Management of Hypertension and Cardiovascular Risk Factors in African Americans

African Americans have one of the highest rates of hypertension in the world. They develop hypertension earlier in life than the general population, and their rates are higher than whites for stage 3 hypertension and target organ damage, including heart failure, end-stage renal disease, and fatal and nonfatal stroke. Blood pressure lowering with a wide range of agents, especially diuretics, has been shown to be effective in controlling hypertension and reducing cardiovascular risk in all patients regardless of their race or ethnicity. Angiotensin-converting enzyme (ACE) inhibitors have also been demonstrated to be effective in controlled clinical trials in treating hypertension and preventing the mortality and morbidity associated with hypertension-related target organ damage. However, until recently, African American patients have been underrepresented in clinical trials, and there is a question regarding the efficacy of ACE inhibitors as monotherapy in these individuals in reducing blood pressure and cardiovascular events. Nevertheless, while we await the results of ongoing investigations that will address questions regarding outcome with ACE inhibitors in different racial groups, there is a need to make reasonable recommendations based on available data for the use of these medications in African American patients. This supplement to The Journal of Clinical Hypertension will define some of the unique aspects of hypertension in African Americans, including epidemiology of hypertension and cardiovascular disease, the increased prevalence of type 2 diabetes mellitus and heart failure, and the increased incidence of left ventricular dysfunction in this population. Drs. John Flack and Keith Ferdinand and Ms. Samar Nasser review the epidemiology of hypertension and other cardiovascular risk factors in African Americans, including diabetes, obesity, dyslipidemia, and renal disease. The adverse consequences associated with elevated blood pressure, both alone and in combination with other risk factors, are described. The importance of geography, lifestyle, and socioeconomic factors are highlighted. Drs. Elijah Saunders and James Gavin discuss the role of the renin-angiotensin-aldosterone system in African Americans and how it impacts hypertension and cardiovascular disease. The authors focus on the underutilization of ACE inhibitors in minority populations, as well as other therapeutic strategies for treating hypertension and preventing cardiovascular events. It is noted that particular care must be taken to ensure appropriate dosing of ACE inhibitors in highrisk populations. The optimal treatment of hypertension and cardiovascular risk in African Americans is reviewed by Drs. Jackson Wright and Janice Douglas. Results from older studies that showed the importance of lowering blood pressure are reviewed, including the Systolic Hypertension in the Elderly Program (SHEP)1 and the Hypertension Detection and Follow-Up Program (HDFP).2 The authors also explain newer outcome trials evaluating the effect of hypertension treatment on minority patients, such as the African American Study of Hypertension and Kidney Disease (AASK),3 which studied the benefit of ACE inhibition (usually with a diuretic) in this high-risk population. The importance of recent data from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT)4 will be noted, as well as clinical findings in the African American cohorts in the Losartan Intervention for Endpoint Reduction in Hypertension study (LIFE).5 Based on the evidence, the authors discuss treatment approaches for minority outpatients with hypertension, with an emphasis on target organ risk reduction. Drs. Rohit Arora, Luther Clark, and Malcolm Taylor then examine the treatment benefits of ACE inhibitors in the treatment for high-risk hypertensive patients, with specific recommendations on the use of ACE inhibition in African American patients with left ventricular dysfunction, renal disease, heart failure, stroke, and acute myocardial infarction. The authors further discuss use of ACE inhibition in high-risk patients, including those who are hospitalized post-myocardial infarction. Finally, Drs. Karol Watson and Kenneth Jamerson review the importance of lifestyle modification in the treatment of hypertension and cardiovascular risk in African Americans.6 Their paper reviews the results from studies evaluating the effect of hypertension treatment in these individuals, such as the diet interventions in the Dietary Approaches to Stop Hypertension (DASH)7 and DASHing With Less Salt8 and discusses the use of statins and other medications. Considering the disproportionate target organ damage, death, and disability associated with hypertension in African Americans, this supplement as a whole and in part should help clinicians better understand how to approach this difficult-to-treat population. Specifically, intensive blood pressure lowering using diuretic therapy as the initial step and the appropriate utilization of ACE inhibitors should help to minimize racial disparities in cardiovascular disease. Although diuretics continue to be the proven therapy for lowering blood pressure in all patients, including African Americans, ACE inhibitors also provide protective benefits for reducing cardiovascular risk and target organ damage.