Does race play a significant role in the management of hypertension?

Race and Hypertension Management: Evidence-Based Perspective

Race does play a significant role in hypertension management, but primarily in initial drug selection rather than blood pressure targets or overall treatment goals—all patients regardless of race should be treated to the same blood pressure targets with the understanding that certain medication classes work differently across racial groups.

Key Differences by Race/Ethnicity

Prevalence and Severity

• African Americans have substantially higher hypertension burden with more severe disease, earlier onset, and worse outcomes including 1.8-times greater risk of fatal stroke, 1.5-times greater risk of heart failure, and 4.2-times greater risk of end-stage renal disease compared to whites 1.
• African-American life expectancy is 5.4 years shorter than Caucasians, with hypertension being the single largest contributor to this disparity 1.
• Hypertension-attributable mortality rates per 1,000 persons are dramatically higher for non-Hispanic blacks (50.1 for men, 35.6 for women) compared to non-Hispanic whites (19.3 for men, 15.8 for women) 1.

Control Rates

• Control rates are lower for blacks (43.8% for men, 52.3% for women), Hispanic Americans (43.5% for men), and Asian Americans (39.9% for men, 46.8% for women) compared to whites (53.8% for men, 59.1% for women) 1.
• In Hispanic Americans, lower control results primarily from lack of awareness and treatment, whereas in blacks, awareness and treatment rates match or exceed whites, but hypertension is more severe and certain agents are less effective 1.

Medication Selection: Where Race Matters Most

Initial Therapy for Black Patients Without Heart Failure or CKD

In black adults with hypertension but without heart failure or chronic kidney disease (including those with diabetes), initial antihypertensive treatment should include a thiazide-type diuretic or calcium channel blocker 1.

Evidence for Differential Drug Response

• Monotherapy with beta-blockers, ACE inhibitors, or ARBs lowers blood pressure to a lesser degree in African Americans than whites 1.
• In the ALLHAT trial with over 15,000 blacks, ACE inhibitors were less effective than thiazide diuretics or calcium channel blockers, resulting in 40% greater risk of stroke, 32% greater risk of heart failure, and 19% greater risk of cardiovascular disease 1.
• The FDA label for lisinopril explicitly states: "ACE inhibitors, including lisinopril, have an effect on blood pressure that is less in black patients than in non-blacks" 2.
• However, these interracial differences in blood pressure-lowering are abolished when ACE inhibitors or ARBs are combined with a diuretic 1.

Combination Therapy: The Great Equalizer

Two or more antihypertensive medications are recommended to achieve a blood pressure target of less than 130/80 mm Hg in most adults with hypertension, especially in black adults 1.

• Most patients with hypertension, especially blacks, require ≥2 antihypertensive medications to achieve adequate blood pressure control 1.
• The combination of an ACE inhibitor or ARB with a calcium channel blocker or thiazide diuretic produces similar blood pressure lowering in blacks as in other racial or ethnic groups 1.
• A single-tablet combination that includes either a diuretic or calcium channel blocker may be particularly effective in achieving blood pressure control in blacks 1.
• Racial and ethnic differences should not be the basis for excluding any class of antihypertensive agent in combination therapy 1.

Blood Pressure Targets: No Racial Differences

Blood pressure targets should be the same regardless of race—less than 130/80 mm Hg for most adults 1.

• The 2017 ACC/AHA guidelines do not recommend different blood pressure goals based on race or ethnicity 1.
• In clinical trials, lowering blood pressure prevents sequelae of hypertension in all racial or ethnic groups 1.
• When medications and provider services were provided free of charge (as in the Hypertension Detection and Follow-up Program), African American men treated with intensive stepped-care actually benefited more than whites 1.
• No race/ethnic difference in blood pressure control was noted in SPRINT, even in the <120 mmHg arm, when chlorthalidone and amlodipine were provided at no cost 1.

Special Considerations for Specific Populations

Black Patients with Comorbidities

• ACE inhibitors and ARBs are recommended in black patients with hypertension, diabetes, and nephropathy, but they offer no advantage over diuretics or calcium channel blockers in hypertensive patients with diabetes without nephropathy or heart failure 1.
• ACE inhibitors and ARBs are recommended as components of multidrug antihypertensive regimens in blacks with chronic kidney disease 1.
• Beta-blockers are recommended for black patients with heart failure or those with coronary heart disease who have had a myocardial infarction 1.
• A 28% reduction in mortality was observed in African Americans who received beta-blocker therapy after acute myocardial infarction 1.
• Greater preservation of renal function occurred in African Americans with hypertensive nephrosclerosis treated with a regimen containing an ACE inhibitor compared with beta-blocker or calcium antagonist 1.

Hispanic/Latino Patients

• Hispanics are a heterogeneous subgroup with varying hypertension rates depending on ancestry (Caribbean, Mexico, Central/South America, or Europe) 1.
• Hispanics from Mexico and Central America have lower cardiovascular disease rates than US whites, whereas those of Caribbean origin have higher rates 1.
• Hispanic Americans have lower rates of hypertension awareness and treatment than whites and blacks, with high prevalence of comorbid cardiovascular risk factors 1.

Genetic Considerations

• The excess risk of chronic kidney disease outcomes in some blacks with hypertension may be due to high-risk APOL1 (apolipoprotein L1) genetic variants 1.
• The rate of renal decline associated with this genotype appears largely unresponsive to either blood pressure lowering or RAS inhibition 1.

Lifestyle Modifications: Universal Benefit with Enhanced Effect

Weight reduction and sodium reduction are recommended for all prehypertensive and hypertensive patients but may be particularly effective in minorities 1.

• The salt content of some traditional diets in minorities may be very high 1.
• The low-sodium DASH eating plan was associated with greater reductions in blood pressure in African Americans than other demographic subgroups 1.

Side Effect Considerations

African Americans and Asians have a 3- to 4-fold higher risk of angioedema and more cough attributed to ACE inhibitors than whites 1.

Addressing Disparities: Beyond Pharmacology

Socioeconomic and Access Factors

• Much of the variance in hypertension-related sequelae across racial or ethnic groups may be attributable to differences in socioeconomic conditions, access to healthcare services, or attitudes, beliefs, and deficits in accurate health-related information 1.
• African Americans have more concomitant conditions that increase cardiovascular disease risk, including obesity (especially in black women), type 2 diabetes, sedentary lifestyle, low socioeconomic status, and higher levels of psychosocial stress 1.
• Despite significant improvements in coronary heart disease and cardiovascular disease risk from 1999 to 2010 for whites, average blood pressure and total cholesterol levels were unchanged and prevalence of diabetes increased in black patients 1.

Treatment Intensity

• Blacks and whites are more likely than Hispanics to have therapy intensified (81.5% and 80.9% vs. 70.8%) 3.
• Interventions to reduce disparities should increase physician awareness of the need to intensify drug therapy more aggressively without waiting for multiple clinic visits 4, 3.

Common Pitfalls to Avoid

• Do not use race as a reason to withhold ACE inhibitors or ARBs in black patients who need them for heart failure, chronic kidney disease, or as part of combination therapy 1.
• Do not assume all patients within a racial/ethnic group have identical risk profiles or treatment responses 1.
• Do not set different blood pressure targets based on race—the disparate burden of hypertension on African Americans argues for equally aggressive or more aggressive blood pressure control, not less 1.
• Do not overlook the importance of addressing socioeconomic barriers, access to care, and medication affordability, which contribute significantly to disparities in outcomes 1.