Health Outcome Disparities Between Black and Non-Black Patients with Hypertension
Black patients with hypertension experience substantially worse cardiovascular and renal outcomes compared to non-Black patients, with 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, despite having similar or higher rates of hypertension awareness and treatment. 1
Mortality and Morbidity Differences
Black patients face dramatically elevated hypertension-related mortality compared to non-Hispanic whites and other racial groups:
Age-adjusted hypertension-attributable mortality rates (per 1,000 persons) in 2014 were 50.1 for Black men and 35.6 for Black women, compared to only 19.3 and 15.8 for non-Hispanic white men and women respectively 1
Stroke burden is particularly severe, with 1.3-times greater risk of non-fatal stroke and 1.8-times greater risk of fatal stroke in Black patients 1, 2
Heart failure develops at younger ages in Black patients and progresses more rapidly, with 1.5-times greater risk and higher rates of initial and recurrent hospitalizations 1, 2
End-stage renal disease occurs at 4.2-times the rate in Black patients, potentially related to high-risk APOL1 genetic variants that appear largely unresponsive to blood pressure lowering or RAS inhibition 1, 2
Blood Pressure Control Disparities
Despite equal or higher awareness and treatment rates, Black patients achieve worse blood pressure control:
Control rates among treated hypertensive patients: 43.8% for Black men vs. 53.8% for white men; 52.3% for Black women vs. 59.1% for white women 1
Disease severity is greater in Black patients at presentation, with higher baseline blood pressures requiring more aggressive treatment 1, 2
The control gap is not due to lack of awareness or treatment (which are at least as high as in whites), but rather to more severe hypertension and differential medication efficacy 1
Treatment Response Differences
Monotherapy Efficacy
Black patients demonstrate reduced blood pressure lowering with specific medication classes when used alone:
ACE inhibitors, ARBs, and beta-blockers are less effective as monotherapy in Black patients compared to whites, with 40% greater risk of stroke, 32% greater risk of heart failure, and 19% greater risk of cardiovascular disease when used alone 2, 3
Thiazide diuretics and calcium channel blockers are more effective in lowering blood pressure and reducing cardiovascular events than RAS inhibitors or beta-blockers in Black patients 1, 2
Combination Therapy Equalizes Outcomes
The racial differences in blood pressure lowering are abolished when ACE inhibitors or ARBs are combined with a diuretic 2. This is the critical clinical takeaway—combination therapy eliminates the efficacy gap.
When chlorthalidone and amlodipine were provided at no cost in SPRINT, no race/ethnic difference in blood pressure control was noted, even in the intensive <120 mmHg arm 2
Single-tablet combinations including either a diuretic or calcium channel blocker are particularly effective in achieving blood pressure control in Black patients 1
Evidence-Based Treatment Algorithm for Black Patients
Initial Therapy Selection
For Black adults without heart failure or chronic kidney disease (including those with diabetes):
For Black adults with heart failure:
- Use ACE inhibitors or ARBs as components of multidrug regimens, with addition of beta-blockers 1
- In NYHA class III/IV heart failure, adjunctive isosorbide dinitrate plus hydralazine reduced total mortality by 43% in Black patients 1
For Black adults with chronic kidney disease:
- ACE inhibitors and ARBs are recommended as components of multidrug regimens 1, 2
- However, they offer no advantage over diuretics or calcium channel blockers in diabetic patients without nephropathy or heart failure 1, 2
Achieving Blood Pressure Targets
Two or more antihypertensive medications are required to achieve blood pressure targets <130/80 mmHg in most adults with hypertension, especially in Black adults 1, 2. This is a Class I recommendation with moderate-quality evidence.
- Most Black patients will require combination therapy from the outset, particularly if systolic blood pressure is >15 mmHg or diastolic blood pressure is >10 mmHg above goal 3
Critical Pitfalls to Avoid
Never withhold ACE inhibitors or ARBs from Black patients who need them for heart failure, chronic kidney disease, or as part of combination therapy based solely on race 2. The reduced monotherapy efficacy does not apply to combination regimens.
Do not use racial differences as justification to exclude any antihypertensive class in combination therapy 1. The combination of an ACE inhibitor or ARB with a calcium channel blocker or thiazide diuretic produces similar blood pressure lowering in Black patients as in other racial groups 1.
Be aware that Black patients and Asian patients have 3- to 4-fold higher risk of angioedema and more cough with ACE inhibitors compared to whites 2, which may necessitate switching to ARBs.
Quality of Life Considerations
Black patients with heart failure develop symptoms at earlier ages and experience more rapid disease progression with higher hospitalization rates 1. The adjunctive use of isosorbide dinitrate plus hydralazine in Black patients with NYHA class III/IV heart failure not only reduced mortality but also improved time to first hospitalization and quality of life 1.
Much of the variance in hypertension-related outcomes across racial groups may be attributable to differences in socioeconomic conditions, access to healthcare services, and health literacy rather than purely biological factors 2. Addressing these social determinants is essential for improving outcomes.