The 2017 clinical practice hypertension guidelines from the American College of Cardiology (ACC)/American Heart Association (AHA), state that a thiazide-type diuretic or a calcium channel blocker should be part of initial antihypertensive treatment for black adults with hypertension who do not have heart failure or chronic kidney disease, including those with diabetes mellitus. (Strong Recommendation (Level B – Randomized Trials)].1 Based on the evidence, the International Society on Hypertension in Blacks (ISHB) also recommends monotherapy with a thiazide-type diuretic or calcium channel blocker for blacks with blood pressure ≤10 mm Hg above target levels.2
People of black African descent tend to have higher blood pressure at an earlier age than people of white European descent.2-7 It is often more difficult to control.2,3,6,7 They also have a higher incidence of diabetes and higher and earlier rates of cardiovascular mortality with more renal and cardiac organ damage.2,3,6-9
Studies have shown that initial treatment of hypertensive blacks with a thiazide diuretic or a calcium channel blocker is the most effective and associated with lower rates of adverse cardiovascular outcomes than starting treatment with drugs that are first-line treatment choices for white patients, such as an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB).3,8
The large Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial8 found a thiazide-type diuretic was more effective in preventing cerebrovascular, heart failure, and combined cardiovascular outcomes compared to an ACE inhibitor in the black patient subgroup, which included large numbers of diabetic and nondiabetic patients. It also found there were no differences in outcomes (cerebrovascular, coronary heart disease, combined cardiovascular, and kidney outcomes, or overall mortality) between the thiazide-type diuretic and calcium channel blocker.
The 2017 ACC/AHA hypertension guidelines recommend starting adults with hypertension, especially black adults, on two or more antihypertensive medications to help them reach a blood pressure target of less than 130/80 mm Hg. [Strong Recommendation (Level of Evidence C – Limited Data)].1 For blacks with blood pressure more than 15/10 mm Hg above target, the ISHB also recommends a two-drug regimen that includes one of the preferred drugs combined with a small dose of an ACE inhibitor or ARB.2
A 2016 systematic review3 analyzed 35 trials with a total of 25 540 patients with African ancestry. They found that most patients reached their blood pressure goal (50% – 70%), but 95% of those who reached their goal needed combination therapy. Thiazide and thiazide-like diuretics and calcium channel blockers were significantly more effective at lowering both systolic and diastolic blood pressures in black patients compared to ACE inhibitors, ARBs, alpha-adrenergic blockers, and beta blockers.
References
- 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: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension 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 2010; 56 (5): 780-800.
- Brewster LM, van Montfrans GA, Oehlers GP, Seedat YK. Systematic review: antihypertensive drug therapy in patients of African and South Asian ethnicity. Intern Emerg Med 2016; 11 (3): 355-374.
- Nwankwo T, Yoon SS, Burt V, Gu Q. Hypertension among adults in the United States: National Health and Nutrition Examination Survey, 2011-2012. NCHS Data Brief 2013; (133): 1-8.
- Racial/Ethnic disparities in the awareness, treatment, and control of hypertension - United States, 2003-2010. MMWR Morb Mortal Wkly Rep 2013; 62 (18): 351-355.
- Still CH, Craven TE, Freedman BI, et al. Baseline characteristics of African Americans in the Systolic Blood Pressure Intervention Trial. J Am Soc Hypertens 2015; 9 (9): 670-679.
- Flack JM, Ferdinand KC, Nasser SA. Epidemiology of hypertension and cardiovascular disease in African Americans. J Clin Hypertens (Greenwich) 2003; 5 (1 Suppl 1): 5-11.
- Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA 2002; 288 (23): 2981-2997.
- Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics-2016 update: a report from the American Heart Association. Circulation 2016; 133 (4): e38-360.
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