20-25 kg/m²), regular aerobic exercise (150 minutes/week), and alcohol limitation to <100g/week provide cumulative reductions of 10-20 mmHg 5, 6.
These lifestyle interventions enhance the efficacy of pharmacologic therapy and should be implemented immediately 6.
Important Pitfalls to Avoid
Do not start with an ACE inhibitor or ARB as monotherapy in Black patients, as this violates guideline recommendations and is less effective than CCB or thiazide diuretic-based regimens 1, 2, 4.
Do not use beta-blockers as first-line therapy unless there are compelling indications (heart failure, post-MI, angina), as they are not recommended for initial hypertension treatment in any population 1, 5, 8.
Do not delay treatment intensification—this patient requires immediate action given the Grade 2 hypertension readings 2.
Verify medication adherence before assuming treatment failure, as non-adherence is the most common cause of apparent resistant hypertension 5, 7.