What are the best blood pressure medications for hypertrophic cardiomyopathy (HCM) in African Americans?

From the Guidelines

The combination of hydralazine and isosorbide dinitrate is the most effective blood pressure medication for hypertrophic cardiomyopathy in African Americans, as it has been shown to reduce morbidity and mortality in this population. This recommendation is based on the 2013 ACCF/AHA guideline for the management of heart failure, which suggests that the combination of hydralazine and isosorbide dinitrate can be useful in reducing morbidity or mortality in patients with current or prior symptomatic HFrEF who cannot be given an ACE inhibitor or ARB due to drug intolerance, hypotension, or renal insufficiency 1.

The benefits of hydralazine and isosorbide dinitrate in African Americans with hypertrophic cardiomyopathy are well-documented, with studies showing that this combination can reduce mortality and improve symptoms in this population 1. The mechanism of action of these medications involves reducing peripheral resistance and improving cardiac output, which can help alleviate symptoms such as chest pain, shortness of breath, and palpitations.

Some key points to consider when using hydralazine and isosorbide dinitrate in African Americans with hypertrophic cardiomyopathy include:

• Starting with a low dose and titrating gradually under medical supervision to minimize side effects
• Monitoring blood pressure, heart rate, and symptom improvement regularly
• Avoiding excessive alcohol, caffeine, and strenuous exercise, which can exacerbate symptoms
• Considering alternative medications, such as beta-blockers or calcium channel blockers, if hydralazine and isosorbide dinitrate are not tolerated or effective.

Overall, the combination of hydralazine and isosorbide dinitrate is a effective and recommended treatment option for hypertrophic cardiomyopathy in African Americans, and should be considered as a first-line treatment in this population 1.

From the FDA Drug Label

In the LIFE study, Black patients with hypertension and left ventricular hypertrophy treated with atenolol were at lower risk of experiencing the primary composite endpoint compared with Black patients treated with losartan The primary endpoint was the first occurrence of stroke, myocardial infarction or cardiovascular death, analyzed using an intention-to-treat (ITT) approach In the subgroup of Black patients (n=533,6% of the LIFE study patients), there were 29 primary endpoints among 263 patients on atenolol (11%, 26 per 1000 patient-years) and 46 primary endpoints among 270 patients (17%, 42 per 1000 patient-years) on losartan Losartan may be administered with other antihypertensive agents. Losartan is indicated to reduce the risk of stroke in patients with hypertension and left ventricular hypertrophy, but there is evidence that this benefit does not apply to Black patients

The best blood pressure medication for hypertrophic cardiomyopathy in African Americans is not explicitly stated in the provided drug labels. However, the labels suggest that losartan may not be the most effective option for Black patients with hypertension and left ventricular hypertrophy, as the LIFE study found that atenolol was associated with a lower risk of cardiovascular events in this population 2. Verapamil is also mentioned as a treatment option, but its effectiveness in African Americans with hypertrophic cardiomyopathy is not directly addressed in the provided labels 3.

• Key points:
  • Losartan may not be the most effective option for Black patients with hypertension and left ventricular hypertrophy.
  • Atenolol was associated with a lower risk of cardiovascular events in Black patients in the LIFE study.
  • Verapamil is a treatment option, but its effectiveness in African Americans with hypertrophic cardiomyopathy is not directly addressed.
• Main idea: The best blood pressure medication for hypertrophic cardiomyopathy in African Americans is not explicitly stated, but losartan may not be the most effective option.

From the Research

Blood Pressure Medications for Hypertrophic Cardiomyopathy in African Americans

• The choice of blood pressure medication for hypertrophic cardiomyopathy (HCM) in African Americans is crucial, as this population is more likely to present with heart failure and has decreased survival after hospital discharge following out-of-hospital cardiac arrest 4.
• Studies have shown that diuretics, such as chlorthalidone, may be a logical first-line choice for blood pressure reduction in African Americans, as they have been associated with greater reductions in blood pressure and a relative risk reduction in stroke compared to angiotensin-converting enzyme (ACE) inhibitors like lisinopril 5.
• However, combination therapy with ACE inhibitors plus diuretics may be beneficial in African American patients, and the use of diuretics in combination with other agents, such as calcium channel blockers, may be effective in reducing blood pressure and improving outcomes 5, 6.
• The International Society of Hypertension in Blacks guidelines recommend the use of lifestyle modification and combination therapy, including diuretics and calcium channel blockers, to reach appropriate blood pressure goals in African American patients 6.
• Recent studies have also suggested that the use of a single-pill formulation with an angiotensin receptor blocker (ARB) or ACE inhibitor and a thiazide diuretic may be effective in African American patients, particularly when considering both race and gender in treatment strategies 7.
• Further research is needed to elucidate the effects of HCM on African American populations, as they are underrepresented in HCM research and may experience health disparities 8.

Key Considerations

• African American patients with systolic blood pressure >15 mm Hg or a diastolic blood pressure >10 mm Hg above goal should be treated with first-line combination therapy 5, 6.
• The choice of drugs for combination therapy in African American patients may be different from those used in non-African American patients, and consideration should be given to the use of diuretics and calcium channel blockers 5, 6.
• Longitudinal studies with large samples of African American patients with HCM are necessary to elucidate how HCM affects this population and to inform treatment strategies 8.