What is the first-line anti-hypertensive (high blood pressure) medication in African Americans?

From the Guidelines

Thiazide diuretics and calcium channel blockers are the first-line antihypertensive medications for Black patients, with a preference for combination therapy including a thiazide-like diuretic plus CCB or CCB plus ARB, as recommended by the 2020 International Society of Hypertension global hypertension practice guidelines 1. The most recent and highest quality study, published in 2020, suggests that Black patients develop hypertension and associated organ damage at younger ages and have a higher risk of kidney disease, stroke, heart failure, and mortality than other ethnic groups 1. Key considerations for managing hypertension in Black patients include:

• Annual screening for hypertension in adults 18 years and older
• Lifestyle modification with a focus on salt restriction, increased intake of vegetables and fruits, weight management, and reducing alcohol intake
• First-line pharmacological therapy with a single pill combination including a thiazide-like diuretic plus CCB or CCB plus ARB
• Preference for ARBs over ACE inhibitors due to the higher risk of angioedema in Black patients 1 Some studies suggest that ACE inhibitors and ARBs are less effective as monotherapy in Black patients unless there are compelling indications such as chronic kidney disease or heart failure 1. However, the 2020 International Society of Hypertension global hypertension practice guidelines provide the most recent and highest quality recommendations for managing hypertension in Black patients, prioritizing combination therapy with a thiazide-like diuretic plus CCB or CCB plus ARB 1. Additionally, the 2022 harmonization of the American College of Cardiology/American Heart Association and European Society of Cardiology/European Society of Hypertension blood pressure/hypertension guidelines supports the use of combination therapy in Black patients and recommends initial antihypertensive drug therapy with a thiazide-type diuretic or CCB 1. When starting treatment, it is recommended to begin with the lower dose and titrate up if blood pressure remains uncontrolled after 2-4 weeks, with combination therapy necessary if blood pressure is significantly elevated (>20/10 mmHg above goal) 1. Lifestyle modifications, including sodium restriction, weight loss, regular exercise, and limiting alcohol consumption, should accompany pharmacological treatment for optimal blood pressure control 1.

From the FDA Drug Label

Some antihypertensive drugs have smaller blood pressure effects (as monotherapy) in black patients, and many antihypertensive drugs have additional approved indications and effects (e.g., on angina, heart failure, or diabetic kidney disease). The FDA drug label does not answer the question.

From the Research

Anti-Hypertensive Treatment in Blacks

• The first-line treatment for hypertension in blacks is a topic of discussion among medical professionals, with various studies providing insights into the most effective approaches 2, 3, 4, 5, 6.
• According to the study published in 2007, the primary means of prevention and early treatment of hypertension in African Americans will be the appropriate use of lifestyle modification, and the choice of drugs for combination therapy in African American patients may be different 2.
• The study published in 2005 suggests that effective combinations for blacks include beta-adrenoceptor antagonist/diuretic, ACE inhibitor/diuretic, ACE inhibitor/calcium channel antagonist, and angiotensin receptor antagonist/diuretic 3.
• Another study published in 2005 found that diuretic-based treatment resulted in the lowest risk of heart failure in both black and nonblack hypertensive patients, and thiazide-type diuretics remain the drugs of choice for initial therapy of hypertension in both black and nonblack hypertensive patients 4.
• A review published in 2022 states that first-line drug therapy for hypertension consists of a thiazide or thiazidelike diuretic, an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, and a calcium channel blocker, and should be titrated according to office and home SBP/DBP levels to achieve target blood pressure levels 5.
• However, the Eighth Joint National Committee (JNC-8) published hypertension guidelines that varied depending on patient race, with different treatment recommendations for Black and non-Black patients, removing ACE inhibitors and ARBs from the algorithm for Black patients 6.

Key Findings

• Thiazide-type diuretics are often recommended as the first-line treatment for hypertension in blacks 4, 5.
• Combination therapy may be necessary to reach appropriate blood pressure goals in African American patients 2, 3.
• The choice of drugs for combination therapy in African American patients may be different due to varying responsiveness to monotherapy with ACE inhibitors, angiotensin receptor blockers, and beta blockers 2.