What is the relationship between Hypertension (High Blood Pressure) and African Americans?

From the Guidelines

African Americans with hypertension should be treated with a comprehensive approach, starting with thiazide diuretics or calcium channel blockers as first-line therapy, due to their superior efficacy in this population, as recommended by the 2020 International Society of Hypertension Global Hypertension Practice Guidelines 1.

Key Recommendations

• Thiazide diuretics, such as hydrochlorothiazide 12.5-25mg daily or chlorthalidone 12.5-25mg daily, are effective first-line options for African American patients with hypertension.
• Calcium channel blockers, like amlodipine 5-10mg daily, are also recommended as first-line therapy.
• Lifestyle modifications, including reducing sodium intake to less than 2,300mg daily, following the DASH diet, maintaining regular physical activity, limiting alcohol consumption, and achieving a healthy weight, are equally important.
• ACE inhibitors and ARBs may be less effective as monotherapy in African Americans but work well in combination therapy, especially for those with diabetes or kidney disease, as noted in the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults 1.

Rationale

The physiological basis for these recommendations stems from the fact that African Americans often have lower renin levels and may be more salt-sensitive, making salt retention a key factor in their hypertension, as discussed in the 2020 U.S. Department of Veterans Affairs/U.S. Department of Defense Clinical Practice Guideline 1.

Monitoring and Adherence

Regular blood pressure monitoring is essential, with a goal of less than 130/80 mmHg. Medication adherence should be emphasized, and patients should be screened for secondary causes if blood pressure remains difficult to control despite multiple medications.

Considerations

The 2020 International Society of Hypertension Global Hypertension Practice Guidelines 1 and the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults 1 provide the most recent and highest quality evidence for the management of hypertension in African Americans.

From the FDA Drug Label

In the LIFE study, Black patients with hypertension and left ventricular hypertrophy treated with atenolol were at lower risk of experiencing the primary composite endpoint compared with Black patients treated with losartan (both cotreated with hydrochlorothiazide in the majority of patients) The primary endpoint was the first occurrence of stroke, myocardial infarction or cardiovascular death, analyzed using an intention-to-treat (ITT) approach In the subgroup of Black patients (n=533,6% of the LIFE study patients), there were 29 primary endpoints among 263 patients on atenolol (11%, 26 per 1000 patient-years) and 46 primary endpoints among 270 patients (17%, 42 per 1000 patient-years) on losartan This finding could not be explained on the basis of differences in the populations other than race or on any imbalances between treatment groups. The LIFE study provides no evidence that the benefits of losartan on reducing the risk of cardiovascular events in hypertensive patients with left ventricular hypertrophy apply to Black patients [see CLINICAL STUDIES (14.2)].

The LIFE study found that Black patients with hypertension and left ventricular hypertrophy treated with atenolol had a lower risk of experiencing the primary composite endpoint compared to those treated with losartan.

• The primary endpoint included stroke, myocardial infarction, or cardiovascular death.
• The study found that losartan may not be as effective in reducing the risk of cardiovascular events in Black patients with hypertension and left ventricular hypertrophy compared to atenolol 2.
• The RENAAL study also included Black patients and found that losartan reduced the risk of doubling of serum creatinine, end-stage renal disease, and death in patients with type 2 diabetes and nephropathy 2.

From the Research

Hypertension in African Americans

• Hypertension is a major clinical and public health problem in African Americans due to its high prevalence, premature onset, and high burden of co-morbid factors 3.
• 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 risk of hypertension-related complications, including stroke, heart disease, and kidney disease, with mortality rates 4 to 5 times higher than in whites 4.

Treatment of Hypertension in African Americans

• Optimal antihypertensive treatment requires a comprehensive approach that includes lifestyle modifications and drug therapy 3.
• The most effective drug combinations for controlling blood pressure in African Americans include calcium antagonists, angiotensin-converting enzyme inhibitors, and thiazide diuretics 3, 4.
• National guidelines recommend different pharmacologic management of hypertension for Black/African Americans compared to non-Black/African Americans, with an emphasis on using diuretics and calcium channel blockers as initial therapy 5, 6.
• However, some studies suggest that an individualized approach to hypertension therapy may be more important than race-based guidelines, as providers following race-based guidelines may still result in worse hypertension control for African Americans 6.

Blood Pressure Control in African Americans

• Blood pressure control rates are lower in African Americans, especially men, compared to other major race/ethnicity-sex groups, with overall control rates of 29.9% for non-Hispanic Black men 3.
• Uncontrolled hypertension is more common in African Americans, with 46.4% of African Americans having uncontrolled hypertension compared to 39.0% of non-African Americans 6.
• Earlier hypertension treatment in African Americans, prior to the onset of significant pressure-related target organ injury, may prevent or attenuate the age-related rise in blood pressure and reduce residual cardiovascular disease risk 7.