Effects Of Hypertension On

Hypertension is a debilitating disease that afflicts 26% people in the world. Regarded as the silent killer, hypertension does not show any external symptoms, but gradually hardens arteries leading to higher risks for kidney failure, cardiovascular diseases and stroke (Kearney et. al, 2005). In USA, over 77 million people are recorded to be suffering from hypertension currently, and the number is expected to increase within the next 15 years as a significant chunk of the US population grows old (AHA, 2013). Though hypertension, also known as high blood pressure, is quite common among American people, it is more prevalent among African Americans than other ethnic communities. According to the American Heart Association, the prevalence of high blood pressure among African Americans is the highest among any ethnic group in the US (St. John Providence Health System, 2014). A new research study in Circulation: Cardiovascular Quality and Outcomes shows that high blood pressure is more prevalent among African women than African men, white men and women. A study conducted on 70,000 people in the 12 southeastern states within USA, known as the ‘Stroke Belt’ because of higher rate of stroke incidents, showed that 64% African American women suffer from hypertension compared to 52% white women and 51% black and white men (AHA, 2013). This essay would discuss the causes of high prevalence of hypertension cases among African-American women and the interventions to reduce this phenomenon.Effects Of Hypertension On African American Race Essay

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What is Hypertension?
Hypertension is a medical terminology of the condition called high blood pressure. When blood is pumped into the system by the heart, it puts pressure on the artery walls. When the pressure exerted by the flow of blood becomes heavier on the artery walls, it results in a condition known as high blood pressure or hypertension. Systolic refers to the pumping phase of the heartbeat, and diastolic refers to the resting phase between heartbeats. Blood pressure number is read with the systolic number over the diastolic number (St. John Providence Health System, 2014). According to the National Heart, Lung, and Blood Institute (NHLBI), in a normal healthy person, the blood pressure at a systolic level should be less than 140 and less than 90 at a diastolic level. When the blood pressure becomes at least 140 or higher at the systolic level and at least 90 or higher at the diastolic level, it is considered as hypertension or high blood pressure (St. John Providence Health System, 2014). However, hypertension is diagnosed when several readings of blood pressure on different occasions show high blood pressure level.Effects Of Hypertension On African American Race Essay

Causes of Hypertension among African American Women
There are various opinions as regards the causes of the prevalence of hypertension in African American women. According to some researchers, genetic factors account for the higher rate of prevalence of hypertension in Black American women, while another group of researchers believe that environmental factors are more to be blamed for the condition.

Genetic Factors
According to some researchers, African Americans have an enhanced ability to store sodium in their blood, a phenomenon that might have resulted from their days of slavery when they were transported from Africa to USA via ships. This ability to store sodium in blood protected the black African slaves from fatal salt-depletive diseases like diarrhea and vomiting, but the same ability now contributes to hypertension when their descendants consume American foods, which are higher in sodium content compared to African foods (Fuchs, 2011). A team of researchers from the National Institutes of Health (NIH) conducted a study on 1,017 African Americans in 2009 and made the discovery of five genetic variants that explain the high prevalence of blood pressure in Black Americans. In order to probe further into their findings, the researchers examined DNA of 980 West Africans with or without high blood pressure, and they discovered that the genetic variants detected in African Americans matched with the blood pressure of West Africans (NIH, 2009). This finding is of great significance because many African-Americans are the descendants of the Western Africans.Effects Of Hypertension On African American Race Essay

Environmental Factors
Besides genetic factors, environmental factors such as lifestyle, obesity and physical inactivity are also responsible for the growing number of hypertension cases among African Africans. A few environmental factors are discussed below:

Obesity and Lack of Exercise
Obesity is a condition that has affected USA in epidemic proportions, but if any race that has been hit the hardest by this epidemic is African Americans, especially, the black women. In comparison with 32% white women and 41% Hispanic women, 60% black women are obese (Dingfelder, 2013). According to the National Institutes of Health (NIH) and Centers for Disease Control (CDC), obesity or overweight is one of the primary reasons for high blood pressure. In order to check obesity, one needs to follow a regular exercise regimen along with controlling diet, but many African American women avoid exercising in order to protect their expensive hairdo (Dingfelder, 2013). Since hairstyle maintenance and hair care are quite expensive, many African Americans prefer to lead a sedentary lifestyle and forgo any sort of activity that can ruin their hair.Effects Of Hypertension On African American Race Essay

Poor Diet
Poor diet also contributes to hypertension and cardiovascular diseases. An unhealthy diet, constituted of high calorie and high fat foods, results in clogging of the arteries and veins by fatty deposits. Such diet initially raises blood pressure in our body and if not controlled, gradually will affect heart and other vital organs of the body. African American women, due to the lack of knowledge and proper education and also due to the poor socioeconomic conditions, nurture very poor dietary habits. Compared to women of other ethnic groups, African American women consume the highest quantity of high fat, high calorie and high cholesterol food per day. Their average diet includes 43% of total calories from high fat foods with over 15% from saturated fat (Huggins, 2006). As a result of such poor dietary decisions, African American women suffer from higher rate of obesity and hypertension.

Alcohol consumption is another contributive factor to hypertension. Heavy drinkers who consume at least two drinks per day are two times more likely to develop hypertension than non-drinkers. It has been observed that alcohol consumption among African Americans, especially women, is considerably lower than white women. However, it is seen that African American women start drinking heavily in the middle age, and this habit leads many black women to develop hypertension in their middle years (NCADD, 2014).Effects Of Hypertension On African American Race Essay

Stress is another contributive factor for hypertension. Stress shoots up adrenaline in our body leading to an increase in blood pressure. African American women are more stressed out than white women. Studies show that black women frequently encounter racial discrimination and unfair treatment in employment and housing that add to their stress level (Scott, 2013). Furthermore, material hardship and other stressful life events such as job loss, divorce and marriage also take a toll on their health. As a result, black women not only begin to suffer from hypertension earlier than their white counterparts, they also suffer from accelerated aging, diabetes, obesity and cardiovascular diseases.

Interventions involve techniques and methods that help keep the risk of hypertension at bay. It also helps the patients of high blood pressure keep their pressure under control. There are many well-tested and proven interventions, which if followed, can whittle away the risk of hypertension significantly. Below are discussed some of the intervention techniques that could prove helpful for African American women to keep their high blood pressure under control.Effects Of Hypertension On African American Race Essay

Reduction in Dietary Sodium (Salt) Intervention
Salt is considered as one of the biggest culprits of hypertension. Salt regulates the fluids in our body. A normal healthy person needs only 500 mg of sodium daily (UMMC, 2013). However, the American fast food culture is high on sodium content, and therefore, African American women, who nurture poor dietary habits, often consume food that are not only high in calorie but also high in salt content. Furthermore, due to genetic reasons, African Americans have an enhanced ability to store sodium in their body. Hence, any high sodium diet may only increase their risks of hypertension. Therefore, black women should significantly cut down on their sodium intake by reducing the fast food consumption and canned foods. Research has shown that even a small percentage of reduction of salt intake can improve the systolic pressure. For example, Cutler and his team have observed that if the salt intake can be reduced by 77mmol/day, then the systolic pressure will reduce by 1.9mmHg (NHLBI, 2014).Effects Of Hypertension On African American Race Essay

Weight Loss Intervention
After the diagnosis of hypertension is made, one may either opt for prescribed medication or go for lifestyle changes to keep hypertension at bay. According to CDC and NIH, obesity or overweight is one of the primary causes of hypertension. Therefore, the loss of even a small amount of weight may bring the blood pressure down and control high blood pressure. However, a person of normal weight or an underweight person may also suffer from hypertension if he is not careful about diet and lives a sedentary life style. It is imperative to cherish healthy life style practices composed of healthy and balanced diet and a routine exercise program. The clinical review “Clinical Guidelines for the identification Evaluation and treatment of overweight and obesity” also emphasizes upon weight loss to reduce blood pressure (NHLBI, 2014). The findings of 11 research studies show that a significant weight loss contributes to the reduction of both systolic and diastolic pressure. 2 pound reduction of body weight reduces systolic blood pressure by 1.6mmHg and diastolic blood pressure by 1.3mmHg (NHLBI, 2014). In fact, weight loss not only helps in the reduction of blood pressure immediately, it also keeps the pressure from increasing further. Weight loss is very useful for reducing blood pressure in overweight people suffering from hypertension.Effects Of Hypertension On African American Race Essay

Education and Awareness
Lack of education among African-American communities is one of the main reasons for the widespread and increasing rate of hypertension cases among African-American women. Only 18% African-American fourth graders in the U.S born families and 7% of the immigrant families scored higher than “proficient” in reading in a survey conducted by Annie E. Casey foundation (Bossip, 2014). It has also been found that African-American women are far more likely to conceive their first child during teenage years than their Asian or white counterparts. This shows that the overall education and awareness of African-American females are quite inferior to the country’s average. They are in many cases ignorant about the causes and after-effects of hypertension. Community awareness programs on hypertension will help them learn about how obesity, poor dietary decisions, alcohol consumption and lack of exercise can lead to high blood pressure. Schools, media, government agencies and NGOs should take a combined responsibility to make the African-American community aware of the evils of hypertension and how it can be detrimental for the health and well-being of women.

Hypertension is one of the most prevalent diseases in USA. The number of hypertension cases is slated to increase significantly over the next few years as a large portion of the US population grows old. Among all the ethnic groups in USA, hypertension is highest among African-American women. There are several reasons contributing to hypertension among black women. Genetically, the body of an African-American person can retain more sodium than a normal white American person. The higher sodium content in the body leads to higher chances of developing hypertension. There are other factors like high obesity rate among African-American women, high sodium and high fat diet, diabetes, stress and overconsumption of alcohol leading to hypertension among African-American women. Interventions like low sodium diets, weight loss programs and better quality of education and awareness will help reduce the number of cases among African-American women significantly.Effects Of Hypertension On African American Race Essay

Contributing Factors to Hypertension Disparity and Treatment in African-Americans
There are several physiological and hemodynamic determinants of hypertension in African-Americans. Although there is speculation about possible differences in etiology and pathophysiology, no single, unique cause of hypertension has been identified that explains the high prevalence of hypertension in African-Americans. Obesity is a major contributing factor to hypertension. This association is thought to be due to an increase in factors such as angiotensin, leptin, and renal medullary compression, leading to increased sympathetic nervous system activation, and decreased adiponectin, leading to elevated blood pressure and increased cardiovascular risk.5,6 Harshfield and others have shown that obese African-Americans have higher rates of sodium retention than whites, and that the percent body fat is related to sodium retention.7 Importantly, the prevalence of obesity is highest in African-American women, at 35.7%. African-Americans have a 51% higher prevalence of obesity, and Hispanics (28.7%) have 21% higher obesity prevalence compared with whites (23.7%)8 The rapid rate of growth of obesity in African-Americans in particular predicts a likely increase in hypertension. Another frequently cited etiological factor is salt sensitivity among African-Americans. Salt sensitivity is described as an increase in blood pressure in response to a high-salt diet.Effects Of Hypertension On African American Race Essay


High blood pressure (hypertension) is a major health condition which affects many Americans. This health condition may increase the risk of cardiovascular disease and stroke. A normal blood pressure consists of systolic blood pressure divided by diastolic blood pressure, 120/80mmHg (millimeters of mercury). High blood pressure is defined as systolic pressure which is greater than 140mm Hg, and diastolic pressure which is over 90mm Hg. Hypertension influences the health outcomes of black Americans more than other races in the United States. Racial discrimination and socioeconomic status are two major factors which influence the rate of high blood pressure in the black American population

Physiological studies of hypertensives indicate that the prevalence of salt sensitivity in African-Americans is 50%, whereas the prevalence in whites is 40%.9,10 Thus, not all hypertension is explained by salt sensitivity in African-Americans. Recent investigations of genetics suggest that the T594M variant polymorphism explains some of the variance in blood pressure (BP) response to salt intake; however, this particular gene is infrequent, occurring in 5% of African-Americans, and it is estimated to explain only 3% of the variance in response.11 There has been speculation that the salt-sensitivity phenotype is a ‘survival response’ in African-Americans related to the transatlantic slave trade and the hardship invoked; however, there is no firm biological proof of this concept. At this point there are no specific genes that completely explain the disparity of hypertensive disease in African-Americans.Effects Of Hypertension On African American Race Essay

Other physiological changes have been described in African-Americans, such as increased alpha receptor sensitivity, decreased beta receptor sensitivity, increased sympathetic nervous system activity due to stress, increased endothelin, increased transforming growth factor-beta (TGF-β1), decreased prostaglandin E2, decreased urinary dopamine after salt loading, and a decrease in atrial natriuretic peptide (ANP) after salt loading. However, none of these physiological findings is unique to African-Americans.12–21 Recently, investigators have identified differences in the balance of endothelial nitric oxide (NO) and reactive oxide species (ROS) between African-Americans and whites. It appears that, in healthy individuals, African-Americans have a relative reduction in the NO/ROS ratio compared with whites.22 Thus, the vasculature has less available NO for ‘natural’ vasodilation.Effects Of Hypertension On African American Race Essay

These physiological changes may have some bearing on the best drug choices for treatment in African-Americans. In as much as physiology is important in the management of hypertension in African-Americans, the environment, sociology, and culture have a significant effect on treatment. Socioeconomic disadvantage and poor access to care play a role in the excess burden of hypertension. Interestingly, the rate of hypertension in blacks living in America is higher than in blacks living in Africa. This difference is more striking in Africans living in rural Africa, where the rate of hypertension is much lower than in urban Africans, highlighting the importance of the environment in hypertension.23–25

Perceptions about hypertension among African-Americans may affect behavior in terms of compliance and adherence to therapy. In a survey of hypertensive African-Americans, patients had appropriate clinical expectations of their role in treatment, the desire to be educated by their physicians, and the belief that medications would lower BP and the risk of complications from hypertension.

Racism has plagued this country since its inception and continues to be one of the greatest problems our
society faces. The non-white population in America has continually been subjected to individual and
institutional forms of racism despite the efforts of civil rights groups and political leaders to eliminate
discrimination in all its forms. The views and opinions of entire groups of people are disregarded as a
result of racial discrimination, which stifles America’s progress and places countless individuals in a
position of hopeless discontent. Social inequality is most often the topic of conversation whenever one
considers the destructive nature of racism, however one must also consider the negative effects racism
has on an individual’s physical and mental well-being. Wide spread racism has a negative effect on the
psychological and physiological health of non-whites.
It is necessary to discuss the etiological model that research has employed to explain the effects of
racism-related stress on one’s psychological and physiological well-being. Research has shown that
racial discrimination is a stressful experience for non-whites (Clark, Anderson, Clark, & Williams,
1999; Harrell, 2000; Nyborg & Curry, 2003). In one study conducted by Klonoff and Landrine (1999),
ninety-five percent of a sample population of African Americans reported that racial discrimination was
a stressful experience (Nyborg & Curry, 2003, p. 259). The link between stress and health has been the
topic of numerous studies, and it is this link that will form the basis for the discussion of racism-related
dysfunction. Racism-related stress has been identified by numerous researchers as an etiological basis
for the psychological and physiological dysfunction experienced by non-whites (Clark, et al., 1999;
Harrell, 2000; Nyborg & Curry, 2003).Effects Of Hypertension On African American Race Essay
Specific attention is given to the topic of racism-related stress by Harrell (2000). According to her
research, there are six types of racism-related stress that have the potential to affect the well-being of an
individual: racism-related life events, vicarious racism experiences, daily racism micro stressors,
chronic-contextual stress, collective experiences, and transgenerational transmission (Harrell, 2000, p.
45-47). The first type of racism-related stress is the result of specific, time-limited experiences of racism
in which one feels discriminated against, harassed, or judged (Harrell, 2000, p. 45). One may also
experience stress as a result of hearing about or seeing another person’s experience with racism. This
constitutes a vicarious experience of racism (Harrell, 2000, p. 45). Racism-related stress, however, is not
always overt, and this is exampled in the subtle daily reminders that one is different. These racism micro
John Crocker*
Graduate Student, M.Ed. in School Counseling Program, Rivier College
John Crocker
stressors may be as simple as being watched in a store or overlooked and discounted in an office setting;
however their effects are no less deleterious (Harrell, 2000, p. 45-46). To this point, racism-related stress
has been discussed in the context of specific events that either compound one’s stress level directly or
vicariously. However, three more types of racism-related stress exist that operate on a societal level and
which are more closely related to the concept of institutional racism.Effects Of Hypertension On African American Race Essay
Chronic-contextual stress occurs when non-whites are forced to live in a society in which they are
subjected to differential treatment and an unequal distribution of resources (Harrell, 2000, p. 46). Nonwhite families are forced to cope with the unfair treatment and adapt to an environment in which they
are given less of an opportunity for success. One example of chronic-contextual stress is poor
educational resources in non-white communities (Harrell, 2000, p. 46). Collective experiences, another
type of racism-related stress, can be seen when one perceives that the racial group with which they
identify is generally not treated fairly. For example, one may experience an increase in stress as a result
of witnessing a stereotypical portrayal of the race with which they identify on television or in the news
(Harrell, 2000, p. 46). Lastly, it is believed that historical injustices aimed at specific racial groups can
be transmitted to new generations. Transgenerational transmission of stress can affect an individual who
perceives that the group with which they identify has been historically mistreated or oppressed (Harrell,
2000, p. 46-47).
It should also be noted that the research in question uses a phenomenological approach to the
experience of racism (Harrell, 2000, p. 44-45). The individual who experiences racism does so as a
result of their subjective perception of the actions of others (Clark, et al., 1999, p. 806-807). “Perceived
racism” is a concept that will assist one in understanding the connection between stress and the negative
effects of racism (Clark, et al., 1999, p. 808). This approach validates the stress response of the
individual perceiving the racism and allows one to consider the negative implications of those subtler
instances of racism that are not objectively considered as representative of racist behavior (Clark, et al.,
1999, p. 806; Harrell, 2000, p. 45).Effects Of Hypertension On African American Race Essay
Racism-related stress has been discussed in its various forms, and a stress model has been
suggested to explain the etiology of the negative impacts that racism has on the psychological and
physical well-being of non-whites. It is now important to discuss the various psychological stress
responses to the repeated exposure to perceived racism. Exposure to racism may cause one to become
anxious, paranoid, angry, helpless/hopeless, frustrated, resentful, and fearful (Clark, et al., 1999, p. 811;
Harrell, 2000, p. 47-48; Nyborg & Curry, 2003, p. 264). These stress responses can affect one’s ability
to function in school, work, and social settings as well as increasing the potential for violent out bursts
and suicidal ideations. One study, conducted by Nyborg and Curry (2003), showed a correlation
between personal experiences with racism and lower-self concept, higher levels of hopelessness, and
depressive symptoms (Nyborg & Curry, 2003, p. 264). It is likely that perception of institutional racism
will evoke similar responses if one considers all forms of racism-related stress as having a negative
impact on psychological well-being. Harrell’s (2000) outline of racism-related stress supports this
Coping strategies may be adopted in response to psychological distress (Clark, et al., 1999, p. 809-
811). Many times, however, these coping strategies only serve to amplify or compound one’s problems
(Clark, et al., 1999, p. 809). For example, personal experiences with racism have been found to be
connected to behavior problems in African American boys (Nyborg & Curry, 2003, p. 263). Increased
hostility and aggression are common forms of active coping responses that have been associated with
racism-related psychological distress (Clark, et al., 1999, p. 811; Harrell, 2000, p. 47-48; Nyborg &
Curry, 2003, p. 263). Other forms of negative coping strategies are verbal expression of anger, substance Effects Of Hypertension On African American Race Essay
abuse, cigarette smoking, and poor eating habits (Clark, et al., 1999, p. 811; Harrell, 2000, p. 47-48).
One may adopt a negative coping strategy in order to try and alleviate feelings of depression, anxiety,
frustration, or anger. These coping strategies do not serve to resolve the underlying problem of racism
and often lead to the unfair stigmatization of individuals who have been placed in psychologically
distressful situations. Also, substance abuse and poor eating habits are good examples of coping
strategies that can have a negative physiological effect on an individual.
It is important to understand the interconnectivity of psychological and physical health when
considering the negative effects of racism. The persistent experience of racism-related psychological
distress can result in psychosomatization and an increased potential for serious physiological health
problems (Clark, et al., 1999, p. 811-812; Harrell, 2000, p. 47-48). Some racism-related physiological
effects include hypertension, cardiovascular reactivity, and neuroendocrine responses (Clark, et al.,
1999, p. 811-812; Harrell, 2000, p. 47-48). Clark et al. (1999, p. 811) noted that racism-related stress can
have a serious impact on the resting blood pressure of African Americans. Another serious physiological
outcome related to racism-related stress is poor immune system functioning (Clark, et al., 1999, p. 811-
812). Some research has suggested that the healing process is slowed as a result of stress (Clark, et al.,
1999, p. 812). It is important to consider the disadvantages that one faces when their health is
compromised and they are expected to perform in a society in which stress is a daily consideration.
Racism-related stress complicates the lives of non-whites in a number of very serious ways. In
addition to creating the widely discussed social inequalities, racism has been shown to have a negative
impact on one’s psychological and physiological well-being. The psychological distress caused by
racism-related stress can be debilitating and may increase the potential that one will adopt negative
coping strategies in an effort to alleviate their depression, anxiety, frustration, and anger. Negative
coping strategies, such as substance abuse and poor eating habits, affect one’s physiological and social
well-being and do not serve to eliminate one’s problems. Prolonged exposure to racism-related
psychological distress can also cause psychosomatization, which can affect one’s physiological wellbeing in a number of serious ways. One may experience increased blood pressure, hypertension, poor
immune system functioning, and a slower rate of healing as a result of stress-related
psychosomatization. To quote Harrell (2000, p. 48), “The evidence is compelling, and growing, that
racism is pathogenic with respect to a variety of physical and mental health outcomes.”Effects Of Hypertension On African American Race Essay

However, most of these African-Americans also had inappropriate, non-biomedical expectations of their treatment: 38% expected a cure, 38% did not expect to take antihypertensive medications for life, and 23% took medications only with symptoms.26 These known factors play a role in the disparity of hypertension control in African-Americans and therefore are important to consider in developing treatment plans.

Treatment Options
Diet and exercise remain the essential features of treatment recommendations for hypertension, especially given the obesity rates in this population. The Dietary Approaches to Stop Hypertension (DASH) study has demonstrated efficacy in reducing BP. It was particularly effective in African-Americans, producing impressive BP lowering even without weight loss or reductions in dietary sodium intake. The combination diet reduced BP by 13.2/6.1mmHg among African-Americans with hypertension and by 4.3/2.6mmHg among normotensive African-Americans. By comparison, in whites the reduction in BP was 6.3/4.4mmHg in hypertensives and 2.0/1.2mmHg in normotensives.27,28 The difficulty with DASH in African-Americans, as with all populations, is long-term maintenance and adherence to the diet without support.Effects Of Hypertension On African American Race Essay

While it is well known that all of the available antihypertensive classes of drug reduce blood pressure to some extent in all hypertensives, the Veterans Affairs (VA) Cooperative study showed that BP response to various drug classes differs by ethnicity and geographical residence. This implies that BP response is affected by genetic as well as cultural and environmental determinants. African-Americans had the best BP response to the calcium channel blocker and diuretic treatment arm in both the VA Cooperative and the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) studies.29,30 In several studies, the BP response to renin–angiotensin system (RAS) blockers in African-Americans is less robust than in whites.30,31 Despite this, the African-American Study of Kidney Disease and Hypertension (AASK) demonstrated that protection from renal disease progression was most improved with an angiotensin-converting enzyme (ACE) inhibitor compared with beta-blocker- or calcium-channel-blocker (CCB)-based therapy.32 In addition, it is important to remember that the primary outcome of the reduction in cardiovascular events in ALLHAT was equivalent between diuretics, calcium channel blockers, and ACE inhibitor therapy.30 Historically, African-Americans have been less responsive to beta-blockers than whites, in particular to traditional beta-blockers.Effects Of Hypertension On African American Race Essay

However, the data for the newer vasodilating betablockers (carvedilol, labetalol, and nebivolol) differ from older agents with respect to beta-adrenoceptor affinity and selectivity and partial agonist activity, which may affect the BP response in clinical use. Early studies of nebivolol demonstrate that part of the mechanism is based on increasing the availability of the natural vasodilator, NO.35 At baseline, African-Americans have less available NO in endothelial cells in vitro; however, the NO balance is restored in the presence of nebivolol.36 In a study of 300 African-Americans treated with nebivolol, the drug reduced BP safely and effectively with a nearly 60% response rate.37 BP response in African-Americans on labetalol is better than with the beta- 1-selective blocker atenolol.38 Similarly, Jawa found that carvedilol is more successful in African-Americans than metoprolol in reducing BP. 39 However, in a trial of heart failure, BP response to carvedilol was not significantly different from that of whites in the study.40

While the discussion of responses to monotherapy in African-Americans is important, given the severity of hypertension and high prevalence of comorbidities in African-Americans the most common scenario is likely to be combination therapy. In the ALLHAT study with 36% African-American participants, the average number of medications was two. In the AASK study, the average number of medications was nearly four.32 There have been only a few trials of combination therapy in hypertension and only one had African-American participants.41–43 The Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) of high-risk hypertensives showed that an ACE inhibitor/CCB combination was superior to beta-blocker/thiazide diuretic treatment in the reduction of cardiovascular mortality. However, there were no black patients in this trial. The second combination therapy trial is the Avoiding Cardiovascular Events through COMbination Therapy in Patients LIving with Systolic Hypertension (ACCOMPLISH) study, which compared the effects of ACE inhibitor/CCB with ACE inhibitor/thiazide therapy on cardiovascular mortality and morbidity in high-risk patients with hypertension. The study of 11,400 patients, including 11.9% African-Americans and 60% diabetics, showed that ACE inhibitor/CCB reduced cardiovascular disease mortality and morbidity by 20% more than ACE inhibitor/thiazide over five years.43 Furthermore, 24-hour ambulatory BP monitoring demonstrated similar BP control in both study arms.Effects Of Hypertension On African American Race Essay

There have been no published analyses by ethnicity from the ACCOMPLISH study. These two trials suggest that RAS blockade + CCB is a favorable combination compared with other options in reducing cardiovascular mortality, although the underlying reason for this success remains unclear. Additional studies may further elucidate the optimal combination for specific patient profiles. The ONgoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial (ONTARGET) is a comparison of combination RAS blockade with ACE inhibitor/angiotensin II receptor blocker (ARB) (ramipril/telmisartan) or RAS monotherapy with ARB (telmisartan) with RAS monotherapy with ACE inhibitor (ramipril).45 All three study arms reduced cardiovascular mortality and morbidity similarly despite somewhat greater BP reduction in the combination (ACE inhibitor/ARB) group. This trial of 25,570 included only 2.5% blacks, thus there is limited power to make any statements that are specific to blacks. Other, smaller studies have shown that combination ACE inhibitor/ARB therapy reduces proteinuria in patients with renal disease better than monotherapy with ACE or ARB, while a secondary analysis of renal outcomes in ONTARGET did not show such benefits.46,47 The ONTARGET population, however, had minimal renal disease relative to the patients in previous renal studies. Thus, this particular combination of RAS blockade with both ACE inhibitor/ARB may not be ideal for cardiovascular protection in patients without proteinuric renal disease, yet with renal disease it remains a reasonable choice for treatment. There are only two small studies of dual RAS blockade with the direct renin inhibitor (DRI) aliskerin and ACE inhibitor or ARB. These trials do show benefit in reducing target organ damage such as left ventricular hypertrophy (LVH) or albuminuria without significant increase in adverse events,48–51 yet there are no ethnic-specific data from these trials.Effects Of Hypertension On African American Race Essay

The International Society on Hypertenson in Blacks (ISHIB) consensus statement on hypertension in African-Americans, published in 2003, suggested that African-Americans should be managed aggressively with combination therapy when BP was 15/10mmHg greater than their BP goal. The recommended goals for treatment were initially <130/80mmHg for hypertensives with diabetes and chronic kidney disease, while the goal for other hypertensives was <140/90mmHg.52 However, more recently other high-risk patient profiles have been added to the more aggressive treatment goal. Individuals with heart disease, angina, peripheral vascular disease, stroke, transient ischemic attack, or left ventricular dysfunction and congestive heart failure have a BP goal of <130/80mmHg.53 Thus, far more hypertensive African-Americans should have their BP lowered to <130/80mmHg.Effects Of Hypertension On African American Race Essay

Adherence and compliance concerns continue to be a major barrier in African-Americans to achieving excellent control. Aggressive management with strategic choices of combination therapy when BP is greater than 15/10mmHg above the goal BP seems the most appropriate approach to managing hypertension in uncomplicated African-American patients with moderate to severe stage 2 hypertension. However, in high-risk patients this approach is indicated even in stage 1 level hypertension since the goal is lower.

At the opposite end of the spectrum of BP is the pre-hypertensives group (BP 120–139/80–89mmHg). There are no databases with extensive longitudinal follow-up of African-Americans showing the rate of progression of BP elevation from pre-hypertension to hypertension. The Framingham data showed a four-year progression rate of 44% in individuals with BPs of 130–139/85–89mmHg, while the Trial of Preventing Hypertension (TROPHY) showed a rate of 63%, although both populations were primarily white.54,55 Nevertheless, NHANES cross-sectional data show a high prevalence of elevated BP at every age group in African-Americans and the BP level is higher within each class of BP in African-Americans. BP elevation and target organ damage occur earlier in African-Americans; therefore, the progression rate is most likely as high as in the TROPHY study, or perhaps even higher. Although the TROPHY study has shown that treatment in this range of BP is safe and well tolerated with an ARB, there are insufficient data to warrant treatment of all individuals in this range of pre-hypertensive BPs. Close follow-up of these individuals is the best approach to limit the early damage related to BP in African-Americans. Effects Of Hypertension On African American Race Essay

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