INTRODUCTION — Hypertension is a major problem in Black patients; the incidence and prevalence of cardiovascular and renal complications of hypertension are greater than in other race/ethnicity groups [1]. The adjusted relative risk of stroke, for example, is more than twice as high in hypertensive Black patients aged 45 to 64 years as compared with similarly aged hypertensive White patients (table 1) [2]. As a result, effective antihypertensive therapy is particularly important in these patients [3]. (See "Hypertensive complications in Black individuals".)

Goal blood pressure in hypertensive patients, including Black patients, is discussed elsewhere (table 2). (See "Goal blood pressure in adults with hypertension".)

The majority of the disparity in hypertension control is accounted for by lower control rates in Black males as compared with White males (table 3). In addition to needing more widespread and effective therapy of Black patients with hypertension, novel methods to enhance screening, patient education, and management of drug therapy, such as methods illustrated by the barber-based interventional trials [4,5], may increase hypertension control in Black males and improve racial equity in hypertension control.

CHOICE OF ANTIHYPERTENSIVE DRUGS — The optimal choice of drug or combination of drugs in Black patients principally depends upon the presence or absence of comorbid conditions and the specific efficacy of the agent(s) to attain goal blood pressure [6]. Overall, the initial choice of antihypertensive drugs in Black patients is similar to that in older adults.

Overview — Recommendations about the choice of antihypertensive therapy are presented elsewhere. Briefly:

●Initial antihypertensive therapy usually consists of a single drug or combination of two drugs. If monotherapy is used for Black hypertensive patients, we suggest a dihydropyridine calcium channel blocker, although a thiazide diuretic such as chlorthalidone is a reasonable alternative [7-10]. The use of these two classes of drugs as initial antihypertensive therapy in Black patients is also endorsed by the American College of Cardiology and American Heart Association (ACC/AHA) and the European Societies of Hypertension and Cardiology (ESH/ESC) [1,11]. (See "Choice of drug therapy in primary (essential) hypertension", section on 'Initial monotherapy'.)

●If a combination of two drugs is used initially, or if combination therapy is used because monotherapy is insufficient, we suggest a dihydropyridine calcium channel blocker combined with either an angiotensin-converting enzyme (ACE) inhibitor or angiotensin II receptor blocker (ARB) [7,8]. However, in patients with edema or other signs of hypervolemia, combination therapy with a thiazide diuretic and either an ACE inhibitor or ARB may be most effective. (See "Choice of drug therapy in primary (essential) hypertension", section on 'Combination therapy'.)

●For Black hypertensive patients not controlled on the combination of a dihydropyridine calcium channel blocker with an ACE inhibitor or ARB, we suggest addition of a diuretic (eg, chlorthalidone 12.5 to 25 mg daily) [8,10]. (See "Treatment of resistant hypertension".)

●Black patients are at greater risk for treatment resistant hypertension than White patients [12]; thus, a fourth agent may often be required. In such patients, we suggest a potassium-sparing diuretic (in particular, a mineralocorticoid receptor antagonist such as spironolactone or eplerenone) [13]. Patients who have moderate to advanced chronic kidney disease (estimated glomerular filtration rate [GFR] <45 mL/min/1.73 m²) or a baseline serum potassium >4.6 mEq/L have an increased risk for hyperkalemia [14]. Monitoring of serum potassium should be performed in all patients treated with potassium-sparing diuretics or mineralocorticoid receptor antagonists, with more frequent monitoring in those at highest risk for hyperkalemia. (See "Major side effects of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers" and "Treatment of resistant hypertension".)

The following sections present the data related to these different treatment options for Black patients with hypertension:

●Nonpharmacologic therapy

●Calcium channel blockers

●Thiazide diuretics

●ACE inhibitors or ARBs

●Potassium-sparing diuretics

Nonpharmacologic therapy — Nonpharmacologic therapy includes the Dietary Approaches to Stop Hypertension (DASH) eating plan, which lowers blood pressure to a greater degree in Black patients as compared with White patients [15], dietary salt restriction, weight loss in patients with obesity, avoidance of excess alcohol, and exercise [16,17]. (See "Overview of hypertension in adults", section on 'Treatment' and "Diet in the treatment and prevention of hypertension" and "Salt intake, salt restriction, and primary (essential) hypertension" and "Exercise in the treatment and prevention of hypertension".)

With the exception of sodium restriction and DASH [15,18], nonpharmacologic interventions to lower blood pressure have not been well studied in populations of Black individuals, but available data suggest that the major components of nonpharmacologic therapy are similarly or more effective in Black patients as they are in White patients [19]. The following reports illustrate some of the benefits:

●One study randomized 46 Black males with severe untreated hypertension to antihypertensive therapy alone or with regular exercise (45 minutes of stationary cycling three times per week) which was begun after the blood pressure was controlled [17]. The exercise group showed a further 5 mmHg reduction in blood pressure and regression of left ventricular hypertrophy, changes which were not seen in the control group.

●In a trial of 40 Black patients, four weeks of a low-sodium diet was associated with a reduction in the blood pressure from 159/101 to 151/98 mmHg [20].

Calcium channel blockers — Calcium channel blockers have proven efficacy in Black patients. This has been demonstrated in a number of trials [21-24]. As examples:

●One controlled trial evaluated the efficacy of monotherapy with six different antihypertensive drugs in almost 1300 males with initial diastolic pressures between 95 and 109 mmHg; a successful response was defined as a fall in diastolic pressure to below 90 mmHg at the end of the titration phase and 95 mmHg at one year [21,25]. The response rates in older Black patients were 85 percent for diltiazem, 64 percent for hydrochlorothiazide, and only 33 percent for captopril (figure 1).

●In a random, open-label comparative study performed in 409 South African Black males and females, the dihydropyridine calcium channel blocker (nifedipine GTS) provided a statistically greater reduction in blood pressure and control rate of hypertension than a diuretic (hydrochlorothiazide), a nondihydropyridine calcium channel blocker (sustained-release verapamil), or an ACE inhibitor (enalapril) [23].

●The Comparison of Three Combination Therapies in Lowering Blood Pressure in Black Africans (CREOLE) trial examined the effects of amlodipine plus perindopril, amlodipine plus hydrochlorothiazide, and perindopril plus hydrochlorothiazide on ambulatory blood pressure at six months in 621 hypertensive Black patients [7]. Systolic pressure was reduced by 18, 17, and 14 mmHg, respectively, and, after adjusting for age and baseline pressure, was 3 mmHg lower in the groups taking the dihydropyridine calcium channel blocker compared with the group taking an ACE inhibitor and diuretic.

●The ACCOMPLISH trial evaluated the efficacy of initial combination therapy in 11,506 hypertensive patients (1416 of whom were Black individuals [12.3 percent]) who were at high risk for cardiovascular events; almost all of whom were being treated with antihypertensive drugs [24]. The patients were randomly assigned (without a washout period) to combination therapy with benazepril (20 mg/day) plus either amlodipine (5 mg/day) or hydrochlorothiazide (12.5 mg/day); dose escalation was performed as necessary. The primary end point occurred significantly less often in the benazepril-amlodipine group (9.6 versus 11.8 percent, hazard ratio 0.80, 95% CI 0.72-0.90). Office blood pressure control and 24-hour blood pressure measurements were similar in the two groups. The results were similar in the subset of Black patients [8]. (See "Choice of drug therapy in primary (essential) hypertension", section on 'ACCOMPLISH trial'.)

Thiazide diuretics — A number of comparative studies have demonstrated that Black patients generally respond well to diuretic therapy, with the fall in blood pressure exceeding that of monotherapy with an ACE inhibitor, ARB, or a beta blocker (figure 1) [21,26,27]. This increased efficacy of diuretics (with concurrent salt restriction) suggests an important role for volume in the genesis of hypertension in these patients; the observation that Black patients have a higher frequency of salt sensitivity than White patients (as defined by a rise in blood pressure with salt loading and/or decline of blood pressure with salt restriction) is compatible with this hypothesis [16].

In addition to improved efficacy, the ALLHAT trial of patients with mild hypertension who were at increased risk for cardiovascular disease showed that chlorthalidone (12.5 to 25 mg/day) produced fewer cardiovascular complications than amlodipine or lisinopril [28]. Subset analysis showed that these benefits were as or more prominent in Black patients (figure 2A-D).

Further prespecified analyses on the subgroup of Black patients also reported specific benefits with chlorthalidone [29]. Compared with chlorthalidone:

●Amlodipine was associated with a higher risk of heart failure (relative risk [RR] 1.37, 95% CI 1.24-1.51), a difference that was similar in Black patients and other patients.

●Lisinopril was associated with an increased risk for heart failure (RR 1.3), stroke (RR 1.4), and combined cardiovascular outcomes (RR of 1.19). Although the superiority of chlorthalidone over lisinopril in reducing heart failure was observed regardless of race, the reductions in stroke and combined cardiovascular outcomes with chlorthalidone were observed only in Black patients.

These differences may have been due at least in part to a lower attained blood pressure in Black patients (mean systolic pressure 4 mmHg lower with chlorthalidone than lisinopril). However, analysis of outcomes with lisinopril and chlorthalidone using time-dependent blood pressure adjustment did not alter the conclusions concerning benefits with chlorthalidone compared with lisinopril among Black patients.

ACE inhibitors — Black patients, as a group, have a smaller blood pressure reduction than White patients in response to ACE inhibitors, ARBs, and most beta blockers when given as monotherapy (figure 1) [21,29,30]. However, these drugs are effective when given in combination with thiazide diuretics [31-33] or calcium channel blockers. In one study, for example, enalapril alone produced only a minimal antihypertensive effect, whereas combination therapy with 12.5 mg of hydrochlorothiazide lowered the blood pressure from 157/101 to 132/86 [32]. Another study demonstrated similar blood pressure lowering with combination valsartan/hydrochlorothiazide and amlodipine (16/10 and 15/9 mmHg, respectively) [33].

Chronic kidney disease — Despite the observation that Black patients are generally more responsive to calcium channel blockers than to monotherapy with ACE inhibitors, there are clear benefits to ACE inhibitors, usually in combination with other antihypertensive agents, in those with chronic kidney disease, at least that due to hypertensive nephrosclerosis. This was illustrated in the African American Study of Kidney Disease and Hypertension (AASK) [34,35].

AASK trial — The AASK trial included 1094 African Americans with long-standing hypertension, otherwise unexplained slowly progressive chronic kidney disease, and mild proteinuria (mean approximately 500 to 600 mg/day but a median of approximately 100 mg/day); this pattern in Black patients is almost always associated with histologic changes compatible with nephrosclerosis as the sole disease [36].

The patients were allocated to one of three drugs: ramipril (463 patients), metoprolol (441 patients), or amlodipine (217 patients), and to one of two blood pressure goals, 125/75 or 140/90 mmHg. The primary end point was the rate of change in GFR; the secondary clinical composite outcome was the time to first event including a 50 percent reduction in GFR, an actual decrease in GFR of 25 mL/min per 1.73 m², the onset of renal failure, or death.

At study end after approximately four years, the average blood pressure was 128/78 and 141/85 mmHg in the lower and usual blood pressure group, respectively [37,38]. The mean rate of change in GFR and the rate of the secondary composite end point were similar with both blood pressure goals, suggesting that the lower blood pressure goal may not provide further benefit in slowing the progression of renal failure. However, there was a nonsignificant trend favoring the lower blood pressure goal in patients with higher baseline proteinuria. This finding is consistent with the Modification of Diet in Renal Disease trial, in which lower blood pressure goals were most beneficial in those excreting at least 2 to 3 grams of protein per day [39,40].

With respect to the different antihypertensive agents, the following results were reported:

●Patients administered ramipril had significantly decreased risk of the secondary clinical composite outcome when compared with those given metoprolol (6.9 versus 8.7 percent per year, risk reduction 22 percent, 95% CI 1 to 38 percent) or amlodipine (risk reduction 38 percent, 95% CI 14 to 56 percent).

●Significant differences in the slope of the GFR were not consistently observed with any of the drug group comparisons. In addition, the incidence of the secondary composite outcome was similar between the amlodipine and metoprolol groups.

These findings extend consensus recommendations that an ACE inhibitor should be the first drug for renal protection in patients with proteinuric chronic renal disease to include Black patients with hypertensive nephrosclerosis [27]. (See "Antihypertensive therapy and progression of nondiabetic chronic kidney disease in adults".)

Potassium-sparing diuretics — Some Black patients, particularly those with low plasma renin activity, appear to have increased activity of the amiloride-sensitive epithelial sodium channel (ENaC) in the collecting tubule [13,41,42]. This suggests that mineralocorticoid receptor antagonism or amiloride to inhibit the ENaC may provide additional antihypertensive benefits.

The antihypertensive effects of amiloride, spironolactone, and the combination were therefore examined in 98 Black hypertensive individuals with low plasma renin activity who were already receiving a diuretic (thiazide or loop diuretic) and a calcium channel blocker [43]. Concomitant ACE inhibitor use was not allowed given concerns regarding hyperkalemia. Amiloride (10 mg), spironolactone (25 mg), and the combination successfully reduced blood pressure by 12/4, 7/3, and 14/2 mmHg, respectively, after nine weeks of treatment. In our view, the slight benefit of combination therapy with spironolactone and amiloride does not justify the increased risk of hyperkalemia (which developed only in patients on combination therapy). The larger effect of amiloride compared with spironolactone in this study may be dose related, or may reflect, in part, greater basal activity of the ENaC among Black patients that is independent of aldosterone [41].

Adherence — A variety of factors are associated with reduced adherence to antihypertensive therapy (table 4); some factors may improve adherence (table 5). (See "Patient adherence and the treatment of hypertension".)

Several methods that appear to increase adherence and control among Black patients include:

●Peer-based education – Randomized trials conducted in urban, barbershops owned by Black individuals found that hypertension control rates were significantly increased when blood pressure checks, counseling, and, in one trial, meetings with pharmacists were offered in conjunction with haircuts among Black male patrons [4,5]. In another trial, a video that conveyed the personal stories of other Black patients with hypertension significantly improved blood pressure [44].

●Single-pill combination therapy – Using single-pill antihypertensive combinations is one such method that may be particularly beneficial in Black patients with hypertension. In a retrospective cohort including 106,621 hypertensive patients, single-pill combination therapy was associated with greater blood pressure control at one year than two-pill combination therapy or monotherapy [45]. The difference in control rates comparing single-pill with two-pill combinations was larger among Black patients (63 versus 51 percent) than among White patients (73 versus 67 percent).

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Hypertension in adults".)

SUMMARY AND RECOMMENDATIONS

●Hypertension is a major problem in Black patients; the incidence and prevalence of cardiovascular and renal complications of hypertension are greater than in other race/ethnicity groups and likely reflect the higher prevalence, earlier onset, and greater severity of hypertension in Black patients. (See 'Introduction' above.)

●Most expert panels recommend similar blood pressure goals for hypertensive Black patients as compared with other patient groups. Goal blood pressure is discussed in detail elsewhere. (See "Goal blood pressure in adults with hypertension".)

●Lifestyle therapy should be offered to all Black patients with hypertension. (See 'Nonpharmacologic therapy' above.)

●Initial antihypertensive therapy usually consists of a single drug or combination of two drugs. If monotherapy is used for Black hypertensive patients, we suggest a dihydropyridine calcium channel blocker or a thiazide-like diuretic (such as chlorthalidone) rather than other drugs (Grade 2C). (See 'Overview' above and 'Calcium channel blockers' above and 'Thiazide diuretics' above.)

●If a combination of two drugs is used initially, or if combination therapy is used because monotherapy is insufficient, we suggest a dihydropyridine calcium channel blocker combined with either an angiotensin-converting enzyme (ACE) inhibitor or angiotensin II receptor blocker (ARB) (Grade 1B). However, in patients with edema or other signs of hypervolemia, combination therapy with a thiazide diuretic and either an ACE inhibitor or ARB may be most effective. (See 'Overview' above and 'Calcium channel blockers' above.)

●For Black hypertensive patients not controlled on the combination of a dihydropyridine calcium channel blocker with an ACE inhibitor or ARB, we suggest addition of a diuretic (eg, chlorthalidone 12.5 to 25 mg daily) rather than other agents (Grade 2B). (See 'Overview' above and 'Thiazide diuretics' above.)

●Black patients are at greater risk for treatment resistant hypertension than White patients; thus, a fourth agent may often be required. In such patients, we suggest a potassium-sparing diuretic (in particular, a mineralocorticoid receptor antagonist such as spironolactone or eplerenone) (Grade 2B). (See "Treatment of resistant hypertension".)

Patients who have moderate to advanced chronic kidney disease (estimated glomerular filtration rate [GFR] <45 mL/min/1.73 m²) or a baseline serum potassium >4.6 mEq/L have an increased risk for hyperkalemia. Monitoring of serum potassium should be performed in all patients treated with potassium-sparing diuretics or mineralocorticoid receptor antagonists, with more frequent monitoring in those at highest risk for hyperkalemia. (See 'Overview' above and 'Potassium-sparing diuretics' above.)

●Despite the observation that Black patients are generally more responsive to calcium channel blockers than to monotherapy with ACE inhibitors, there are clear benefits to ACE inhibitors, usually in combination with other antihypertensive agents, in Black patients with chronic kidney disease, at least that due to hypertensive nephrosclerosis. (See 'Chronic kidney disease' above.)

●A variety of factors are associated with reduced adherence to antihypertensive therapy (table 4). Some factors may improve adherence and blood pressure control (table 5), including peer-based education and single-pill combination antihypertensive therapy. (See 'Adherence' above.)