Some clinical studies suggest that black people have a better blood pressure response to thiazide diuretics than white people.1-3 Studies also show black people have a better blood pressure response to thiazides than to angiotensin converting enzyme (ACE) inhibitors.1-3
In the landmark Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), the percentages of non-black people achieving a blood pressure less than 140/90 mm Hg at four years were 69% in the chlorthalidone group, 69% in the amlodipine group, and 67%, in the lisinopril group.3 Among black people these percentages were 63% for chlorthalidone, 60% for amlodipine, and 54% for lisinopril, suggesting that black patients respond better to chlorthalidone than amlodipine or lisinopril, whereas white patients responded very similarly to all three.3 In addition to improved blood pressure control among black participants, stroke was decreased by 40% in the chlorthalidone group compared to the lisinopril group.3 The six-year rate of stroke per 100 black persons was 6.0 (SE 0.4) in the chlorthalidone group and 8.0 (SE 0.6) in the lisinopril group [RR 1.40 (1.17-1.68) p<0.001].3 For the combined CVD outcome (≥1 of combined CHD, fatal or nonfatal stroke, non-hospitalized treated angina, heart failure, and treated peripheral arterial disease) the six-year rate was 26.8 (SE 0.7) in the chlorthalidone group and 28.4 (SE 1.0) in the lisinopril group [RR 1.19 (1.09-1.3) p<0.001].3
According to the 2017 High Blood Pressure Clinical Practice Guideline, pharmacological treatment for black hypertensives should be initiated with a thiazide-type diuretic or with a calcium channel blocker (CCB).4 The 2010 update of the International Society on Hypertension in Blacks consensus statement, states that if blood pressure is ≤10 mm Hg above target levels, monotherapy with a diuretic or calcium channel blocker is preferred.5
- Comparison of propranolol and hydrochlorothiazide for thr initial treatment of hypertension. I. Results of short-term titration with emphasis on racial differences in response. Veterans Administration Cooperative Study Group on Antihypertensive agents. JAMA. Oct 22 1982;248(16):1996-2003.
- Materson BJ, Reda DJ, Cushman WC, et al. Single-drug therapy for hypertension in men. A comparison of six antihypertensive agents with placebo. The Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents. N Engl J Med. Apr 1 1993;328(13):914-921.
- Wright JT, Jr., Dunn JK, Cutler JA, et al. Outcomes in hypertensive black and nonblack patients treated with chlorthalidone, amlodipine, and lisinopril. JAMA. Apr 6 2005;293(13):1595-1608.
- Whelton PK, Carey RM, Aronow WS, et al. 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. A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. 2017.
- Flack JM, Sica DA, Bakris G, et al. Management of high blood pressure in Blacks: an update of the International Society on Hypertension in Blacks consensus statement. Hypertension. Nov 2010;56(5):780-800.