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Correspondence: Daniel T. Lackland, DrPH, Department of Neurosciences, Medical University of South Carolina, Suite 501, Harborview Office Tower, Charleston, SC 29425
The racial disparity in hypertension and hypertension-related outcomes has been recognized for decades with African Americans with greater risks than caucasians. Blood pressure levels have consistently been higher for African Americans with an earlier onset of hypertension. Although awareness and treatment levels of high blood pressure have been similar, racial differences in control rates are evident. The higher blood pressure levels for African Americans are associated with higher rates of stroke, end-stage renal disease and congestive heart failure. The reasons for the racial disparities in elevated blood pressure and hypertension-related outcomes risk remain unclear. However, the implications of the disparities of hypertension for prevention and clinical management are substantial, identifying African American men and women with excel hypertension risk and warranting interventions focused on these differences. in addition, focused research to identify the factors attributed to these disparities in risk burden is an essential need to address the evidence gaps.
The racial disparities in hypertension and hypertension-related disease outcomes have been related mortality morbidity risks compared with their white counterparts. These excess risks from elevated blood pressure have a dramatic effect on life expectancy for African American men and women, which is significantly less than for Caucasian Americans. Stroke mortality risks are 2-fold greater for African Americans.
End-stage renal disease is 5 times more common for African American men and women. In addition, the age of onset of diseases such as stroke is considerably earlier for African Americans. For example, a 45-year-old African American man residing in the Southeast has the stroke risk of a 55-year-old white man in the Southeast and a 65-year-old white man residing in the Midwest.
Although high blood pressure affects all segments of the population, high blood pressure rates are more prevalent among African American men and women.
Specifically, the population attributable risk of hypertension and 30-year mortality among white men was 23.8% compared with 45.2% among black men and 18.3% for white women compared with 39.5% for black women. These excess disease risks have been long recognized and reported from the Evans County Heart Study
which were both initiated in 1960 specifically to study these racial disparities in cardiovascular disease in adults. Similarly, the Bogalusa Heart Study
has been established to assess cardiovascular risk factors in this population. Furthermore, the REasons for Geographic And Racial Differences in Stroke (REGARDS) study has further documented and confirmed the racial and geographic differences in awareness, treatment and control of hypertension.
Racial and geographic differences in awareness, treatment, and control of hypertension: the REasons for Geographic And Racial Differences in Stroke study.
With these large epidemiology studies, high blood pressure has been a common significant factor associated with the excess disease burden for African Americans.
Nearly one third of the adult population in the united States is considered to have hypertension with elevated blood pressure (≥140/90 mm Hg) and/or being treated with antihypertensive medication. The prevalence of hypertension is higher in both middle-aged and older African Americans compared with non-Hispanic whites.
As presented in Figure 1, data from the National Health and Nutrition Examination Survey (NHANES) show the racial disparities with black men and women having significantly higher rates of hypertension than white men and women.
The prevalence rates increased for all 4 race-sex groups from the 1988 to 1994 period to the 2009 to 2010 period. However, the racial disparities in hypertension prevalence remained consistent over the time periods. These racial differences are evidence at all ages. Blacks are found to develop hypertension at an earlier age than whites. An assessment of U.S. children aged 8 years to 17 years found systolic blood pressures (SBPs) to be 2.9 mm Hg and 1.6 mm Hg higher in black boys and girls compared with age-matched white boys and girls.
Adaptations are themselves works protected by copyright. So in order to publish this adaptation, authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation.
Although large-scale clinical trials have consistently demonstrated that the control of elevated blood pressure significantly reduces the risk of major cardiovascular disease, stroke and end-stage renal disease outcomes, a substantial portion of patients with hypertension do not achieve blood pressure control.
Data from the National Health and Examination Survey suggest that blood pressure is controlled for less than two thirds of all patients on antihypertensive medications.
African Americans demonstrated poorer blood pressure control compared with Caucasians. Figure 2 presents the hypertension control rates for all 4 race-sex groups from 1988 to 2010. Although the high blood pressure control rates improved from the 1988 to 1994 period to the 2009 to 2010 period for all 4 race-sex groups, the racial disparities remained consistent. These findings of disparities in hypertension control are consistent with other studies.
Racial and geographic differences in awareness, treatment, and control of hypertension: the REasons for Geographic And Racial Differences in Stroke study.
Racial and geographic differences in awareness, treatment, and control of hypertension: the REasons for Geographic And Racial Differences in Stroke study.
Hypertension awareness, treatment, and control – continued disparities in adults: United States, 2005–2006. National Center for Health Statistics,
NCHS data brief no Hyattsville, MD2008
Rates of awareness of hypertension and treatment patterns of antihypertensive therapy are similar for both race groups and even better among black men and women compared with white men and women. Likewise, treatment with nonpharmacological therapy does not explain the racial disparities in hypertension control. Results from clinical trials have included race in results with suggested treatment effects for the various racial groups. Dietary factors including sodium and potassium, while different for blacks and whites, do not explain the racial disparities in hypertension. The Dietary Approaches to Stop Hypertension (DASH) diet with sodium restriction found better BP reduction for African Americans than Caucasians, indicating that black individuals may respond differently than whites.
Similarly, treatment of elevated blood pressure with antihypertensive medications and different medications may produce different effects in African Americans and whites. Calcium channel blockers and diuretics have been proposed as being particularly effective for African Americans with hypertension.
Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers have not been shown to be as effective in black populations compared with white populations.
Similarly, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and β blockers have been reported to be less effective in blacks with heart failure compared with white patients.
Adaptations are themselves works protected by copyright. So in order to publish this adaptation, authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation.
The higher hypertension prevalence at earlier ages and more severe blood pressure levels correlate with the higher disease risks for blacks compared with whites. The risk ratios for stage 1 hypertension (≤140/90 mm Hg) and stage 2 hypertension (≥160/95 mm Hg) are presented in Table 1 for the 4 race-sex groups and 30-year all-cause morality.
The risk ratios are significant for all but are greater for black men and women. Likewise, the risk ratios are higher in the more severe blood pressure levels for all 4 race-sex groups with higher risks for black men and women compared with white men and women.
Comparison of cardiovascular risk factors for high brachial pulse pressure in blacks versus whites (Charleston Heart Study, Evans County Study, NHANES I and II Studies).
The disparities of higher prevalence and greater risks from high blood pressure are most evident with the population attributable risks, which are nearly twice as great for black men and women (Table 2).
Table 1Thirty-year mortality risk ratios and 95% CI for elevated blood pressure (≥140/90 mm Hg) adjusting forage, socioeconomic status, smoking, high cholesterol and diabetes: Charleston and Evans County Heart Studies, 1960
Adaptations are themselves works protected by copyright. So in order to publish this adaptation, authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation.
Adaptations are themselves works protected by copyright. So in order to publish this adaptation, authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation.
In addition to hypertension risk from categories, the racial disparity is also evident in blood pressure level. Table 3 shows results from REGARDS and an impact of a 10-mm Hg higher level of SBP for white and black participants.
In the total cohort, there was a 14% increased risk of stroke associated with a 10-mm Hg higher SBP (hazard ratio [HR], 1.14; 95% confidence interval [CI], 1.08–1.21). However, racial differences in this association were identified (P-value for interaction, 0.02) with an 8% increase in whites (HR, 1.08; 95% CI, 1.00–1.16) and a 24% increase in blacks (HR, 1.24; 95% CI, 1.14–1.35).
Thirty-year survival for black and white hypertensive individuals in the Evans County Heart Study and the hypertension detection and follow-up program.
Table 3Hazard ratio and 95% CI for stroke and 10 mm Hg systolic blood pressure differential racial susceptibility, reasons for geographic and racial disparities in Stroke Study
Adaptations are themselves works protected by copyright. So in order to publish this adaptation, authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation.
Although the disparities in blood pressure levels, hypertension prevalence and control and high blood pressure risks are evident, the factors associated with the race differences are less evident. However, several parameters are proposed that may contribute to the disparities.
While salt intake affects blood pressure in most individuals and populations, there are racial differences in intake and handling of sodium and potassium.
Although the prevalence of salt sensitivity was similar for African American and Caucasian women, the magnitude of blood pressure increase was different.
Blood pressure increase was greater in African Americans, with a positive association of salt sensitivity associated with Na Ca2 intake and the ratios of Na:K and Ca2:Mg2.
Racial differences in body mass index have long been recognized and suggestive of disparities in blood pressure level and hypertension prevalence. African Americans have been identified with higher rates of obesity and overweight at different age groups.
However, while body mass affects blood pressure level in both race groups, anthropometric measurements do not explain all of the disparities in high blood pressure levls.
Resistant hypertension is defined as uncontrolled blood pressure despite the use of 3 or more antihypertensive agent classes or controlled blood pressure with 4 or more agents.
Refractory hypertension represents the extreme phenotype of hypertension treatment failure and is defined as the use of 5 or more antihypertensive classes of medication with a SBP of ≥140 mm Hg and/or diastolic blood pressure of ≥90 mm Hg.
The prevalence ratios for refractory hypertension when compared with individuals with resistant hypertension were 3.00 (1.68–5.37) for African Americans.
Likewise, there are numerous other factors with significant racial differences that could affect the disparities in hypertension including social determinants, access to care, fetal/early life origins and differential treatment response.
Hypertension in African Americans Working Group of the International Society on Hypertension in Blacks
et al.
Management of high blood pressure in African Americans: consensus statement of the hypertension in African Americans Working Group of the International Society on Hypertension in Blacks.
The racial disparities in hypertension and hypertension risks have significant implications for high blood pressure prevention, management and control programs and strategies, as well as gaps in research. Decades of hypertension control efforts have been attributed in part to the decline in stroke mortality identified for the past decades.
National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure and National High Blood Pressure Education Program Coordinating Committee
et al.
The Seventh report of the Joint National Committee on prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report.
2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8).
Wright JT, Fine LJ, Lackland DT, et al. Evidence supporting a systolic blood pressure goal of less than 150 mm Hg in patients aged 60 years or older: the minority view. Ann Intern Med Available at http://annals.org/. Accessed January 13, 2014.
Likewise, there remain evidence gaps for the factors associated with the disparities. Thus, the evidence-based guidelines for prevention, treatment and management of hypertension inadequately address the excess risk of high blood pressure for African Americans. The opportunity is great for the implementation of research epidemiological studies and clinical trials focused on the assessment of the racial disparities in blood pressure levels and hypertension risks. These results could be used to implement strategies to close the racial disparity gap in high blood pressure risks.
REFERENCES
Lackland D.T.
Bachman D.L.
Carter T.D.
et al.
The geographic variation in stroke incidence in two areas of the southeastern stroke belt: the Anderson and Pee Dee Stroke Study.
Racial and geographic differences in awareness, treatment, and control of hypertension: the REasons for Geographic And Racial Differences in Stroke study.
Hypertension awareness, treatment, and control – continued disparities in adults: United States, 2005–2006. National Center for Health Statistics,
NCHS data brief no Hyattsville, MD2008
Comparison of cardiovascular risk factors for high brachial pulse pressure in blacks versus whites (Charleston Heart Study, Evans County Study, NHANES I and II Studies).
Thirty-year survival for black and white hypertensive individuals in the Evans County Heart Study and the hypertension detection and follow-up program.
Hypertension in African Americans Working Group of the International Society on Hypertension in Blacks
et al.
Management of high blood pressure in African Americans: consensus statement of the hypertension in African Americans Working Group of the International Society on Hypertension in Blacks.
National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure and National High Blood Pressure Education Program Coordinating Committee
et al.
The Seventh report of the Joint National Committee on prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report.
2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8).
Wright JT, Fine LJ, Lackland DT, et al. Evidence supporting a systolic blood pressure goal of less than 150 mm Hg in patients aged 60 years or older: the minority view. Ann Intern Med Available at http://annals.org/. Accessed January 13, 2014.
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