A 58-year-old Black man was referred to the preventive cardiology clinic for a new diagnosis of essential hypertension. He has no other medical history. He was found to have blood pressure (BP) 142/93 mm Hg during a routine employer-based health screening at his software company. He reports feeling well overall and exercises four times a week at a moderate intensity. His father experienced a myocardial infarction at 54 years of age.
On physical examination, his BP is 145/90 mm Hg when measured using an appropriately positioned upper arm cuff of the correct size after he sat quietly for 5 min with his back supported and both feet on the ground. The remainder of his examination is within normal limits. Further laboratory testing reveals normal renal function and electrolytes. His 10-year risk of atherosclerotic cardiovascular disease (ASCVD) according to the pooled cohort equations is estimated at 10.3%.
Which one of the following is the best approach to manage his BP?
The correct answer is: D. Start chlorthalidone and re-evaluate in 1 month.
For adults with stage 2 hypertension, defined as BP ≥140/90 mm Hg, the 2017 multisociety Guideline for the Prevention, Detection, Evaluation, and Management of High BP in Adults recommends initiating a pharmacologic agent in addition to nonpharmacologic measures.1 In the United States, Black adults experience a disproportionately higher prevalence of hypertension and higher rates of hypertension-attributable morbidity and mortality than non-Hispanic white adults, emphasizing the importance of promptly initiating therapy for stage 2 hypertension and minimizing clinical inertia in the context of such disparities.
In general, first-line recommendations for antihypertensive therapy are angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs), calcium channel blockers (CCBs), or thiazide diuretics. However, there are differences by race/ethnicity that are important to consider. In Black patients, thiazide diuretics or CCBs are preferred first-line agents over ACE inhibitors or ARBs according to this guideline. The landmark ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack) trial randomized 33,357 participants (35% Black) with hypertension and at least one other coronary disease risk factor to chlorthalidone, amlodipine, or lisinopril for a mean follow-up of 4.9 years. The ALLHAT trial found that overall BP lowering was most effective in the chlorthalidone group. In a prespecified subgroup analysis, chlorthalidone resulted in a greater decrease in systolic BP in Black participants than lisinopril (p < 0.001 for interaction by race). In Black participants, risk for stroke was higher in the lisinopril group versus the chlorthalidone group, whereas no such differences were seen in non-Black participants.2 In another subgroup analysis of the ALLHAT trial, BP lowering was less effective in the lisinopril group compared with the amlodipine group, with a mean follow-up BP difference of 3.9/2.1 mm Hg in Black women and 2.7/1.6 mm Hg in Black men. There were elevated rates of stroke and angioedema with lisinopril compared with amlodipine in Black participants.3
In this patient with stage 2 hypertension and a family history of coronary artery disease, prompt hypertension control is important. His goal BP is <130/80 mm Hg by guidelines based on his 10-year ASCVD risk being >10%. Thus, of the available answer choices, a thiazide or thiazide-like diuretic would be recommended as initial therapy in addition to nonpharmacologic approaches, with timely re-evaluation to ensure adequate BP control and cardiovascular risk reduction.
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Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APha/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2018;71:e127-e248.
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;293:1595-608.
Leenen FH, Nwachuku CE, Black HR, et al.; Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial Collaborative Research Group. Clinical events in high-risk hypertensive patients randomly assigned to calcium channel blocker versus angiotensin-converting enzyme inhibitor in the antihypertensive and lipid-lowering treatment to prevent heart attack trial. Hypertension 2006;48:374-84.