MODULE 3: Using Thiazide-Type Diuretics in African Americans with Hypertension

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Medical Education Library

MODULE 3: Using Thiazide-Type Diuretics in African Americans with Hypertension

August 2012 · Vol. 61, No. 08 Suppl: S20-S22

References

1. Roger VL, Go AS, Lloyd-Jones DM, et al. American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics–2012 update: a report from the American Heart Association. Circulation. 2012;125(1):e2-e220.

2. Egan BM, Zhao Y, Axon RN. US trends in prevalence, awareness, treatment, and control of hypertension, 1988-2008. JAMA. 2010;303(20):2043-2050.

3. Johnson EF, Wright JT. Management of hypertension in black populations. In: Oparil S, Weber MA, eds. Hypertension: A Companion to Brenner and Rector’s The Kidney. 2nd ed. Philadelphia, PA: Elsevier Saunders; 2005:587–595.

4. National Center for Health Statistics. Health, United States, 2009: With Special Feature on Medical Technology. Hyattsville, MD. 2010. Table 72.

5. Prather AA, Blumenthal JA, Hinderliter AL, Sherwood A. Ethnic differences in the effects of the DASH diet on nocturnal blood pressure dipping in individuals with high blood pressure. Am J Hypertens. 2011;24(12):1338-1344.

6. Svetkey LP, Simons-Morton D, Vollmer WM, et al. Effects of dietary patterns on blood pressure: subgroup analysis of the Dietary Approaches to Stop Hypertension (DASH) randomized clinical trial. Arch Intern Med. 1999;159(3):285-293.

7. Appel LJ, Moore TJ, Obarzanek E, et al. DASH Collaborative Research Group. A clinical trial of the effects of dietary patterns on blood pressure. N Engl J Med. 1997;336(16):1117-1124.

8. Wright JT, Jr, Dunn JK, Cutler JA, et al. ALLHAT Collaborative Research Group. Outcomes in hypertensive black and nonblack patients treated with chlorthalidone, amlodipine, and lisinopril. JAMA. 2005;293(13):1595-1608.

9. Materson BJ, Reda DJ, Cushman WC, et al. The Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents. Single-drug therapy for hypertension in men. A comparison of six antihypertensive agents with placebo. N Engl J Med. 1993;328(13):914-921.

10. Wright JT, Jr, Probstfield JL, Cushman WC, et al. ALLHAT findings revisited in the context of subsequent analyses, other trials, and meta-analyses. Arch Intern Med. 2009;169(9):832-842.

11. Neal B, MacMahon S, Chapman N. Blood Pressure Lowering Treatment Trialists’ Collaboration. Effects of ACE inhibitors, calcium antagonists, and other blood-pressure-lowering drugs: results of prospectively designed overviews of randomised trials. Lancet. 2000;356(9246):1955-1964.

12. Turnbull F. Effects of different blood-pressure-lowering regimens on major cardiovascular events: results of prospectively-designed overviews of randomised trials. Lancet. 2003;362(9395):1527-1535.

13. Effects of treatment on morbidity in hypertension. II. Results in patients with diastolic blood pressure averaging 90 through 114 mm Hg. JAMA. 1970;213(7):1143-1152.

14. Hypertension Detection and Follow-up Program Cooperative Group. Five-year findings of the Hypertension Detection and Follow-up Program: mortality by race-sex and blood pressure level. A further analysis. J Community Health. 1984;9(4):314-327.

15. The Systolic Hypertension in the Elderly Program Cooperative Research Group. Implications of the systolic hypertension in the elderly program. Hypertension. 1993;21(3):335-343.

16. Wright JT, Jr, Harris-Haywood S, Pressel S, et al. Clinical outcomes by race in hypertensive patients with and without the metabolic syndrome: Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Arch Intern Med. 2008;168(2):207-217.

17. Rahman M, Pressel S, Davis BR, et al. Renal outcomes in high-risk hypertensive patients treated with an angiotensin-converting enzyme inhibitor or a calcium channel blocker vs a diuretic: a report from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Arch Intern Med. 2005;165(8):936-946.

18. Chobanian AV, Bakris GL, Black HR, et al. Joint National Committee on Prevention Detection Evaluation and Treatment of High Blood Pressure; National Heart, Lung, and Blood Insitute; National High Blood Pressure Education Program Coordinating Committee. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42(6):1206-1252.

19. Flack JM, Sica DA, Bakris G, et al. International Society on Hypertension in Blacks. Management of high blood pressure in blacks: an update of the International Society on Hypertension in Blacks consensus statement. Hypertension. 2010;56(5):780-800.

20. Mancia G, Laurent S, Agabiti-Rosei E, et al. Reappraisal of European guidelines on hypertension management: a European Society of Hypertension Task Force document. Blood Press. 2009;18(6):308-347.

21. Canadian Hypertension Education Program. The 2012 CHEP Recommendations. Hypertension Canada Web site. http://www.hypertension.ca/chep-recommendations. Published 2012. Accessed April 15, 2012.

In comparative trials with newer classes of antihypertensives, THZDs have remained unsurpassed in preventing complications of hypertension, including in African Americans (TABLE). ALLHAT was the first outcome study to evaluate the relative benefit of antihypertensive treatment initiated with newer classes of antihypertensive agents vs treatment initiated with a THZD in blacks. ALLHAT included more than 15,000 African Americans and Afro-Caribbeans and confirmed the findings of studies in other populations that neither an ACEI, a CCB, or alpha-blocker–initiated therapy surpassed therapy initiated with a THZD (CTD) in lowering BP or in preventing CVD or renal outcomes.^8,10 Overall, the THZD-based therapy was superior to the alpha-blocker, ACEI, and CCB-based therapies in preventing 1 or more major forms of CVD, including stroke and heart failure (HF). In blacks, THZD-based therapy was superior to alpha-blocker–based therapy in lowering BP and in preventing overall CVD (especially HF and stroke), and was superior to the ACEI-based regimen in preventing stroke, HF, and overall CVD (a composite of CHD, stroke, and HF endpoints). Compared with CCB-based therapy (ie, amlodipine), THZD (CTD)-based therapy was similar in overall CVD protection but superior in preventing HF.

These results in ALLHAT were even more impressive in blacks with diabetes or the metabolic syndrome (TABLE).¹⁶ In addition to the above-mentioned CVD outcomes in black hypertensive patients, neither the CCB-based nor the ACEI-based regimens were superior to the THZD-based regimen in preventing ESRD overall or when stratified by diabetes or baseline estimated glomerular filtration rate.^10,16,17 In black ALLHAT participants with diabetes or the metabolic syndrome, CTD was associated with substantially reduced rates of ESRD compared with those randomized to doxazosin, amlodipine, or the ACEI lisinopril.¹⁶ It should also be noted that nearly all previous renal outcome trials with renin-angiotensin system inhibitors included background therapy with a diuretic.¹⁷

Recommendations

Most national and international guidelines recommend THZDs as first-line therapy in African Americans.^18-21 Calcium channel blockers are a reasonable alternate first-line choice in African Americans who are unable to tolerate a diuretic.

In addition, the Joint National Committee (JNC-7) guidelines recommend the use of ACEIs and ARBs as first-line therapy in all patients with hypertension comorbid with chronic kidney disease (CKD) or HF, including African Americans.¹⁸ These drugs, along with alpha-blockers and all other agents in the antihypertensive armamentarium, should be used as add-on therapy, as needed, to achieve BP goals in African Americans already receiving a THZD or CCB.

Importantly, multiple drug therapy should be considered for initial treatment in all individuals whose BP is more than 20/10 mm Hg above target.¹⁸ In addition, multiple antihypertensive agents are usually required to achieve long-term control in most patients, particularly in African Americans who, as noted earlier, tend to have more-severe hypertension.¹⁹

Conclusion

Treatment of hypertension in African Americans should include both lifestyle modifications and pharmacologic intervention, usually with multiple agents. In the absence of compelling indications for alternative therapies, THZD-based regimens should be considered first-line treatment given significant evidence from large randomized studies that document their ability to reduce both BP and hypertensive complications in this population.

Monotherapy with ACEIs, ARBs, direct renin inhibitors, or beta-blockers is less effective in lowering BP in African Americans than in other populations. ACEIs and ARBs should be included in antihypertensive regimens prescribed for African Americans with concomitant CKD or HF. They can also be considered as add-on therapy to regimens containing a THZD or CCB in the absence of these conditions.