What blood pressure medications work best for Black men and which ones don't?

The ALLHAT trial, the largest antihypertensive trial ever conducted with more than 33,000 participants, found that the ACE inhibitor lisinopril was associated with higher blood pressure and a trend toward higher cardiovascular event rates in Black patients compared to the thiazide diuretic chlorthalidone. This is the most important pharmacological finding in Black cardiovascular medicine and is still not consistently applied in clinical practice.

The clinical guidance from ALLHAT and the 2017 ACC/AHA guidelines: for Black patients with hypertension, first-line treatment should prioritize thiazide-type diuretics (chlorthalidone is preferred over hydrochlorothiazide based on outcome data) or long-acting calcium channel blockers (amlodipine). ACE inhibitors and ARBs are less effective as monotherapy in Black patients because of the predominance of low-renin, volume-dependent hypertension in this population. They are not contraindicated, in combination with a thiazide or CCB, they add meaningful benefit, particularly in patients with diabetes, chronic kidney disease, or proteinuria. The distinction is: monotherapy versus combination. ACE inhibitors as the only medication in a Black patient with hypertension is the pattern the evidence argues against. (ALLHAT Collaborative Research Group, JAMA, 2002)

Cardiologist's calibrated position, Solid (1) for thiazide-first or CCB-first as guideline-concordant in Black patients without diabetes or CKD.

What to do: At your next blood pressure medication review, ask: "Given the ALLHAT trial data, is my current regimen optimized for my racial background?" If you are on an ACE inhibitor as the only antihypertensive and your pressure is not well-controlled, this is a conversation worth having.

For the full picture, read The Cardiac Inheritance.