[135] This is considered a Reviewed, New-replaced recommendation, as new evidence from the SR focused on composite cardiovascular outcomes, in contrast to the 2014 VA/DoD HTN CPG recommendation for which the primary literature was evaluated to recommend thiazide-type diuretics as first-line. The confidence in the quality of evidence was moderate, as the authors of the SR adjusted outcomes so that the blood pressure reductions in each drug class were similar.[135] This led to the conclusion that antihypertensive drugs from the same classes have the same blood pressure lowering effect, which may or may not be true. Thomopoulos et al. (2015) did not include the same individual components of the critical outcome in the SR as the guideline-defined composite cardiovascular outcome (which was comprised of cardiovascular and all-cause mortality, stroke, CHF, kidney function, safety and blood-pressure lowering).[135] However, overall, the consensus of the Work Group was that the critical outcome results supported that the four antihypertensive drug classes produced similar effects on reducing composite cardiovascular events. Recommendation 24. In African American patients with hypertension, we recommend against using an angiotensin- converting enzyme inhibitor or angiotensin II receptor blocker as monotherapy. (Strong against | Not Reviewed, Not Changed) Discussion In addition to being recommended as primary pharmacologic therapy for HTN for reduction in composite cardiovascular outcomes in this CPG (see Recommendation 23), a thiazide-type diuretic or CCB are appropriate initial choices for African Americans with HTN.[136] Of the 33,357 participants in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack (ALLHAT) trial, 35% were African American.[137] A subgroup analysis of this patient population found that the ACEI (lisinopril) was less effective in lowering blood pressure than the thiazide-type diuretic (chlorthalidone) or the long-acting dihydropyridine (LA DHP) CCB (amlodipine).