Initial Antihypertensive Medication for Black Males

First-Line Monotherapy Options

• The American College of Cardiology recommends starting with either a thiazide-type diuretic (chlorthalidone 12.5-25 mg daily or hydrochlorothiazide 25-50 mg daily) or a calcium channel blocker (amlodipine 5-10 mg daily) as first-line monotherapy for black males with newly diagnosed hypertension 1, 2
• Chlorthalidone is the preferred thiazide due to superior cardiovascular outcome data and longer half-life compared to hydrochlorothiazide 1
• Thiazide diuretics are more effective than ACE inhibitors or ARBs at lowering blood pressure in black patients 1, 2
• Amlodipine is equally effective as chlorthalidone for blood pressure reduction and cardiovascular outcomes in black patients 1

Combination Therapy

• If blood pressure is >15/10 mmHg above goal, start with combination therapy immediately rather than monotherapy 1
• Most black patients will require two or more medications to achieve target BP <130/80 mmHg 1, 2

Critical Pitfalls to Avoid

• ACE inhibitors and ARBs are significantly less effective as monotherapy in black patients 1
• Black patients have a greater risk of angioedema with ACE inhibitors 1, 2

Titration Algorithm

• Start with monotherapy (thiazide or CCB) if BP is <15/10 mmHg above goal 1
• Increase to full dose after 2-4 weeks if target not achieved 3
• Add second agent (the other first-line class not initially chosen) if BP remains uncontrolled 3, 1

Target Blood Pressure and Monitoring

• Target BP is <130/80 mmHg with goal to reduce BP by at least 20/10 mmHg 3, 1
• Achieve target within 3 months of initiating therapy 3, 2

Special Clinical Scenarios

• For patients with chronic kidney disease with proteinuria, include ACE inhibitor or ARB as part of multidrug regimen 1
• For patients with heart failure, add beta-blocker to the regimen 1
• For patients with diabetes, the same first-line recommendations apply (thiazide or CCB) 1