Treatment of hypertension in blacks
- Brent M Egan, MD
Brent M Egan, MD
- Professor of Medicine
- University of South Carolina School of Medicine-Greenville
- Care Coordination Institute
- Section Editors
- George L Bakris, MD
George L Bakris, MD
- Editor-in-Chief — Nephrology
- Section Editor — Hypertension
- Professor of Medicine
- The University of Chicago
- Norman M Kaplan, MD
Norman M Kaplan, MD
- Editor-in-Chief — Nephrology
- Section Editor — Hypertension
- Clinical Professor of Internal Medicine
- University of Texas Southwestern Medical Center
Hypertension is a major problem in black patients; the incidence and prevalence of cardiovascular and renal complications of hypertension are greater than in other race/ethnicity groups. The adjusted relative risk of stroke, for example, is more than twice as high in hypertensive blacks aged 45 to 64 years as compared with similarly aged hypertensive whites . As a result, effective antihypertensive therapy is particularly important in these patients . (See "Hypertensive complications in blacks".)
According to the 2010 recommendations from the International Society on Hypertension in Blacks , antihypertensive therapy is recommended for blacks without target-organ damage or concomitant cardiovascular diseases at blood pressures greater than 135/85 mmHg and, for those at higher risk, at blood pressures greater than 130/80 mmHg. In addition, monotherapy is de-emphasized in favor of combination therapy. On the other hand, many authorities, including various expert panels, have not recommended initiating antihypertensive therapy at lower blood pressure goals in black patents than in other patient groups (table 1)[4-6].
The majority of the black-white disparity in hypertension control is accounted for by lower control rates in black men as compared with white men. In addition to needing more widespread and effective therapy of blacks with hypertension, novel methods to enhance screening and patient education, such as that illustrated by the barber-based interventional trial , may increase hypertension control in black men and improve racial equity in hypertension control.
CHOICE OF ANTIHYPERTENSIVE DRUGS
The optimal choice of drug or combination of drugs in black patients principally depends upon the presence or absence of comorbid conditions and the specific efficacy of the agent(s) to attain goal blood pressure . Overall, the choice of antihypertensive drugs in black patients is similar to that in older adults.
Overview — Recommendations about the choice of antihypertensive therapy are presented elsewhere. Briefly:
- Howard G, Lackland DT, Kleindorfer DO, et al. Racial differences in the impact of elevated systolic blood pressure on stroke risk. JAMA Intern Med 2013; 173:46.
- Gibbs CR, Beevers DG, Lip GY. The management of hypertensive disease in black patients. QJM 1999; 92:187.
- Flack JM, Sica DA, Bakris G, et al. Management of high blood pressure in Blacks: an update of the International Society on Hypertension in Blacks consensus statement. Hypertension 2010; 56:780.
- Wright JT Jr, Agodoa LY, Appel L, et al. New recommendations for treating hypertension in black patients: evidence and/or consensus? Hypertension 2010; 56:801.
- James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 2014; 311:507.
- Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens 2013; 31:1281.
- Victor RG, Ravenell JE, Freeman A, et al. Effectiveness of a barber-based intervention for improving hypertension control in black men: the BARBER-1 study: a cluster randomized trial. Arch Intern Med 2011; 171:342.
- Brewster LM, van Montfrans GA, Kleijnen J. Systematic review: antihypertensive drug therapy in black patients. Ann Intern Med 2004; 141:614.
- Krause T, Lovibond K, Caulfield M, et al. Management of hypertension: summary of NICE guidance. BMJ 2011; 343:d4891.
- Calhoun DA, Jones D, Textor S, et al. Resistant hypertension: diagnosis, evaluation, and treatment: a scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research. Circulation 2008; 117:e510.
- Khosla N, Kalaitzidis R, Bakris GL. Predictors of hyperkalemia risk following hypertension control with aldosterone blockade. Am J Nephrol 2009; 30:418.
- Falkner B, Kushner H. Effect of chronic sodium loading on cardiovascular response in young blacks and whites. Hypertension 1990; 15:36.
- Kokkinos PF, Narayan P, Colleran JA, et al. Effects of regular exercise on blood pressure and left ventricular hypertrophy in African-American men with severe hypertension. N Engl J Med 1995; 333:1462.
- Chang A, Appel LJ. Public health: Effects of sodium and potassium intake on health outcomes. Nat Rev Nephrol 2013; 9:376.
- Appel LJ, Brands MW, Daniels SR, et al. Dietary approaches to prevent and treat hypertension: a scientific statement from the American Heart Association. Hypertension 2006; 47:296.
- Swift PA, Markandu ND, Sagnella GA, et al. Modest salt reduction reduces blood pressure and urine protein excretion in black hypertensives: a randomized control trial. Hypertension 2005; 46:308.
- Materson BJ, Reda DJ, Cushman WC, et al. Single-drug therapy for hypertension in men. A comparison of six antihypertensive agents with placebo. The Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents. N Engl J Med 1993; 328:914.
- Saunders E, Weir MR, Kong BW, et al. A comparison of the efficacy and safety of a beta-blocker, a calcium channel blocker, and a converting enzyme inhibitor in hypertensive blacks. Arch Intern Med 1990; 150:1707.
- Sareli P, Radevski IV, Valtchanova ZP, et al. Efficacy of different drug classes used to initiate antihypertensive treatment in black subjects: results of a randomized trial in Johannesburg, South Africa. Arch Intern Med 2001; 161:965.
- Jamerson K, Weber MA, Bakris GL, et al. Benazepril plus amlodipine or hydrochlorothiazide for hypertension in high-risk patients. N Engl J Med 2008; 359:2417.
- Materson BJ, Reda DJ, Cushman WC. Department of veterans Affairs single-drug therapy of hypertension study. Revised figures and new data. Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents. Am J Hypertens 1995; 8:189.
- Seedat YK. Varying responses to hypotensive agents in different racial groups: black versus white differences. J Hypertens 1989; 7:515.
- Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003; 289:2560.
- ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA 2002; 288:2981.
- Wright JT Jr, Dunn JK, Cutler JA, et al. Outcomes in hypertensive black and nonblack patients treated with chlorthalidone, amlodipine, and lisinopril. JAMA 2005; 293:1595.
- Racial differences in response to low-dose captopril are abolished by the addition of hydrochlorothiazide. Br J Clin Pharmacol 1982; 14 Suppl 2:97S.
- Middlemost SJ, Tager R, Davis J, Sareli P. Effectiveness of enalapril in combination with low-dose hydrochlorothiazide versus enalapril alone for mild to moderate systemic hypertension in black patients. Am J Cardiol 1994; 73:1092.
- Weir MR, Ferdinand KC, Flack JM, et al. A noninferiority comparison of valsartan/hydrochlorothiazide combination versus amlodipine in black hypertensives. Hypertension 2005; 46:508.
- Weir MR, Gray JM, Paster R, Saunders E. Differing mechanisms of action of angiotensin-converting enzyme inhibition in black and white hypertensive patients. The Trandolapril Multicenter Study Group. Hypertension 1995; 26:124.
- Agodoa LY, Appel L, Bakris GL, et al. Effect of ramipril vs amlodipine on renal outcomes in hypertensive nephrosclerosis: a randomized controlled trial. JAMA 2001; 285:2719.
- Douglas, JG. African American Study of Kidney Disease and Hypertension. American Heart Association Scientific Sessions 2001.
- Fogo A, Breyer JA, Smith MC, et al. Accuracy of the diagnosis of hypertensive nephrosclerosis in African Americans: a report from the African American Study of Kidney Disease (AASK) Trial. AASK Pilot Study Investigators. Kidney Int 1997; 51:244.
- Wright JT Jr, Bakris G, Greene T, et al. Effect of blood pressure lowering and antihypertensive drug class on progression of hypertensive kidney disease: results from the AASK trial. JAMA 2002; 288:2421.
- Wright JT Jr, Agodoa L, Contreras G, et al. Successful blood pressure control in the African American Study of Kidney Disease and Hypertension. Arch Intern Med 2002; 162:1636.
- Klahr S, Levey AS, Beck GJ, et al. The effects of dietary protein restriction and blood-pressure control on the progression of chronic renal disease. Modification of Diet in Renal Disease Study Group. N Engl J Med 1994; 330:877.
- Appel LJ, Wright JT Jr, Greene T, et al. Intensive blood-pressure control in hypertensive chronic kidney disease. N Engl J Med 2010; 363:918.
- Pratt JH, Ambrosius WT, Agarwal R, et al. Racial difference in the activity of the amiloride-sensitive epithelial sodium channel. Hypertension 2002; 40:903.
- Saha C, Eckert GJ, Ambrosius WT, et al. Improvement in blood pressure with inhibition of the epithelial sodium channel in blacks with hypertension. Hypertension 2005; 46:481.
- Bosworth HB, Powers B, Grubber JM, et al. Racial differences in blood pressure control: potential explanatory factors. J Gen Intern Med 2008; 23:692.
- Bosworth HB, Dudley T, Olsen MK, et al. Racial differences in blood pressure control: potential explanatory factors. Am J Med 2006; 119:70.e9.
- Houston TK, Allison JJ, Sussman M, et al. Culturally appropriate storytelling to improve blood pressure: a randomized trial. Ann Intern Med 2011; 154:77.
- Egan BM, Bandyopadhyay D, Shaftman SR, et al. Initial monotherapy and combination therapy and hypertension control the first year. Hypertension 2012; 59:1124.