Therapy of Hypertension in African Americans

John M. Flack; Samar A. Nasser; Phillip D. Levy

Disclosures

Am J Cardiovasc Drugs. 2011;11(2):83-92. 

In This Article

Abstract and Introduction

Abstract

Hypertension in African Americans is a major clinical and public health problem because of the high prevalence and premature onset of elevated blood pressure (BP) as well as the high burden of co-morbid factors that lead to pharmacological treatment resistance (obesity, diabetes mellitus, depressed glomerular filtration rate, and albuminuria). BP control rates are lower in African Americans, especially men, than in other major race/ethnicity-sex groups; overall control rates are 29.9%for non-Hispanic Black men. Optimal antihypertensive treatment requires a comprehensive approach that encompasses multifactorial lifestyle modifications (weight loss, salt and alcohol restriction, and increased physical activity) plus drug therapy. The most important initial step in the evaluation of patients with elevated BP is to appropriately risk stratify them to allow determination of whether they are truly hypertensive and also to determine their goal BP levels. The overwhelming majority of African American hypertensive patients will require combination anti-hypertensive drug therapy to maintain BP consistently below target levels. The emphasis is now appropriately on utilizing the most effective drug combinations for the control of BP and protection of target-organs in this high-risk population. When BP is >15/10 mmHg above goal levels, combination drug therapy is recommended. The preferred combination is a calcium antagonist/angiotensin-converting enzyme inhibitor or, alternatively, in edematous and/or volume overload states, a thiazide diuretic/angiotensin-converting inhibitor.

Introduction

Hypertension in African Americans is a major clinical and public health problem because of the high prevalence and premature onset of elevated blood pressure (BP) in this population.[1] Moreover, the common occurrence of pressure-related target-organ injury (e.g. left ventricular hypertrophy, heart failure) and the high prevalence of risk-augmenting co-morbidities such as diabetes mellitus and chronic kidney disease in African Americans markedly increase the likelihood of pressure-related morbidity and mortality in this group at any given BP level.[2] These issues result in the long-term exposure of large proportions of African Americans to higher than optimal BP and disproportionate development of associated consequences.

BP control rates are lower in African Americans, especially men, than in other major race/ethnicity-sex groups; overall control rates are 29.9% for non-Hispanic Black men.[3] Even amongst drug-treated African Americans with hypertension, only 45%have been reported to attain BP control.[4] Hypertension places an exceptionally high toll on the African American population, accounting for approximately 30% and 20% of all deaths, respectively, in African American men and women[5] and 15% of the overall racial difference in potential life-years lost.[6] Thus, enhancing BP control rates represents a profoundly important strategy for the improvement of health status and reduction of pressure-related racial health disparities (e.g. heart failure, retinopathy, stroke) that disproportionately afflict the African American population.

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