Hypertension Outcomes and Management in Black Adults

Mortality and Morbidity Disparities

• Black adults with hypertension have a 1.8‑fold higher risk of fatal stroke, a 1.5‑fold higher risk of heart failure, and a 4.2‑fold higher risk of end‑stage renal disease compared with non‑Black adults, despite comparable or higher rates of hypertension awareness and treatment. 1, 2, 3
• Age‑adjusted hypertension‑attributable mortality in 2014 was 50.1 per 1,000 for Black men and 35.6 per 1,000 for Black women, versus 19.3 and 15.8 per 1,000 for non‑Hispanic White men and women, respectively. 1, 2, 4
• Black adults experience a 1.3‑fold greater risk of non‑fatal stroke and a 1.8‑fold greater risk of fatal stroke compared with non‑Black adults. 1, 2, 3
• The risk of heart failure is 1.5‑fold higher in Black adults; disease onset occurs at younger ages and is associated with higher rates of initial and recurrent hospitalizations. 1, 5
• End‑stage renal disease occurs 4.2‑fold more frequently in Black adults, a disparity linked to high‑risk APOL1 genetic variants that respond poorly to blood‑pressure lowering or renin‑angiotensin system (RAS) inhibition. 1, 2, 3

Blood‑Pressure Control Gaps

• Among treated hypertensive patients, control rates are 43.8 % for Black men vs 53.8 % for White men, and 52.3 % for Black women vs 59.1 % for White women. 1, 2, 3, 6
• Black adults present with more severe hypertension (higher baseline blood pressures) requiring more aggressive therapeutic regimens. 1, 4
• The control gap is not explained by lower awareness or treatment rates (which are at least equal to those of White adults) but by greater disease severity and differential efficacy of antihypertensive drug classes. 1, 2, 4

Pharmacologic Efficacy by Drug Class

• Thiazide‑type diuretics and calcium‑channel blockers (CCBs) achieve superior blood‑pressure reduction and lower cardiovascular event rates in Black adults compared with RAS inhibitors or β‑blockers when used as monotherapy. 4
• Single‑tablet combination products that include either a thiazide diuretic or a CCB are especially effective for attaining blood‑pressure control in Black adults. 7, 4

Initial Antihypertensive Therapy Recommendations

• For Black adults without heart failure or chronic kidney disease (including those with diabetes): initiate therapy with a thiazide‑type diuretic or a calcium‑channel blocker. 1, 7, 2, 3, 6
• For Black adults with heart failure: incorporate ACE inhibitors or ARBs into a multidrug regimen together with β‑blockers; in NYHA class III/IV heart failure, adding isosorbide dinitrate + hydralazine reduces total mortality by ≈ 43 %. 7, 4, 5
• For Black adults with chronic kidney disease: ACE inhibitors and ARBs are recommended as components of multidrug therapy, although they do not confer additional benefit over diuretics or CCBs in diabetic patients without nephropathy or heart failure. 7, 4

Blood‑Pressure Target Achievement

• Achieving a target blood pressure < 130/80 mm Hg in most hypertensive adults—particularly Black adults—generally requires two or more antihypertensive agents. This is a Class I recommendation supported by moderate‑quality evidence. 1, 7, 2, 3, 6

Clinical Pitfalls to Avoid

• Do not withhold ACE inhibitors or ARBs from Black patients who need them for heart failure, chronic kidney disease, or as part of combination therapy solely based on race. 7, 4
• Do not exclude any antihypertensive class from combination regimens on the basis of racial differences; combining an ACE inhibitor or ARB with a thiazide diuretic or CCB yields blood‑pressure reductions comparable to those in other racial groups. 7, 4

Quality‑of‑Life Impact

• In Black patients with NYHA class III/IV heart failure, the combination of isosorbide dinitrate + hydralazine not only lowers mortality but also improves time to first hospitalization and overall quality of life. 5

Hypertension Management in Diverse Populations

Introduction to Racial Disparities in Hypertension

• African Americans have a substantially higher hypertension burden, with more severe disease, earlier onset, and worse outcomes, including a 1.8-times greater risk of fatal stroke, 1.5-times greater risk of heart failure, and 4.2-times greater risk of end-stage renal disease compared to whites 8, 9.
• The American College of Cardiology recommends that all patients, regardless of race, should be treated to the same blood pressure targets, with the understanding that certain medication classes work differently across racial groups 8, 9.

Medication Selection and Efficacy

• The American Heart Association suggests that initial antihypertensive treatment for black adults with hypertension, but without heart failure or chronic kidney disease, should include a thiazide-type diuretic or calcium channel blocker 8, 10.
• Monotherapy with beta-blockers, ACE inhibitors, or ARBs lowers blood pressure to a lesser degree in African Americans than whites, with a 40% greater risk of stroke, 32% greater risk of heart failure, and 19% greater risk of cardiovascular disease 11, 12, 13.
• However, these interracial differences in blood pressure-lowering are abolished when ACE inhibitors or ARBs are combined with a diuretic 11, 12, 13.

Combination Therapy and Blood Pressure Targets

• The American College of Cardiology recommends that two or more antihypertensive medications are used to achieve a blood pressure target of less than 130/80 mm Hg in most adults with hypertension, especially in black adults 8, 10.
• No race/ethnic difference in blood pressure control was noted in SPRINT, even in the <120 mmHg arm, when chlorthalidone and amlodipine were provided at no cost 14.

Special Considerations for Specific Populations

• ACE inhibitors and ARBs are recommended in black patients with hypertension, diabetes, and nephropathy, but they offer no advantage over diuretics or calcium channel blockers in hypertensive patients with diabetes without nephropathy or heart failure 8, 9.
• The excess risk of chronic kidney disease outcomes in some blacks with hypertension may be due to high-risk APOL1 genetic variants 8, 10, 9.

Lifestyle Modifications and Side Effects

• Weight reduction and sodium reduction are recommended for all prehypertensive and hypertensive patients, but may be particularly effective in minorities 11, 12, 13.
• African Americans and Asians have a 3- to 4-fold higher risk of angioedema and more cough attributed to ACE inhibitors than whites 11, 12, 13.

Addressing Disparities and Common Pitfalls

• Much of the variance in hypertension-related sequelae across racial or ethnic groups may be attributable to differences in socioeconomic conditions, access to healthcare services, or attitudes, beliefs, and deficits in accurate health-related information 11, 12, 13.
• The American College of Cardiology advises against using race as a reason to withhold ACE inhibitors or ARBs in black patients who need them for heart failure, chronic kidney disease, or as part of combination therapy 8, 9.