Race-based Therapy for Hypertension: Possible Benefits and Potential Pitfalls

Keith C. Ferdinand; Daphne P. Ferdinand

Disclosures

Expert Rev Cardiovasc Ther. 2008;10(6):1357-1366. 

In This Article

Hypertension in African-Americans: Epidemiology & Environment-related Factors

There are certain unique aspects of hypertension in African-Americans, including increased morbidity and related mortality, increased severity, with possible premature onset, and increased incidence of target organ damage, including left ventricular (LV) hypertrophy, HF, impaired renal function and end-stage renal disease.[5,6,7] The prevalence of hypertension in Blacks in the USA is among the highest in the world. Compared with Whites, Blacks develop hypertension at an earlier age and their average BPs are much higher. The increased risk of hypertension is apparent even in childhood. The Bogalusa Heart Study demonstrated elevations in BP in Black children under the age of 10 years as compared with White children.[8,9] LV hypertrophy, more common in Blacks and an independent predictor of cardiovascular morbidity and mortality, is directly associated with risk factors and hypertension in particular. A community-based sample of 467 young adults (29% Black and 71% White) aged 20-38 years were examined from childhood to adulthood on an average of six occasions. With an average follow-up of 21.5 years, the data demonstrated that, compared with Whites, Blacks had greater LV mass (index to height; p < 0.05).[8] These characteristics related to African-Americans, along with differences in hypertensive pathophysiology, have impacted the major guidelines subsequently discussed in this article.[10,11]

Blacks in the USA also have the highest rates of CHD mortality, 186.8 versus 182.8 per 100,000 for non-Hispanic Whites and 124.2 for Hispanic Whites.[3,5,7,12] In addition, Blacks with hypertension have an 80% higher chance of dying from a stroke than Whites, 81.6 versus 60.3 per 100,000 for non-Hispanic Whites and 40.0 for Hispanics.[3,5] These disproportionate rates of CVD explain much of the disparity in life expectancy between Black and White men and women.[71] In recent projections, African-Americans males had a life expectancy of 68.6 years versus 75 years for White males.[71] African-American females have a markedly lower life expectancy compared with White females at 75.5 versus 80.2 years. In fact, the life expectancy of African-Americans females more approximates that of White males than White females.[71]

Although genetic factors may be a component of the increased risk in prevalence and complications of hypertension in African-Americans, there are clearly environmental barriers to hypertension control, which include poverty, lack of education and its consequences, lack of adequate patient education, and delayed diagnosis.[13,14] Awareness of hypertension in Blacks is comparable or even higher than that in Whites with similar levels of treatment.[15] Despite increase in awareness in Blacks since the 1980s, control levels continue to lag behind that of the White population.[6] Furthermore, CVD is more common in disadvantaged communities, which often lack safe environments for walking, jogging or cycling, as well as adequate shopping outlets for fresh fruits, vegetables, whole grains or low-saturated-fat protein sources, including lean meats and fish. Related to adverse dietary patterns and physical inactivity, there is an increased proportion of overweight and obesity people, especially among Black females.

Moreover, there may be distrust of the medical profession in some Blacks and an adverse view of the benefits of medications.[16] Provider-related barriers may include lower expectations and a lack of adherence to clinical guidelines for treatment, including clinical inertia and a failure to treat early and aggressively target BP with increased comorbid diseases.[16] Therefore, many Blacks may need complex medical intervention, perhaps making the control of BP more difficult.

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