michigan hypertension core curriculum - State of Michigan

individuals of any race or ethnicity. Once patients have been thoroughly evaluated and the appropriate
BP target selected and communicated to the patient, the practitioner should select therapy based on
the compelling indications for specific treatments that are present. A highly important decision is to
determine whether the patient needs initial treatment with one or two anti-hypertensive agents – a
decision that is significantly dependent upon how far above goal BP the patient is. In patients close
to their goal BP, say less than 10/5 mm Hg above goal, it is not unreasonable to favor diuretics and
calcium antagonists in African Americans given the greater likelihood of lowering BP below target
levels with a single antihypertensive agent. However, the most important aspect of antihypertensive
drug therapy, irrespective of the individual drug(s) chosen for an individual of any race/ethnicity, is to
follow the patient close enough (titrate drugs ~ every 4 – 6 weeks) to ensure that goal BP levels are
achieved and maintained over the long-term. Clearly, informed drug choices are important. And,
in this regard, the most important decisions will related to the optimal use of antihypertensive drug
combinations. The concern about the race/ethnicity of an individual patient and its importance to
successful antihypertensive drug therapy has been grossly overemphasized similar to the misplaced
focus on antihypertensive monotherapy instead of on combination drug therapy. The inordinate
concern about race has led to the under-utilization of therapies with compelling indications in individual
African American patients because of the misplaced concern regarding the lack of BP lowering efficacy
of monotherapy with the drug class (e.g. ACE inihibitors in CKD). In such situations, the drug with the
compelling indication will virtually always be used with other antihypertensive agents if goal BP is to be
attained.
154 Hypertension Core Curriculum