Treat HYPERtension more aggressively in BLACK patients

As a clinical pharmacist, you will be asked more how to treat hypertension in black patients. There's controversy about whether hypertension should be treated more aggressively in black patients than in other races. Over 40% of black adults have hypertension. They also have higher BPs than whites and therefore a higher risk of complications.

Now some experts say that black patients should aim for lower BP goals, under 135/85 mmHg for most patients and under 130/80 mmHg for those at high risk for a cardiovascular event. But critics point out these lower goals aren't evidence based. Recommend getting BP under 140/90 before aiming for a lower goal.

For UNCOMPLICATED hypertension, recommend starting with a calcium channel blocker or thiazide. When used ALONE, each of these lowers BP in black patients better than an ACE inhibitor or beta-blocker. But don't think that ACEIs or beta-blockers don't work as well in blacks as in whites. They can, when COMBINED with other drugs. And most patients need at least two drugs anyway. In this case, recommend adding an ACEI to a thiazide or calcium channel blocker. But caution about angioedema, black patients have up to 4 times the risk of angioedema due to ACEIs than whites. When using three drugs, make sure one is a diuretic to prevent fluid retention. Suggest chlorthalidone if possible, it's longer acting and more potent than hydrochlorothiazide.

Advise patients to decrease sodium intake to help the diuretic work better and reduce urination. Explain that black patients with hypertension are usually more sensitive to salt than whites. If more drugs are needed, suggest adding an aldosterone antagonist, such as spironolactone, or a beta-blocker. Suggest the same drugs for concomitant conditions in blacks as other races, such as an ACEI for diabetes or heart failure. Use our note, "Overview of hypertension", to get more information.

References

• Ortega, L.M., Sedki, E. and Nayer, A. (2015). Hypertension in the African American population: A succinct look at its epidemiology, pathogenesis, and therapy. Nefrología, 35(2), pp.139–145. Available at: https://scielo.isciii.es/pdf/nefrologia/v35n2/revision_breve2.pdf

  NHLBI (2004). National High Blood Pressure Education Program Prevention, Detection, Evaluation, and Treatment of High Blood Pressure The Seventh Report of the Joint National Committee on. [online] Available at: https://www.nhlbi.nih.gov/files/docs/guidelines/jnc7full.pdf