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

Keith C. Ferdinand; Daphne P. Ferdinand


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

In This Article

Guidelines & Hypertension in Black Individuals

This article will comment on specific guidelines that are related to hypertension in Blacks. The use of clinical practice guidelines assists physicians and other practitioners with assessing how the complex area of race/ethnicity and hypertension, as described previously, may actually affect practice. The guidelines attempt to distill much of the drug efficacy, pathophysiology and clinical trials evidence, primarily in African-Americans where data are most robust. Both the International Society on Hypertension in Blacks (ISHIB) and the The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7) recommend the use of thiazide diuretics as first-line therapy in Blacks.[10,11] The ISHIB consensus working group report reviewed clinically relevant scientific data regarding treatment of hypertension in African-Americans and crafted guidelines to guide the ideal management of high BP in African-Americans. This report recommends African-Americans patients with systolic BP of 15 mmHg or higher, or a diastolic BP of 10 mmHg or higher above goal should be treated with first-line combination therapy.[9] The use of combination therapy was further recommended by JNC 7 for patients with systolic BP of 20 mmHg and higher, and/or diastolic of 10 mmHg or higher above goal, although no specific recommendation was noted for African-Americans.

In addition, guidelines for the management of hypertension in the UK, published following a joint initiative between the National Institute for Health and Clinical Excellence and the British Hypertension Society, also confirmed the use of thiazide diuretics and, alternatively, CCBs as first-line therapy in Blacks.[50] The above guidelines essentially address initial therapy or response to monotherapy as more efficacious using the diuretics or alternative CCBs in Blacks; however, most African-Americans will need more than one class of agents. Guidelines may assist clinicians by reflecting on findings from basic science efficacy and outcomes trials, which may provide a framework for treating this population.

Several clinical trials, as previously noted, demonstrate blunted BP-lowering with ACEIs and ARBs and β-blockers in Blacks. The diminished response of Blacks to antihypertensive drugs as monotherapy does not suggest that RAAS-blocking agents (specifically ACEIs, ARBs and β-blockers) should be avoided in high-risk patients when compelling indications are present.


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