Antihypertensive Therapy for African American Patients with Diastolic Dysfunction

First-Line Therapy Options

The American College of Cardiology recommends thiazide-type diuretics or calcium channel blockers as first-line therapy for African American patients with diastolic dysfunction and preserved ejection fraction, with combination therapy often required to achieve adequate blood pressure control 1, 2
Thiazide-type diuretics, such as chlorthalidone 12.5-25 mg/day or hydrochlorothiazide 25-50 mg/day, are more effective in lowering blood pressure and reducing cardiovascular disease events in African Americans than renin-angiotensin system inhibitors 1, 2
Calcium channel blockers, such as amlodipine, are as effective as chlorthalidone in reducing blood pressure, cardiovascular disease, and stroke events in African Americans 1, 2

Most African American patients with hypertension will require two or more antihypertensive medications to achieve adequate blood pressure control, according to the American College of Cardiology 1, 2
A single-tablet combination that includes either a diuretic or a calcium channel blocker may be particularly effective in achieving blood pressure control in African Americans 1, 2

Beta-blockers, ACE inhibitors, ARBs, or calcium channel blockers may be effective in minimizing symptoms of heart failure in patients with preserved ejection fraction and hypertension, with a Class IIb recommendation and Level of Evidence C 4
Aldosterone receptor antagonists, such as spironolactone or eplerenone, should be considered for patients with resistant hypertension, particularly when combined with a thiazide diuretic, as recommended by the American Heart Association 4, 5

African Americans have a greater risk of angioedema with ACE inhibitors compared to other racial groups, according to the American College of Cardiology 1, 2
Non-dihydropyridine calcium channel blockers, clonidine, moxonidine, and hydralazine without a nitrate should be avoided in patients with heart failure with reduced ejection fraction, with a Class III Harm recommendation and Level of Evidence B 4

The target blood pressure is <140/90 mm Hg, but consideration can be given to lowering blood pressure even further to <130/80 mm Hg, as recommended by the American Heart Association 4
In older hypertensive individuals with wide pulse pressures, monitor for very low diastolic blood pressure values (<60 mm Hg) which may cause myocardial ischemia and worsening heart failure 4