The 2014 Eighth Joint National Committee (JNC8) guidelines1 reviewed the existing literature and concluded that in the general black population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic or calcium channel blocker. (For general black population: Moderate Recommendation –Grade B; for black patients with diabetes: Weak Recommendation – Grade C). Based on expert opinion, the guideline recommends that black people with chronic kidney disease (CKD), proteinuria, and hypertension should use an ACE inhibitor or an angiotensin receptor blocker (ARB) as initial therapy, because they have a higher likelihood of progression to end stage renal disease.
People of black African descent tend to have higher blood pressure at an earlier age than people of white European descent.2-7 It is often more difficult to control.2,5-7 They also have a higher incidence of diabetes and higher and earlier rates of cardiovascular mortality with more renal and cardiac organ damage.2,5-9
Studies have shown that initial treatment of hypertensive blacks with an ACE inhibitor or an angiotensin II receptor blocker (ARB) monotherapy was less effective and was associated with adverse cardiovascular outcomes.2,8,10
The large Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) found a thiazide-type diuretic was more effective in improving cerebrovascular, heart failure, and combined cardiovascular outcomes compared to an ACE inhibitor in the black patient subgroup, which included large numbers of diabetic and nondiabetic patients.8 It also found there were no differences in outcomes (cerebrovascular, CHD, combined cardiovascular, and kidney outcomes, or overall mortality) between the diuretic and calcium channel blocker.
However, ACE inhibitors and ARBs have been found to be the most effective antihypertensive drug classes at reversing vascular hypertrophy and lowering the risk and progression of cardiovascular and renal disease in all populations including in black people.11-17 Based on the evidence, the International Society on Hypertension in Blacks (ISHIB) recommends monotherapy with an ARB or ACE inhibitor as an alternative to thiazide-type diuretic or calcium channel blocker for blacks with systolic blood pressure 10 or less mm Hg above target levels. For blacks with blood pressure more than 15/10 mm Hg above target a two-drug regimen is recommended that includes one of the preferred drugs combined with a small dose of an ACE inhibitor or an ARB.6
References
- James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults. JAMA 2014; 311 (5): 507-520.
- Brewster LM, van Montfrans GA, Oehlers GP, Seedat YK. Systematic review: antihypertensive drug therapy in patients of African and South Asian ethnicity. Intern Emerg Med 2016; 11 (3): 355-374.
- Nwankwo T, Yoon SS, Burt V, Gu Q. Hypertension among adults in the United States: National Health and Nutrition Examination Survey, 2011-2012. NCHS Data Brief 2013; (133): 1-8.
- Racial/Ethnic disparities in the awareness, treatment, and control of hypertension - United States, 2003-2010. MMWR Morb Mortal Wkly Rep 2013; 62 (18): 351-355.
- Still CH, Craven TE, Freedman BI, et al. Baseline characteristics of African Americans in the Systolic Blood Pressure Intervention Trial. J Am Soc Hypertens 2015; 9 (9): 670-679.
- Flack JM, Sica DA, Bakris G, et al. Management of high blood pressure in Blacks: an update of the International Society on Hypertension in Blacks consensus statement. Hypertension 2010; 56 (5): 780-800.
- Flack JM, Ferdinand KC, Nasser SA. Epidemiology of hypertension and cardiovascular disease in African Americans. J Clin Hypertens (Greenwich) 2003; 5 (1 Suppl 1): 5-11.
- Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA 2002; 288 (23): 2981-2997.
- Mozaffarian D, Benjamin EJ, Go AS, et al. Heart Disease and Stroke Statistics-2016 Update: A Report From the American Heart Association. Circulation 2016; 133 (4): e38-360.
- Julius S, Alderman MH, Beevers G, et al. Cardiovascular risk reduction in hypertensive black patients with left ventricular hypertrophy: the LIFE study. J Am Coll Cardiol 2004; 43 (6): 1047-1055.
- National Guideline C. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. 2013.
- Palmer SC, Mavridis D, Navarese E, et al. Comparative efficacy and safety of blood pressure-lowering agents in adults with diabetes and kidney disease: a network meta-analysis. Lancet 2015; 385 (9982): 2047-2056.
- Unger T. The role of the renin-angiotensin system in the development of cardiovascular disease. Am J Cardiol 2002; 89 (2a): 3A-9A; discussion 10A.
- Julius S, Kjeldsen SE, Weber M, et al. Outcomes in hypertensive patients at high cardiovascular risk treated with regimens based on valsartan or amlodipine: the VALUE randomised trial. Lancet 2004; 363 (9426): 2022-2031.
- Zanchetti A, Julius S, Kjeldsen S, et al. Outcomes in subgroups of hypertensive patients treated with regimens based on valsartan and amlodipine: An analysis of findings from the VALUE trial. J Hypertens 2006; 24 (11): 2163-2168.
- Brenner BM, Cooper ME, de Zeeuw D, et al. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med 2001; 345 (12): 861-869.
- de Zeeuw D, Ramjit D, Zhang Z, et al. Renal risk and renoprotection among ethnic groups with type 2 diabetic nephropathy: a post hoc analysis of RENAAL. Kidney Int 2006; 69 (9): 1675-1682.
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