Race-based Therapy for Hypertension: Possible Benefits and Potential Pitfalls

Keith C. Ferdinand; Daphne P. Ferdinand


Expert Rev Cardiovasc Ther. 2008;10(6):1357-1366. 

In This Article

Antihypertension Therapy Response in Black Patients

Monotherapy for BP-lowering in Blacks may be more effective with thiazide diuretics and long-acting CCBs than β-blockers, angiotensin-converting enzyme inhibitors (ACEIs), or angiotensin receptor blockers (ARBs).[10] For all patient groups, including Blacks, thiazide diuretics are effective as initial therapy and are well-tolerated medications. As first-line therapy in Blacks, diuretics reduce BP, stroke, HF and overall CVD.[36] Moreover, when additional agents are needed, the thiazide diuretics increase the efficacy of agents such as β-blockers, ACEIs and ARBs. Long-acting CCBs, of both dihydropyridine and nondihydropyridine types, reduce BP, stroke and cardiovascular events effectively in Blacks. At least two large trials, The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), with amlodipine, and the International Verapamil-Trandolapril Study (INVEST), with verapamil SR, have demonstrated cardiovascular benefits in Blacks using long-acting CCB-based therapies.[36,37] While in ALLHAT, lisinopril, starting at 20 mg with a goal of 40 mg, lowered BP (with increased stroke) less effectively than chlorthalidone in INVEST, a long-acting CCB added to larger doses of the ACEI (trandolapril) demonstrated similar BP-lowering and outcomes in Blacks as compared with Whites.

Nevertheless, race is not a powerful predictor of drug response in any individual, and race alone should not be the basis for clinical decisions regarding the class of antihypertensive drug utilized. A meta-analysis of 15 clinical trials demonstrated that a vast majority of Whites and Blacks respond similarly to commonly used antihypertensive drugs.[38] Furthermore, there appeared to be wide variation in drug-associated changes in BP within each race. Manual and computerized searches of MEDLINE (1983 to March 2003) with a total of 9307 White subjects and 2902 Black subjects noted drug-associated changes in diastolic BP. The mean difference between Whites and Blacks ranged from 0.6 to 3.0 mmHg, with a standard deviation within each race of 5.0-10.1 mmHg. The percentage of Whites and Blacks with similar changes in systolic BP ranged from 83 to 93%. The authors concluded that choices of specific medications should not be based on race alone.


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