Treating Hypertension Based On Race

Hypertension is the most common primary diagnosis in the United States, affecting approximately 1 out of 3 Americans. Hypertension is defined as a systolic blood pressure of 140 mmHg or greater or a diastolic blood pressure of 90 mmHg or greater. Hypertension has long-term consequences increasing the risk of peripheral arterial disease, coronary artery disease, myocardial infarction, cerebrovascular disease, congestive heart failure, stroke, and chronic kidney disease. These complications are more prevalent in African Americans compared to Caucasian Americans. Adequate treatment of hypertension, especially in African Americans, is necessary to decrease the risk of potential complications.

Hypertension in African Americans occurs at a younger age which contributes to the lifetime risk of complications secondary to hypertension. Due to increased vasoconstriction, African Americans have more difficult to treat hypertension. Studies also indicate an increase in salt sensitivity in African Americans resulting in more aggressive hypertension.

Current JNC 8 guidelines recommend treating blood pressures with goal of 140/90 mmHg or less in patients less than 60 years old and 150/90 mmHg systolic or less in patients older than 60 years old. Initial pharmacotherapy prescribed is based on comorbidities. For example, patients with diabetes should be placed on an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) for renal protection. Initial pharmacotherapy for non-black patients includes thiazide diuretics, calcium channel blockers, ACE inhibitors, or ARBs. Initial pharmacotherapy for African American patients includes calcium channel blockers or thiazide diuretics.

Antihypertensive medications are some of the most commonly prescribed medications in the United States yet only approximately 50% of patients have controlled blood pressures. The patient’s response to an antihypertensive is in part affected by renin levels. In patients with high plasma renin levels, ACE inhibitors or ARBs will provide greater blood pressure lowering. In patients with low plasma renin levels, such as African American patients, ACE inhibitors and ARBs will not have as great of an affect thus calcium channel blockers and thiazide diuretics are more likely to provide better blood pressure control.
Untreated hypertension is associated with increased risk of cardiovascular events including stroke, coronary artery disease, peripheral arterial disease, and congestive heart failure. There is an increased risk of early onset hypertension and more aggressive hypertension in African Americans. By understanding the pathophysiology of hypertension in African Americans, clinicians can provide more effective pharmacotherapy to control hypertension and reduce the morbidity and mortality associated with hypertension.

Sources
Hypertension by Alexander, M. R.
JNC8 Guidelines for the Management of Hypertension in Adults by American Family Physician.
Systemic review: antihypertensive drug therapy in patients of African and South Asian ethnicity by Brewster, L. M., Van Montfrans, G. A., Oehlers, G. P., & Seedat, Y. K.
Hypertension pharmacogenomics: in search of personalized treatment approaches by Cooper-DeHoff, R. M. & Johnson, J. A.
Pathophysiology: the biologic basis for disease in adults and children by McCance, K., Huether, S., Brashers, V., & Rote, N.
Blood pressure response to metoprolol and chlorthalidone in European and African Americans with hypertension by Mehanna, M., Gong, Y., McDonough, C. W., Beitelshees, A. L., Gums, J. G., Chapman, A. B., …Cooper-DeHoff, R. M.