Uncontrolled Hypertension in Black Men
2018; Lippincott Williams & Wilkins; Volume: 139; Issue: 1 Linguagem: Inglês
10.1161/circulationaha.118.038240
ISSN1524-4539
AutoresKeith C. Ferdinand, Rachel Graham,
Tópico(s)Cardiovascular Disease and Adiposity
ResumoHomeCirculationVol. 139, No. 1Uncontrolled Hypertension in Black Men Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBUncontrolled Hypertension in Black MenIs Cutting Blood Pressure in the Barbershop a Long-Term Solution? Keith C. Ferdinand, MD and Rachel M. Graham, BA Keith C. FerdinandKeith C. Ferdinand Keith C. Ferdinand, MD, Professor, Tulane University SOM, 1430 Tulane Avenue, SL-8548, New Orleans, LA 70112. Email E-mail Address: [email protected] Tulane University School of Medicine, New Orleans, LA (K.C.F.). and Rachel M. GrahamRachel M. Graham Tulane University School of Public Health and Tropical Medicine, New Orleans, LA (R.M.G.). Originally published17 Dec 2018https://doi.org/10.1161/CIRCULATIONAHA.118.038240Circulation. 2019;139:20–23This article is a commentary on the followingSustainability of Blood Pressure Reduction in Black BarbershopsOther version(s) of this articleYou are viewing the most recent version of this article. Previous versions: December 17, 2018: Ahead of Print Article, see p 10Despite having equal hypertension awareness in comparison with white Americans, US blacks have significantly higher prevalence and poorer control rates. Furthermore, the overall age-adjusted death rate related to hypertension in blacks is almost twice that of all other US racial/ethnic subgroups.1,2 Moreover, with the recent systolic/diastolic hypertension designation of ≥130/80 mm Hg, the previous 42% prevalence of US black men considered as hypertensive increases to as much as 59%.3 The publication in Circulation of "Sustainability of Blood Pressure Reduction in Black Barbershops," by Victor et al,4 demonstrates robust benefits at 12 months in their novel Los Angeles Barbershop (LABP) Extension trial in this high-risk population. Nevertheless, several important considerations must be addressed before widespread dissemination of this approach to other locales nationally.Benefits and Challenges of Dissemination of the LABP ExtensionThe LABP Extension clearly demonstrated the effectiveness of a community-partnered team comprising established barbers and clinical pharmacists to control hypertension in black men. The mean baseline systolic blood pressures were 152.4 mm Hg and 154.6 mm Hg for intervention and control groups, respectively.4 In the intervention group, 68% of participants' blood pressures decreased to ≤130/80 mm Hg with the mean systolic blood pressure decreasing by 28.6 mm Hg.4 However, only 11.0% of the control group participants achieved the target blood pressure of ≤130/80 (P<0.02).4 It is impressive that there was no statistical difference between the 12-month results and previously reported 6-month efficacy data, and no serious adverse events related to the treatment.4 Despite these obvious benefits of specialty pharmacist–directed care, the widespread application of this novel approach must realistically account for the total monetary cost of implementation and the generalizability to diverse, even more disadvantaged and hard-to-reach black communities throughout the United States.The reproducibility of the LABP approach may be limited specifically because of its complexity, high costs, and restrictions on nationwide dissemination because of the limited availability of the California-approved Collaborative Practice Agreement giving the pharmacists prescriptive authority (Table).5 The heterogeneous state Collaborative Practice Agreement laws may limit the spectrum of services the clinical pharmacist may perform in various localities.5 Although most states have a form of agreement giving pharmacists prescriptive authority, they may not have an adequate Collaborative Practice Agreement to reproduce the services that the clinical pharmacists were allowed to perform in the California study.5 Moreover, the 2 full-time doctoral-level LABP pharmacists were uniquely trained as hypertension clinicians to accurately measure blood pressure using a validated oscillometric monitor, manage medications, encourage lifestyle changes, and determine plasma electrolytes and creatinine.6Table. National Dissemination of Los Angeles Barbershop ExtensionPotential BenefitsPotential LimitationsUse of effective pharmacotherapy with initial 2-drug regimenFinancial cost of widespread implementationEasily accessible treatment source and point-of-care laboratory testingReproduction of the model in more disadvantaged, underserved communitiesFrequent patient contact and improvement in adherenceLimited availability of specialty-trained pharmacists with Collaborative Practice Agreement in other statesClinical care in a trusted environment with extensive prior relationshipAccess to medical care and drug therapy where uninsured status is widespreadOne hallmark of the LABP Extension is the application of effective, contemporary, evidence-based pharmacotherapy, using a 2-drug regimen, as needed in most adults, especially black individuals. This intensive antihypertensive treatment regimen consisted of amlodipine and a long-acting angiotensin II receptor blocker, such as telmisartan or irbesartan.3 Moreover, the impactful third drug used, indapamide, which has efficacy similar to chlorthalidone, and fourth drug, an aldosterone antagonist, have been shown to be superior in treating resistant hypertension.7 However, the control group participants often lacked highly effective drug therapy, and, in comparison with the intervention group, they received significantly fewer blood pressure medications per participant, including 1.2% aldosterone antagonist (P<0.0001) versus 12.0% in the intervention group.4 Furthermore, medication nonadherence is a significant factor contributing to the existing racial/ethnic disparities in hypertension control. To increase blood pressure control in black men, practical approaches, such as consumer-directed care, smart technology, and digital pillboxes may be impactful.8To curtail the crisis of hypertension morbidity and mortality in black men, it is necessary to address the disparate rates of uninsured status, availability of a primary health provider, and financial barriers to effective medical care and medications.1 Beyond the barbershop, primordial prevention is a critical pathway to curtailing the burden of hypertension, especially in black Americans. Therefore, despite the obvious need for effective pharmacotherapy, lifestyle modification (ie, weight reduction, dietary modification, and increased physical activity) is critical to stem the shamefully disparate burden of hypertension-related death and disability among both black men and women.9 Personal beliefs, values, and culture are equally important determinants of effective blood pressure control. As recently revealed, the Southern Diet, high in calorie-dense foods (including fried food, organ and processed meats, high-fat dairy, and refined carbohydrates but few fruits and vegetables), accounts for ≈52% of the excess prevalence of hypertension among black men.9 Moreover, the 12.3% excess of black men with hypertension is associated with higher salt intake and level of education.9 Unfortunately, the adoption of heart-healthy behaviors is often difficult in communities with fewer resources, inadequate social supports, and prominent barriers to regular exercise, healthy diet, and medical care.Los Angeles County is not the Mississippi delta or other potentially more disadvantaged urban areas. The LABP participants demonstrated unique social and economic characteristics that may not reflect the great diversity of US blacks and cardiovascular disease variation nationally. The LABP clientele's established long-term relationship with their barbershops helped overcome potential distrust of medical care.4 On average, both intervention and control barbershops had been in business for ≈2 decades, with a decade-long duration of patronage for participants. Despite being relatively socioeconomically disadvantaged, most of the volunteers were socially stable with ≈50% either married or living with a partner, and only 4.5% in the intervention group and 8.6% in the control group had less than a high school education, with almost half having some college or an associate degree.6 In addition, almost 80% of the overall cohort had some form of health insurance, much greater than that seen where black populations commonly reside, especially in the South, where Medicaid has not been expanded.6Where does the Medical Community go from Here?Although recognizing the positive effects of the LABP Extension research, clinicians should also recognize present, ongoing initiatives, such as Target:BP, a collaborative initiative of the American Medical Association and American Heart Association. Target:BP collaborates with health providers to develop a customized plan and algorithm, to promulgate best practices and patient education resources to effectively control hypertension.10 In addition, the Million Hearts initiative seeks to improve cardiovascular outcomes, including highlighting hypertension control in blacks, a priority population, using targeted protocols and medication adherence strategies.11 Nevertheless, it is reasonable to continue research seeking the best means to develop broad-scale implementation of the LA Barbershop specialty team approach.Despite the novelty and effectiveness of the LABP Extension, improved, standardized treatment approaches in conventional practice settings may be an even more cost-effective solution to reduce uncontrolled hypertension in black men. For instance, Kaiser Permanente uses a coordinated team-based approach involving the primary care providers and an interdisciplinary support staff, emphasizing culturally tailored patient education to effectively address health behavior and improve adherence.12 Similar to the LABP, the Kaiser Permanente program uses evidence-based guidelines with effective initial single-pill combination pharmacotherapy. Kaiser Permanente blood pressure control rates impressively have improved from 76.6% to 81.4% (using a <140/90 mm Hg cutoff) for blacks, and from 82.9% to 84.2% for white Americans.12 In addition, the overall racial disparity decreased from 6.3% to 2.8%.12 Widespread use of their effective approaches in other established clinical settings nationally is a reasonable means to hypertension control.12Next Steps in the Continued Effort to Control Hypertension in US BlacksResearchers, clinical providers, public officials, and the lay public should continue to support the positive efforts funded by the National Heart, Lung, and Blood Institute's Center for Translational Research and Implementation Science. The center plans, fosters, and supports research to identify the best strategies for ensuring successful integration of evidence-based interventions within clinical and public health settings, such as health centers and worksites, and improved health strategies to reduce or eliminate both domestic and global health disparities in heart, lung, blood, and sleep disorders.13 As reflected in a recent National Heart, Lung, and Blood Institute Working Group report (2016) the use of nontraditional, nonclinical, settings, such as barbershops, faith-based organizations, or homes, for the delivery of team care is promising.14 Although a recent community-based lifestyle intervention in churches led to a significant reduction in hypertension in blacks, the randomized clinical trial of FAITH (Faith-Based Approaches in the Treatment of Hypertension) in Blacks used a cohort comprising 76% women, indicating the uniqueness of the barbershop for targeting men in a trusted environment.15 Overall, it is essential to determine how National Heart, Lung, and Blood Institute community–based research may be used to reach vulnerable and high-risk black women and men in a sustainable and financially realistic manner.As a society, effective blood pressure control in high-risk individuals with intensive antihypertensive medications is cost saving and cost-effective in the long term, regardless of race/ethnicity, sex, socioeconomic status, or geography. The benefits of the recent extension from the LABP randomized trial must be weighed against its complexity, generalizability to diverse populations, and potentially high implementation costs. The impact of residential environment and social determinants must not be overlooked, and effective modifications of the environment may ultimately do more to impact the disparate hypertension burden among various populations than simply treating high-risk persons with antihypertensive medications.DisclosuresDr Ferdinand is a member of the LA Barbershop Data and Monitoring Board. R.M. Graham has no disclosures.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.https://www.ahajournals.org/journal/circKeith C. Ferdinand, MD, Professor, Tulane University SOM, 1430 Tulane Avenue, SL-8548, New Orleans, LA 70112. Email [email protected]eduReferences1. Benjamin EJ, Virani SS, Callaway CW, Chamberlain AM, Chang AR, Cheng S, Chiuve SE, Cushman M, Delling FN, Deo R, de Ferranti SD, Ferguson JF, Fornage M, Gillespie C, Isasi CR, Jiménez MC, Jordan LC, Judd SE, Lackland D, Lichtman JH, Lisabeth L, Liu S, Longenecker CT, Lutsey PL, Mackey JS, Matchar DB, Matsushita K, Mussolino ME, Nasir K, O'Flaherty M, Palaniappan LP, Pandey A, Pandey DK, Reeves MJ, Ritchey MD, Rodriguez CJ, Roth GA, Rosamond WD, Sampson UKA, Satou GM, Shah SH, Spartano NL, Tirschwell DL, Tsao CW, Voeks JH, Willey JZ, Wilkins JT, Wu JH, Alger HM, Wong SS, Muntner P; American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart Disease and stroke statistics-2018 Update: a report from the American Heart Association.Circulation. 2018; 137:e67–e492. doi: 10.1161/CIR.0000000000000558LinkGoogle Scholar2. Ferdinand KC, Armani AM. The management of hypertension in African Americans.Crit Pathw Cardiol. 2007; 6:67–71. doi: 10.1097/HPC.0b013e318053da59CrossrefMedlineGoogle Scholar3. Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C, DePalma SM, Gidding S, Jamerson KA, Jones DW, MacLaughlin EJ, Muntner P, Ovbiagele B, Smith SC, Spencer CC, Stafford RS, Taler SJ, Thomas RJ, Williams KA, Williamson JD, Wright JT2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.J Am Coll Cardiol. 2018; 71:e127–e248. doi: 10.1016/j.jacc.2017.11.006CrossrefMedlineGoogle Scholar4. Victor RG, Blyler CA, Li N, Lynch K, Moy NB, Rashid M, Chang LC, Handler J, Brettler J, Rader F, Elashoff RM. Sustainability of blood pressure reduction in black barbershops.Circulation. 2019; 139:10–19. doi: 10.1161/CIRCULATIONAHA.118.038165LinkGoogle Scholar5. Centers for Disease Control and Prevention. Advancing Team-Based Care Through Collaborative Practice Agreements.2017https://www.cdc.gov/dhdsp/pubs/docs/CPA-Team-Based-Care.pdf. Accessed October 17, 2018.Google Scholar6. Victor RG, Lynch K, Li N, Blyler C, Muhammad E, Handler J, Brettler J, Rashid M, Hsu B, Foxx-Drew D, Moy N, Reid AE, Elashoff RM. A cluster-randomized trial of blood-pressure reduction in black barbershops.N Engl J Med. 2018; 378:1291–1301. doi: 10.1056/NEJMoa1717250CrossrefMedlineGoogle Scholar7. Carey RM, Calhoun DA, Bakris GL, Brook RD, Daugherty SL, Dennison-Himmelfarb CR, Egan BM, Flack JM, Gidding SS, Judd E, Lackland DT, Laffer CL, Newton-Cheh C, Smith SM, Taler SJ, Textor SC, Turan TN, White WB; American Heart Association Professional/Public Education and Publications Committee of the Council on Hypertension; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; Council on Genomic and Precision Medicine; Council on Peripheral Vascular Disease; Council on Quality of Care and Outcomes Research; and Stroke Council. Resistant hypertension: detection, evaluation, and management: a scientific statement from the American Heart Association.Hypertension. 2018; 72:e53–e90. doi: 10.1161/HYP.0000000000000084LinkGoogle Scholar8. Ferdinand KC, Yadav K, Nasser SA, Clayton-Jeter HD, Lewin J, Cryer DR, Senatore FF. Disparities in hypertension and cardiovascular disease in blacks: the critical role of medication adherence.J Clin Hypertens (Greenwich). 2017; 19:1015–1024. doi: 10.1111/jch.13089CrossrefMedlineGoogle Scholar9. Howard G, Cushman M, Moy CS, Oparil S, Muntner P, Lackland DT, Manly JJ, Flaherty ML, Judd SE, Wadley VG, Long DL, Howard VJ. Association of clinical and social factors with excess hypertension risk in black compared with white US adults.JAMA. 2018; 320:1338–1348. doi: 10.1001/jama.2018.13467CrossrefMedlineGoogle Scholar10. American Heart Association, American Medical Association. Target:BP.https://targetbp.org/about-targetbp/program-process-steps/. Accessed October 17, 2018.Google Scholar11. Million Hearts. Million Hearts Framework 2022.https://millionhearts.hhs.gov/files/MH-Framework.pdf. Accessed October 17, 2018.Google Scholar12. Bartolome RE, Chen A, Handler J, Platt ST, Gould B. 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Cluster randomized clinical trial of FAITH (Faith-Based Approaches in the Treatment of Hypertension) in blacks.Circ Cardiovasc Qual Outcomes. 2018; 11:e004691. doi: 10.1161/CIRCOUTCOMES.118.004691LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Marseille B, Commodore‐Mensah Y, Davidson P, Baker D, D'Aoust R and Baptiste D (2021) Improving hypertension knowledge, medication adherence, and blood pressure control: A feasibility study, Journal of Clinical Nursing, 10.1111/jocn.15803, 30:19-20, (2960-2967), Online publication date: 1-Oct-2021. Bryant K, Moran A, Kazi D, Zhang Y, Penko J, Ruiz-Negrón N, Coxson P, Blyler C, Lynch K, Cohen L, Tajeu G, Fontil V, Moy N, Ebinger J, Rader F, Bibbins-Domingo K and Bellows B (2021) Cost-Effectiveness of Hypertension Treatment by Pharmacists in Black Barbershops, Circulation, 143:24, (2384-2394), Online publication date: 15-Jun-2021. Bryant K, Blyler C and Fullilove R (2020) It's Time for a Haircut: a Perspective on Barbershop Health Interventions Serving Black Men, Journal of General Internal Medicine, 10.1007/s11606-020-05764-8, 35:10, (3057-3059), Online publication date: 1-Oct-2020. Maraboto C and Ferdinand K (2020) Update on hypertension in African-Americans, Progress in Cardiovascular Diseases, 10.1016/j.pcad.2019.12.002, 63:1, (33-39), Online publication date: 1-Jan-2020. Blyler C and Rader F (2019) Sustainability of blood pressure reduction in black barbershops, Current Opinion in Cardiology, 10.1097/HCO.0000000000000674, 34:6, (693-699), Online publication date: 1-Nov-2019. Related articlesSustainability of Blood Pressure Reduction in Black BarbershopsRonald G. Victor, et al. Circulation. 2019;139:10-19 January 2, 2019Vol 139, Issue 1 Advertisement Article InformationMetrics © 2018 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.118.038240PMID: 30592660 Originally publishedDecember 17, 2018 Keywordslife stylehypertensionEditorialsAfrican continental ancestry groupblood pressurePDF download Advertisement
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