What is the recommended initial treatment for hypertension in a 55-year-old African-American male?

Initial Antihypertensive Treatment for a 55-Year-Old African-American Male

For a 55-year-old African-American male with hypertension, start with either amlodipine (a calcium channel blocker) 5-10 mg daily or chlorthalidone (a thiazide-type diuretic) 12.5-25 mg daily as first-line monotherapy. 1, 2

Preferred First-Line Options

Calcium Channel Blocker (Amlodipine)

• Amlodipine 5-10 mg once daily is equally effective as chlorthalidone for blood pressure reduction and cardiovascular outcomes in African-American patients 2, 3
• Amlodipine demonstrated superior stroke prevention compared to ACE inhibitors in black patients 3
• FDA-approved for hypertension with proven efficacy in reducing cardiovascular morbidity and mortality 4

Thiazide-Type Diuretic (Chlorthalidone)

• Chlorthalidone 12.5-25 mg daily is the preferred thiazide due to superior cardiovascular outcome data and longer half-life compared to hydrochlorothiazide 2, 5
• In the ALLHAT trial, chlorthalidone was superior to lisinopril in black patients for preventing stroke (40% risk reduction) and heart failure (30% risk reduction) 3
• Thiazide diuretics are more effective than ACE inhibitors or ARBs at lowering blood pressure in black patients 2, 5

Critical Pitfalls to Avoid

Do NOT start with an ACE inhibitor or ARB as monotherapy in this patient 2, 5:

• ACE inhibitors and ARBs are significantly less effective as monotherapy in African-American patients 2, 5
• Black patients have a greater risk of angioedema with ACE inhibitors 5
• In ALLHAT, lisinopril resulted in 40% higher stroke risk and 19% higher combined cardiovascular disease risk compared to chlorthalidone in black patients 3

When to Start Combination Therapy

If blood pressure is >15/10 mmHg above goal (i.e., >145/90 mmHg), start with combination therapy immediately 2:

• Preferred combination: Amlodipine + chlorthalidone 1, 5
• Alternative combination: Amlodipine + ARB (low-dose) 1
• Most African-American patients will require two or more medications to achieve target BP <130/80 mmHg 2, 5

Treatment Titration Algorithm

Step 1 (Monotherapy): Start amlodipine 5 mg daily OR chlorthalidone 12.5 mg daily 2, 5

Step 2 (2-4 weeks later): If BP not at goal, increase to full dose (amlodipine 10 mg or chlorthalidone 25 mg) 1, 2

Step 3 (2-4 weeks later): If BP remains uncontrolled, add the other first-line class not initially chosen (CCB + thiazide combination) 1, 5

Step 4 (If still uncontrolled): Add ARB or ACE inhibitor to the CCB + thiazide combination 1, 5

Step 5 (Resistant hypertension): Add spironolactone 25-50 mg daily, or if not tolerated, consider amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 1

Target Blood Pressure and Monitoring

• Target BP is <130/80 mmHg with goal to reduce BP by at least 20/10 mmHg 1, 2
• Achieve target within 3 months of initiating therapy 1, 2
• Review and adjust treatment every 2-4 weeks until BP is controlled 1
• Use home blood pressure monitoring to confirm office readings 1

Special Clinical Scenarios

If chronic kidney disease with proteinuria is present: Include an ACE inhibitor or ARB as part of a multidrug regimen (not as monotherapy) 5, 6

If heart failure is present: Add a beta-blocker to the regimen 5

If diabetes is present: The same first-line recommendations apply (thiazide or CCB), with target BP <130/80 mmHg 2, 5

Evidence Quality Note

The 2020 International Society of Hypertension guidelines 1 and the American College of Cardiology recommendations 2, 5 provide the most current evidence-based approach. The ALLHAT trial 3, the largest hypertension outcomes trial ever conducted with over 11,000 black participants, provides the strongest evidence that chlorthalidone and amlodipine are superior to lisinopril in African-American patients for preventing cardiovascular events.