Which antihypertensive treatments are most effective in black patients?

Updated: Feb 22, 2019
  • Author: Matthew R Alexander, MD, PhD; Chief Editor: Eric H Yang, MD  more...
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Answer

The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure ("JNC 8") recommends initiating therapy with a thiazide-type diuretic or calcium channel blocker (CCB) in black patients with hypertension. [88, 89]  In addition, regardless of race or diabetes status, in patients 18 years or older with CKD, initial or add-on therapy should consist of an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB) but not both (ie, do not use an ACEI and an ARB in the same patient). [88, 89]

Beta-blocker, ACEI, or ARB monotherapy in black patients may be less effective for BP reduction than in white patients. [5]  In the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), thiazide-type diuretics or CCBs were more effective than ACEIs in black patients. However, combination therapy with a diuretic and agents of the other drug classes eliminated the differences in BP reduction between racial groups. [5]  In general, therapy is initiated at the lowest recommended dose of the selected agent; then, it is titrated upward, or another drug is added to reach the goal BP. [7]

In one study, Weinberger et al reported that the combination of aliskiren and amlodipine, a calcium channel blocker, was more effective than amlodipine alone in treating black patients with stage 2 hypertension and obesity or metabolic syndrome. [105]  However, in December 2011, Novartis, the manufacturer of aliskiren, terminated the ALTITUDE study because of an increased incidence of adverse events (nonfatal stroke, renal complications, hyperkalemia, hypotension) when aliskiren was added to ACEI or ARB therapy. The study involved patients with type 2 diabetes and renal impairment at high risk for cardiovascular and renal events.


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