Why does hypertension management differ in African Americans?

From the Guidelines

Blood pressure management differs for African Americans due to physiological differences that affect treatment response, and they often require different medication approaches, typically starting with calcium channel blockers or thiazide diuretics as first-line treatments. African Americans tend to have lower renin levels and may be more salt-sensitive, making them more responsive to diuretics 1. They also face higher rates of hypertension, earlier onset, and more severe complications including stroke and kidney disease. Additionally, cultural factors affecting diet, stress levels, and healthcare access can impact blood pressure control.

Key Considerations

• Physiological differences, such as suppressed renin-angiotensin-aldosterone system (RAAS) and altered renal sodium handling, contribute to the increased cardiovascular risk in African Americans 1.
• Lifestyle modification should focus on salt restriction, increased intake of vegetables and fruits (potassium intake), weight management, and reducing alcohol intake 1.
• First-line pharmacological therapy is recommended as a single pill combination including a thiazide-like diuretic plus calcium channel blocker (CCB) or CCB plus angiotensin receptor blocker (ARB) 1.
• Among renin-angiotensin system (RAS)-inhibitors, ARBs may be preferred as angioedema is about 3 times more likely to occur with ACE inhibitors among black patients 1.

Treatment Goals

• Treatment goals remain the same as for other populations—typically below 130/80 mmHg—but medication selection should be tailored to these physiological differences for optimal results.
• Annual screening for hypertension is advised for adults 18 years and older, and lifestyle modification should be emphasized to reduce cardiovascular risk 1.

From the FDA Drug Label

Some antihypertensive drugs have smaller blood pressure effects (as monotherapy) in black patients, and many antihypertensive drugs have additional approved indications and effects (e.g., on angina, heart failure, or diabetic kidney disease). These considerations may guide selection of therapy.

Blood pressure management is different for African Americans because some antihypertensive drugs have smaller blood pressure effects in this population. This means that the usual medications used to treat high blood pressure may not be as effective in African Americans, and therefore, alternative therapies or combination therapies may be necessary to achieve adequate blood pressure control 2, 3.

• Key considerations for selecting therapy include the presence of additional indications or effects, such as angina, heart failure, or diabetic kidney disease.
• Guideline recommendations, such as those from the National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC), should be consulted for specific advice on blood pressure goals and management.

From the Research

Background on Hypertension in African Americans

• The prevalence of hypertension in African Americans is among the highest in the world, with blacks developing hypertension at an earlier age and experiencing worse disease severity compared to whites 4.
• African Americans have a higher burden of hypertension, more severe blood pressure elevations, and a greater risk for adverse pressure-related clinical complications, such as stroke and heart failure, compared to whites 5.

Differences in Blood Pressure Management

• The choice of drugs for combination therapy in African American patients may be different, with certain classes and combinations of antihypertensive agents being more effective in this population 4.
• African American patients with systolic BP >15 mm Hg or a diastolic BP >10 mm Hg above goal should be treated with first-line combination therapy 4.
• Randomized prospective data from hypertension endpoint trials show a virtually identical percentage reduction in CVD risk for a given magnitude of BP lowering, irrespective of the presence or absence of pre-treatment CVD across a broad range of BP down to pre-treatment BP levels of 110/70 mm Hg 5.

Barriers to Blood Pressure Control

• Barriers to medication adherence among urban African Americans with hypertension include side effects and forgetting, while facilitators include reminders, routines, and social support 6.
• Key social determinants of health, such as health literacy, socioeconomic status, and access to healthcare, contribute to disparities in blood pressure control 7.
• Low awareness rates and dietary habits also play a role in the disparities in blood pressure control among racial and ethnic minority groups, including African Americans 7.

Opportunities to Improve Blood Pressure Control

• Dietary programs designed to help reduce salt intake, faith-based interventions, and community-based programs have been successful in achieving better blood pressure control among people from racial and ethnic minority groups, including African Americans 7.
• Addressing social determinants of health and unique genetic, social, economic, and cultural diversity within African American communities is crucial to reducing disparities in blood pressure management 7.