What is the recommended initial antihypertensive medication for an African American patient with hypertension?

Initial Antihypertensive Medication for African American Patients

Start with either a thiazide-type diuretic (chlorthalidone 12.5-25 mg daily preferred over hydrochlorothiazide 25-50 mg daily) or a calcium channel blocker (amlodipine 5-10 mg daily) as first-line monotherapy for African American patients with newly diagnosed hypertension. 1, 2

Why These Agents Are Preferred

• Thiazide diuretics and calcium channel blockers are significantly more effective at lowering blood pressure in African Americans compared to ACE inhibitors, ARBs, or beta blockers when used as monotherapy. 1, 3, 2

• Chlorthalidone is the preferred thiazide diuretic because it has superior cardiovascular disease risk reduction data and a longer therapeutic half-life compared to hydrochlorothiazide. 1, 2

• Amlodipine demonstrates equal effectiveness to chlorthalidone for blood pressure reduction and cardiovascular outcomes, though it is less effective at preventing heart failure specifically. 1

Critical Pitfall to Avoid

• Do not start with ACE inhibitors or ARBs as monotherapy in African American patients—they are significantly less effective as single agents in this population. 2, 4

• African Americans have a substantially greater risk of angioedema with ACE inhibitors compared to other racial groups, which is an additional safety concern. 1, 3, 2

When to Start with Combination Therapy

If blood pressure is >15/10 mmHg above the goal of <130/80 mmHg, initiate combination therapy immediately rather than monotherapy. 1, 2

Preferred Initial Combinations:

• CCB + thiazide diuretic 1
• CCB + ARB (low-dose) 1, 3
• Single-tablet combinations are particularly effective for achieving blood pressure control in African Americans 1, 3

Treatment Algorithm

1. Assess baseline blood pressure relative to goal (<130/80 mmHg): 2

2. If BP is <15/10 mmHg above goal:

   • Start monotherapy with chlorthalidone 12.5-25 mg daily OR amlodipine 5-10 mg daily 1, 2
   • Increase to full dose after 2-4 weeks if target not achieved 2
   • Add second agent (the other first-line class) if BP remains uncontrolled 2

3. If BP is >15/10 mmHg above goal:

   • Start combination therapy with CCB + thiazide diuretic OR CCB + low-dose ARB 1, 3
   • Progress to triple therapy (CCB + thiazide + ARB/ACE inhibitor) if needed 1

4. Target achievement within 3 months of initiating therapy 3, 2

Important Reality Check

Most African American patients will require two or more antihypertensive medications to achieve and maintain blood pressure control below <130/80 mmHg. 1, 3, 2, 5 This is not treatment failure—it reflects the pathophysiology of hypertension in this population and should be anticipated from the outset.

Special Clinical Scenarios Where ACE Inhibitors/ARBs Are Indicated

Despite reduced efficacy as monotherapy, ACE inhibitors or ARBs should be included as part of multidrug regimens in these specific situations:

• Chronic kidney disease with proteinuria: ACE inhibitors or ARBs are recommended as components of combination therapy 1, 2
• Heart failure: Add beta-blockers to the regimen along with other agents 1, 2
• Post-myocardial infarction: Beta-blockers are recommended 1
• Diabetes with kidney disease: Include ACE inhibitor or ARB in the combination regimen 6

Dosing Specifics

• Chlorthalidone: 12.5-25 mg daily 1, 2
• Hydrochlorothiazide: 25-50 mg daily (higher doses more effective in Black patients) 1, 3
• Amlodipine: 5-10 mg daily 2

Monitoring Strategy

• Aim to reduce blood pressure by at least 20/10 mmHg from baseline 3, 2
• Achieve target BP <130/80 mmHg within 3 months 3, 2
• If uncontrolled on combination therapy, increase to full doses before adding third agent 3