What is the optimal first‑line antihypertensive regimen for a 48‑year‑old African‑American woman with hypertension?

Optimal First-Line Treatment for Hypertension in a 48-Year-Old African American Woman

Start with either a thiazide diuretic (preferably chlorthalidone 12.5-25 mg daily) or a calcium channel blocker (such as amlodipine) as first-line monotherapy, with the expectation that combination therapy will likely be needed to achieve blood pressure control. 1

Primary Treatment Recommendation

First-Line Monotherapy Options

For African American patients, the evidence strongly supports two preferred initial options:

• Thiazide or thiazide-like diuretics are more effective than ACE inhibitors or ARBs in lowering blood pressure and reducing cardiovascular events in Black patients 1
• Calcium channel blockers (CCBs) demonstrate equivalent efficacy to thiazide diuretics for blood pressure reduction and cardiovascular event prevention in this population 1

Specific Drug and Dosing

Chlorthalidone is the preferred thiazide diuretic over hydrochlorothiazide (HCTZ) based on superior outcomes data:

• Chlorthalidone should be dosed at 12.5-25 mg daily for optimal endpoint protection 1
• If using HCTZ instead, the dose should be 25-50 mg daily 1, 2
• Chlorthalidone has more cardiovascular disease risk reduction data, longer therapeutic half-life, and more effective 24-hour blood pressure control than HCTZ 1

Amlodipine is the preferred CCB if choosing this class:

• Amlodipine is as effective as chlorthalidone in reducing blood pressure, cardiovascular disease, and stroke events 1
• CCBs are less effective than thiazides at preventing heart failure 1

Anticipated Need for Combination Therapy

Most African American patients with hypertension require two or more medications to achieve adequate blood pressure control 1, 2:

• When adding a second agent, combine a thiazide diuretic with a CCB for optimal efficacy 1
• Single-tablet combination products containing a diuretic plus CCB may be particularly effective in Black patients 1, 2
• The combination of these two classes produces similar blood pressure lowering in Black patients as in other racial groups 1

Important Considerations Specific to African American Patients

Why NOT to Start with ACE Inhibitors or ARBs as Monotherapy

• ACE inhibitors and ARBs are less effective as monotherapy in Black patients compared to thiazides or CCBs for both blood pressure reduction and cardiovascular event prevention 1
• Black patients have a greater risk of angioedema with ACE inhibitors compared to other racial groups 1, 2
• These agents should be reserved for specific compelling indications (diabetes with nephropathy, chronic kidney disease, heart failure) or as part of combination therapy 1

Treatment Targets

• Target blood pressure should be <130/80 mmHg based on current ACC/AHA guidelines 2, 3
• Aim to achieve target blood pressure within 3 months of initiating therapy 2

Clinical Algorithm

Step 1: Initiate chlorthalidone 12.5-25 mg daily OR amlodipine 5-10 mg daily 1

Step 2: If blood pressure remains uncontrolled after 4 weeks at adequate doses, add the other first-line agent (thiazide + CCB combination) 1, 2

Step 3: If blood pressure remains uncontrolled on two drugs, add an ACE inhibitor or ARB as the third agent 1

Step 4: For resistant hypertension on three drugs, consider adding spironolactone or a beta-blocker 1

Common Pitfalls to Avoid

• Do not start with ACE inhibitor or ARB monotherapy in an African American patient without compelling indications (such as diabetic nephropathy or heart failure), as these are less effective than thiazides or CCBs in this population 1
• Do not use HCTZ at doses <25 mg daily as lower doses are either unproven or less effective in clinical outcome trials 1
• Do not combine ACE inhibitors with ARBs, as this combination is not recommended 1
• Do not delay adding a second medication if monotherapy is insufficient, as most Black patients require combination therapy 1, 2