What is the recommended treatment for hypertension in African Americans?

Hypertension Treatment in African Americans

For African American adults with hypertension but without heart failure or chronic kidney disease, initial antihypertensive treatment should be a thiazide-type diuretic (chlorthalidone 12.5-25 mg daily preferred) or a calcium channel blocker (such as amlodipine), as these agents are more effective at lowering blood pressure and reducing cardiovascular events than ACE inhibitors or ARBs in this population. 1, 2, 3

First-Line Monotherapy Selection

Thiazide-Type Diuretics (Preferred Option)

• Chlorthalidone 12.5-25 mg daily is the preferred thiazide diuretic due to superior cardiovascular disease risk reduction data and longer therapeutic half-life compared to hydrochlorothiazide 25-50 mg daily 2, 4
• Thiazide diuretics are more effective than renin-angiotensin system (RAS) inhibitors or beta blockers at lowering blood pressure in African Americans 1, 3
• They demonstrate superior reduction in cardiovascular events compared to RAS inhibitors or alpha blockers in this population 1, 2

Calcium Channel Blockers (Equally Acceptable)

• Amlodipine is as effective as chlorthalidone and more effective than lisinopril in reducing blood pressure, cardiovascular disease, and stroke events in African Americans 2, 3
• CCBs provide equivalent blood pressure lowering efficacy to thiazide diuretics in African Americans 1, 5

Agents to Avoid as Monotherapy

• ACE inhibitors demonstrate reduced blood pressure lowering efficacy in African Americans and should not be used as initial monotherapy in uncomplicated hypertension 4, 6
• African Americans have a greater risk of angioedema with ACE inhibitors, making them less safe as first-line agents 2, 3, 4
• Beta blockers and ARBs are less effective than diuretics or CCBs for blood pressure reduction in African Americans without compelling indications 1, 3

Combination Therapy (Required for Most Patients)

When to Initiate Combination Therapy

• Two or more antihypertensive medications are required to achieve blood pressure target <130/80 mmHg in most African American adults with hypertension 1, 2, 3
• If blood pressure is >15/10 mmHg above goal, start immediately with combination therapy rather than monotherapy 2, 4
• Most African American patients will require combination therapy due to more severe hypertension presentation 1, 7, 8

Optimal Two-Drug Combinations

• CCB + thiazide diuretic is the preferred combination for African Americans, providing additive blood pressure lowering and addressing volume-related hypertension 2, 4, 8
• CCB + ARB is an effective alternative combination, as ARBs have less angioedema risk than ACE inhibitors in African Americans 2, 4
• Single-tablet combinations including either a diuretic or CCB are particularly effective for achieving blood pressure control 1, 3
• The combination of an ACE inhibitor or ARB with a CCB or thiazide diuretic produces similar blood pressure lowering in African Americans as in other racial groups 1

Triple Therapy Progression

• If blood pressure remains uncontrolled on two agents, progress to CCB + thiazide diuretic + ARB/ACE inhibitor 2
• For resistant hypertension on triple therapy, add spironolactone or, if not tolerated, consider eplerenone, amiloride, doxazosin, or a beta-blocker 2, 9

Special Clinical Scenarios Requiring Modified Approach

Chronic Kidney Disease with Proteinuria

• ACE inhibitors or ARBs are recommended as components of multidrug regimens in African Americans with CKD and proteinuria due to renoprotective effects 1, 2, 3
• These agents should be combined with a diuretic or CCB, not used as monotherapy 1

Heart Failure

• ACE inhibitors or ARBs plus beta blockers are recommended in African Americans with hypertension and heart failure, as the heart failure indication supersedes race-based recommendations 1, 2, 3
• Diuretics should be added for volume management 1

Coronary Heart Disease Post-MI

• Beta blockers are recommended for African Americans with hypertension who have had a myocardial infarction 1, 2

Diabetes Without Nephropathy or Heart Failure

• Thiazide diuretics or CCBs remain the preferred initial agents, as RAS inhibitors offer no advantage over these agents in African Americans with diabetes but without nephropathy or heart failure 1, 3

Blood Pressure Target

• Target blood pressure is <130/80 mmHg for most African American adults with hypertension 1, 2, 4
• Achieve target within 3 months of initiating therapy, with medication adjustment if goal not reached 4

Critical Pitfalls to Avoid

• Do not use ACE inhibitor or ARB monotherapy in African Americans without compelling indications (CKD with proteinuria, heart failure), as these agents are less effective and ACE inhibitors carry higher angioedema risk 3, 4
• Do not delay combination therapy when blood pressure is significantly elevated (>15/10 mmHg above goal), as monotherapy will be insufficient 2, 4, 8
• Do not exclude any antihypertensive class from combination regimens based solely on race, as combinations produce equivalent blood pressure lowering across racial groups 1
• Be aware that social determinants of health may impede medication access and adherence in African American patients, requiring additional support strategies 3

Adjunctive Lifestyle Modifications

• Weight reduction and sodium restriction are particularly important in African Americans for prevention and adjunctive therapy of hypertension 3, 8, 10
• Lifestyle modifications include increased physical activity, alcohol restriction, and dietary modification (DASH diet) 8, 10
• These interventions may be challenging due to socioeconomic factors and require individualized support 2