Journal of Advances in Medical and Pharmaceutical Sciences

Background: Hypertension is highly prevalent among Black adults and contributes substantially to stroke, heart failure, kidney disease, and premature cardiovascular morbidity. Thiazide and thiazide-like diuretics are widely recommended as foundational antihypertensive agents, but their comparative effectiveness against calcium-channel blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, and alpha-blockers remains clinically important.

Objective: To systematically review evidence published from 1 January 2000 to 30 March 2026 on the effectiveness of diuretic-based antihypertensive therapy compared with other antihypertensive agents for blood-pressure control and clinical outcomes in Black adults with hypertension.

Methods: A PRISMA 2020-, PRISMA-S-, and SWiM-aligned systematic review without meta-analysis was conducted as a completed open-source verification search. The search used PubMed/MEDLINE, PubMed Central, Europe PMC, publisher pages, ClinicalTrials.gov-linked records, guideline pages, DOI checks, and citation chasing. Subscription-database export counts were unavailable. Eligible reports were randomized trials, trial subgroup analyses, secondary trial analyses, indirect comparative analyses, and comparative observational studies involving Black adults with hypertension and a diuretic comparator.

Results: The open-source verification search logged 37 records. Seven methodologic or guideline records were separated from clinical screening, leaving 30 clinical candidate records. After screening and eligibility assessment, 10 reports from four evidence families were included: ALLHAT, PEAR/PEAR-2, CREOLE, and a large HCA Healthcare retrospective cohort. ALLHAT provided the strongest evidence that chlorthalidone was at least comparable to amlodipine and more favorable than lisinopril or doxazosin for several cardiovascular outcomes in Black participants. CREOLE showed that amlodipine-containing dual regimens, including amlodipine plus hydrochlorothiazide, lowered blood pressure more effectively than perindopril plus hydrochlorothiazide in Black African adults. PEAR/PEAR-2 suggested favorable hydrochlorothiazide response compared with atenolol for night blood pressure and greater blood-pressure lowering with chlorthalidone than hydrochlorothiazide, although the latter comparison was indirect. Observational evidence suggested lower cardiovascular event likelihood with calcium-channel blockers than with diuretics but was at serious risk of confounding.

Conclusions: Diuretics, particularly chlorthalidone and hydrochlorothiazide-containing regimens, are effective antihypertensive options in Black adults. Evidence most strongly supports thiazide/thiazide-like diuretics over ACE inhibitors, beta-blockers, and alpha-blockers as default initial therapy for uncomplicated hypertension, while calcium-channel blockers are also highly effective and may be particularly useful in combination therapy. Certainty is moderate for major randomized-trial evidence and lower for indirect, post hoc, and observational findings. No pooled estimate was calculated because of clinical, methodological, comparator, and outcome heterogeneity.