title: Is hypertension more severe among U.S. blacks, or is severe hypertension more common?
abstract: It is frequently stated that the risk of sequelae from hypertension at a given level of severity is higher among blacks than whites, although little empirical evidence supports that supposition. In this work we examined the basis for accepting the existence of a black: white differential in hypertension outcomes in a representative biracial sample of the U.S. population followed in the First National Health and Nutrition Examination Survey (NHANES-1) Epidemiologic Follow-up Study. As well recognized, the risk associated with increasing blood pressure is not dichotomous but varies across the entire distribution in a curvilinear fashion. The rightward skew of the blood pressure distribution with increasing mean levels affects comparisons between populations, since the change in shape results in a change in the mix of case severity. These considerations can influence estimates of the relative population-attributable risk from hypertension, considered as a dichotomous classification in blacks and whites. Although the relative risk of death associated with a systolic blood pressure of > or = 140 mmHg in this study was higher for blacks than for whites (1.7 and 1.5, respectively), with all-cause mortality as the outcome, the logistic coefficient for systolic blood pressure was not significantly different among white as compared with black men (beta = 0.016 vs. 0.010; p = 0.320 for race interaction term) and was slightly greater among white vs. black women (beta = 0.013 vs. 0.010; P = 0.05). After strata-specific blood pressure adjustment, the principal determinant of increased population risk for both black men and women was the higher prevalence of hypertension, not differential severity. The population-attributable risk for hypertension was at least two times higher among blacks because of the higher prevalence among them; moreover, the increased prevalence accounted for 10% of the interethnic difference in mortality. Data from this study indicate that hypertension was not more severe among individual blacks, simply more common in the population.
authors.affiliation: Department of Preventive Medicine and Epidemiology, Loyola University Stritch School of Medicine, Maywood, Illinois 60153, USA.
authors.forename: R S
authors.initials: RS
authors.lastname: Cooper
authors.forename: Y
authors.initials: Y
authors.lastname: Liao
authors.forename: C
authors.initials: C
authors.lastname: Rotimi
mesh_terms: D000328:Adult; D000368:Aged; D044383:Black People; D001794:Blood Pressure; D002318:Cardiovascular Diseases / Q000401:mortality; D003627:Data Interpretation, Statistical; D016208:Databases, Factual; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D006973:Hypertension / Q000145:classification / Q000150:complications / Q000208:ethnology* / Q000401:mortality; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015995:Prevalence; D012307:Risk Factors; D012720:Severity of Illness Index; D012737:Sex Factors; D014481:United States / Q000453:epidemiology; D044465:White People; D001741:Black or African American