What is the most effective antihypertensive medication for a black patient with hypertension?

Best Blood Pressure Medication for Black Patients

For Black patients with hypertension, initial therapy should be either a thiazide-type diuretic or a calcium channel blocker (CCB), not an ACE inhibitor or ARB. 1

First-Line Therapy Recommendations

The American College of Cardiology/American Heart Association (ACC/AHA) 2017 guidelines explicitly state that initial antihypertensive treatment in Black adults should include a thiazide-type diuretic or CCB. 1 This recommendation is based on superior efficacy and cardiovascular outcomes in this population.

Preferred First-Line Options:

• Thiazide-like diuretics: Chlorthalidone 12.5-25 mg once daily or indapamide 1.25-2.5 mg once daily are preferred over hydrochlorothiazide for superior cardiovascular outcomes. 1

• Calcium channel blockers: Amlodipine 5-10 mg once daily is the most commonly studied and effective CCB in Black patients. 2, 1

Evidence Supporting This Approach

The landmark ALLHAT trial demonstrated that in Black hypertensive patients, chlorthalidone resulted in lower rates of heart failure, stroke, and combined cardiovascular disease compared to lisinopril (an ACE inhibitor). 3 Specifically, lisinopril showed a 40% increased risk of stroke (RR 1.40,95% CI 1.17-1.68) and 19% increased risk of combined CVD (RR 1.19,95% CI 1.09-1.30) compared to chlorthalidone in Black patients. 3

Black patients characteristically have low-renin hypertension, which explains why they respond better to diuretics and calcium channel blockers than to ACE inhibitors or ARBs as monotherapy. 4, 5

When to Add a Second Agent

If blood pressure remains uncontrolled on maximum-dose monotherapy (e.g., amlodipine 10 mg), the International Society of Hypertension guidelines recommend adding either a thiazide-like diuretic or an ARB/ACE inhibitor as the second agent. 1

For Black patients specifically, the combination of CCB plus thiazide diuretic may be more effective than CCB plus ACE inhibitor/ARB. 2

Triple Therapy Algorithm:

• If starting with a CCB: Add thiazide diuretic first, then ARB/ACE inhibitor if needed. 2, 1
• If starting with a thiazide: Add CCB first, then ARB/ACE inhibitor if needed. 1

Target Blood Pressure

• Primary target: <130/80 mmHg for most patients. 1
• Minimum acceptable: <140/90 mmHg. 1
• Achieve target within 3 months of treatment initiation or adjustment. 1

Critical Clinical Caveats

Before escalating therapy, always verify medication adherence and confirm diagnosis with home or ambulatory BP monitoring. 1 Non-adherence is the most common cause of apparent treatment resistance. 2

Check for secondary hypertension if BP remains severely elevated or resistant to triple therapy. 1 This includes screening for primary aldosteronism, renal artery stenosis, and obstructive sleep apnea. 2

Consider single-pill combinations to improve adherence and simplify the regimen. 1 Fixed-dose combinations significantly improve medication persistence compared to separate pills. 2

Why ACE Inhibitors/ARBs Are Less Effective as Monotherapy

Multiple studies confirm that Black patients have smaller blood pressure reductions with ACE inhibitors or ARBs as monotherapy compared to diuretics or CCBs. 5, 6 However, ACE inhibitors and ARBs remain effective when combined with CCBs or diuretics, particularly in patients with compelling indications such as chronic kidney disease, diabetes, or heart failure. 2, 1

The response to ACE inhibitors is directly related to baseline plasma renin activity, which tends to be lower in Black patients, explaining the reduced efficacy. 6 In contrast, the response to calcium channel blockers is independent of baseline renin activity and tends to be greater with higher initial blood pressure. 6