From the Guidelines
African Americans with hypertension should be treated with first-line antihypertensive therapy that includes calcium channel blockers or thiazide diuretics, as these medications are more effective in this population due to their pathophysiology of hypertension, which frequently involves salt sensitivity and volume expansion rather than high renin states. This approach is supported by the most recent and highest quality study, which is the 2020 International Society of Hypertension Global Hypertension Practice Guidelines 1. According to this guideline, first-line pharmacological therapy for African Americans with hypertension should include a single pill combination of a thiazide-like diuretic plus a calcium channel blocker (CCB) or a CCB plus an angiotensin receptor blocker (ARB).
The rationale behind this recommendation is based on the physiological differences in African Americans, including a suppressed renin-angiotensin-aldosterone system (RAAS), altered renal sodium handling, increased cardiovascular reactivity, and early vascular aging (large artery stiffness) 1. These differences result in a higher frequency of resistant and nighttime hypertension, and a higher risk of kidney disease, stroke, heart failure, and mortality compared to other ethnic groups.
Key points to consider in the management of hypertension in African Americans include:
- Annual screening for hypertension is advised for adults 18 years and older
- Lifestyle modification should focus on salt restriction, increased intake of vegetables and fruits (potassium intake), weight management, and reducing alcohol intake
- First-line pharmacological therapy should include a single pill combination of a thiazide-like diuretic plus a CCB or a CCB plus an ARB
- Among RAS-inhibitors, ARBs may be preferred as angioedema is about 3 times more likely to occur with ACE inhibitors among black patients
It is essential to regularly monitor blood pressure, kidney function, and electrolytes when initiating or adjusting antihypertensive medications in African American patients. Additionally, if blood pressure remains uncontrolled on first-line therapy, adding a medication from a different class is recommended. The 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults also supports the use of thiazide-type diuretics or CCBs as initial antihypertensive treatment in black adults with hypertension but without heart failure or chronic kidney disease, including those with diabetes 1.
From the Research
Renin Elevation and BP Control in African Americans
- Renin angiotensin system (RAS) inhibitors are often not recommended as initial therapy in African Americans with hypertension due to a greater likelihood of having a low renin profile 2.
- Despite lower circulating renin levels, numerous clinical trials support the efficacy of RAS inhibitors to improve clinical outcomes in African Americans, especially in those with hypertension and risk factors for cardiovascular and related diseases 2.
- 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 3.
Treatment of Hypertension in African Americans
- Thiazide diuretics are effective in African Americans and are often used as initial therapy 4, 5.
- Calcium channel blockers (CCBs) are attractive alternatives to thiazides in patients uncontrolled by or intolerant of thiazides or who have specific indications for these agents 4.
- Angiotensin-converting enzyme inhibitors (ACEIs) are less effective in African Americans when used as monotherapy, but have particular value in therapy for African Americans with concomitant congestive heart failure and may protect against progression of diabetic nephropathy 4, 5.
Hypertension Outcomes in African Americans
- National guidelines recommend different pharmacologic management of hypertension for Black Americans compared with non-Black Americans, and providers seem to be following these guidelines 6.
- However, hypertension control for Black Americans remains worse than non-Black Americans, with 46.4% of Black Americans having uncontrolled hypertension compared with 39.0% of non-Black Americans 6.
- An individualized approach to hypertension therapy for all patients may be more important than race-based guidelines 6.