title: Should African Americans with hypertension be treated differently than non-African Americans?
abstract: African Americans have a higher burden of hypertension, more severe blood pressure (BP) elevations, more concurrent risk-enhancing co-morbidities (e.g., diabetes), sub-clinical vascular injury at lower non-hypertensive BP levels, lower BP control rates, and significantly greater risk for adverse pressure-related clinical complications (e.g., stroke, heart failure) than whites. Randomized prospective data from hypertension endpoint trials show a virtually identical percentage reduction in CVD risk for a given magnitude of BP lowering, irrespective of the presence or absence of pre-treatment CVD across a broad range of BP down to pre-treatment BP levels of 110/70 mm Hg. These data, mostly emanating from white populations, do not necessarily inform practitioners as to the level below which BP should be lowered in those with established, long-standing hypertension; however, these data do provide support for initiating hypertension treatment at lower than conventional BP thresholds. A Mendelian randomized study examining the impact of life-long lower SBP levels showed that lifelong exposure to 10 mm Hg lower SBP was associated with an 82 % lesser rate of SBP rise per decade and a 58 % lower CHD risk that was much greater than the 22 % reduction in CHD reported for the same magnitude of SBP reduction in clinical trials. Arguably, it is the hypertension treatment paradigm that merits reexamination. Earlier hypertension treatment in all populations prior to the onset of significant pressure-related target organ injury might conceivably prevent, or at least significantly attenuate, the well documented age-related rise in BP seen in most Western societies. In addition, this treatment paradigm might also reduce the significant residual CVD risk observed under the current recommended approach to hypertension treatment. This new approach to therapy would likely have substantial clinical and public health benefits in the high-risk, under-treated African American population that suffers outsized devastating consequences from inadequate control of BP.
authors.affiliation: Division of Translational Research and Clinical Epidemiology, Department of Medicine, Wayne State University, Detroit, MI, USA, jflack@med.wayne.edu.
authors.forename: John M
authors.initials: JM
authors.lastname: Flack
authors.forename: Brian A
authors.initials: BA
authors.lastname: Ference
authors.forename: Phillip
authors.initials: P
authors.lastname: Levy
mesh_terms: D000959:Antihypertensive Agents / Q000627:therapeutic use*; D044383:Black People; D002318:Cardiovascular Diseases / Q000208:ethnology / Q000517:prevention & control*; D002986:Clinical Trials as Topic; D003920:Diabetes Mellitus / Q000208:ethnology; D006801:Humans; D006973:Hypertension / Q000188:drug therapy* / Q000208:ethnology*; D058246:Prehypertension / Q000208:ethnology / Q000628:therapy; D051436:Renal Insufficiency, Chronic / Q000208:ethnology; D014481:United States; D001741:Black or African American
chemical_list: D000959:Antihypertensive Agents