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Race and Antihypertensive Drug Therapy: Edging Closer to a New Paradigm

2022; Lippincott Williams & Wilkins; Volume: 79; Issue: 2 Linguagem: Inglês

10.1161/hypertensionaha.121.18545

1524-4563

John M. Flack, Michael Buhnerkempe,

Sodium Intake and Health

HomeHypertensionVol. 79, No. 2Race and Antihypertensive Drug Therapy: Edging Closer to a New Paradigm Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessEditorialPDF/EPUBRace and Antihypertensive Drug Therapy: Edging Closer to a New Paradigm John Mark Flack and Michael Gregory Buhnerkempe John Mark FlackJohn Mark Flack Correspondence to: John M. Flack, Department of Medicine, Southern Illinois University, 701 N. First St. Room D442, P.O. Box 19636, Springfield, IL 62794. Email E-mail Address: [email protected] https://orcid.org/0000-0003-2584-5598 Department of Medicine, Division of General Internal Medicine, Hypertension Section (J.M.F.), Southern Illinois University. and Michael Gregory BuhnerkempeMichael Gregory Buhnerkempe https://orcid.org/0000-0002-5996-8927 Department of Medicine and the Center for Clinical Research (M.G.B.), Southern Illinois University. Originally published12 Jan 2022https://doi.org/10.1161/HYPERTENSIONAHA.121.18545Hypertension. 2022;79:349–351This article is a commentary on the followingSelf-Reported Antihypertensive Medication Class and Temporal Relationship to Treatment GuidelinesThe principal approach to successful hypertension therapeutics is to control blood pressure using dietary and lifestyle changes plus an adequate intensity of drug therapy; the patient must be comfortable with, accept and tolerate the prescribed therapeutics, and the practitioner and their team should engage the patient in therapeutic decisions and avoid therapeutic inertia when blood pressure remains above goal. The elusive goal of our efforts is the attainment of exemplary hypertension control rates with no, to at most minimal, demographic disparities. The reporting of national hypertension control rates overall as well as for various race/ethnicity groups1 provides important information about the success in control of this pervasive clinical problem and whether we have achieved parity across various demographic groups.See related article, pp 338–348So how are we doing? Well, not very good. Hypertension control rates have fallen since 2014 and racial disparities have persisted.2 Race has long been used to guide monotherapy drug selections,3,4 in part, because of lesser average blood pressure response to angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blocker (ARBs), and beta blockers in Black compared with White hypertensives. And also, because among Black hypertensives, thiazide diuretics and calcium antagonists have shown greater average blood pressure responses than other monotherapies.The excellent article in this issue of the journal by Egan et al5 reported on self-reported antihypertensive medication use in Black and White adults and their temporal relationship to hypertension treatment guidelines. National Health and Nutrition Examination Survey (NHANES) data spanning 2 time periods were contrasted (2007–2012 versus 2015–2018). Among Black hypertensives taking antihypertensive medications, calcium antagonist or thiazide-like diuretic therapy rates remain unchanged while calcium antagonist use increased in the later time period. Renin angiotensin system blocker (ACE inhibitors or ARBs) use in Black hypertensives declined dramatically in the later time period. Thus, the authors showed greater use of recommended evidence-based monotherapy and yet concluded that evidence-based monotherapy appears insufficient to improve hypertension control in non-Hispanic Black adults, especially given evidence for worsening therapeutic inertia. This statement builds on another NHANES analysis1 which documented lower overall control rates (<140/90 mm Hg) for Black compared with White hypertensives (41.5% versus 48.2%) during the 2015–2018 time period; also, overall hypertension control rates have declined since 2014 in both Black and White hypertensives. Control rates fell from 46.3% to 38.5% in Black hypertensives and from 57.3% to 45.2% in White hypertensives between the 2013 to 2014 and 2017 to 2018 time periods. Among those self-reporting use of antihypertensive medications hypertension control rates were also lower in Black than in White hypertensives (55.6% versus 69.3%) during the 2015 to 2018 time period. Thus, the greater use of recommended evidence-based monotherapy coincided with a decline in hypertension control in Black hypertensives, and though hypertension control rates simultaneously fell in White hypertensives, the control rate in Black hypertensives was a staggering 14% lower in those undergoing pharmacological treatment.These data make the case that we are unequivocally losing ground in our fight to control hypertension. Moreover, these data show that we are not closing the racial disparity in hypertension control despite the use of more evidence-based monotherapies in Black hypertensives. It is informative to briefly critique the evidence that led to the recommendations for diuretics and calcium antagonists to be preferentially prescribed to Black hypertensives as well as to opine as to whether there is justification for the continued use of Black race to inform the selection of antihypertensive drug therapy.We previously published an ACE inhibitor (quinapril) monotherapy study6 that, similar to other previously published studies, reported a larger (4.7/2.4 mm Hg) blood pressure reduction in White compared with Black hypertensives. However, as shown in Figure, the racial systolic blood pressure distributions, though shifted in their central tendency, heavily overlapped. The spread of blood pressure responses within each group (interquartile range) was ≈4-fold greater than the between-race difference in systolic blood pressure response. Moreover, both groups were well above contemporary blood pressure targets ( 20/10 mm Hg above goal and those with stage 2 hypertension.4 Recent national data suggests combination therapy is not widely applied as substantial under-treatment in drug-treated hypertensives has been observed as ≈40% and 35%, respectively, are taking 1 and 2 drugs.8 Among drug-treated hypertensives with blood pressure ≥ 140/90 mm Hg, 40.2% were taking a single antihypertensive drug. The guideline recommendation for initial treatment with combination therapy, if more broadly embraced, would dramatically reduce the proportion of hypertensives taking single drug therapy, increase the likelihood of blood pressure control in those prescribed monotherapy and would substantively improve hypertension control rates across racial groups, but particularly in Black hypertensives.Exemplary hypertension control programs in clinical settings provide examples of how rigorously applied protocols can improve blood pressure control while reducing racial disparities. The Kaiser Permanente program9 achieves >80% control (<140/90 mm Hg) in both Black and White hypertensives with a low single digit racial disparity in control. Key features of this program are that it is a multi-level team-based approach that is race-informed in the domains of communication and self-management. However, their therapeutic treatment algorithms are agnostic to race/ethnicity. Their successful approach is further justified by the following: (1) the Black:White paradigm of hypertension treatment applies to an increasingly smaller percentage of the hypertension population given changes in population demographics and treatment recommendations and (2) their approach simplifies and adapts complex and highly detailed hypertension guidelines for local use in all patients. The Veterans Administration health care system also has implemented a comprehensive hypertension control program focused on communication and treatment monitoring and adherence that has produced hypertension control rates approaching 80% with Black:White disparities on control that are only slightly greater compared with Kaiser Permanente, but very low relative to national data.10The time has come to shift the focus from race-specific monotherapy treatment recommendations by adopting comprehensive team-based multi-level care models that use race-informed communication, self-care, and dietary strategies coupled with race-agnostic treatment algorithms that minimize therapeutic inertia and promote prescription of an adequate intensity of drug therapy. Recommending optimization of pervasively used monotherapy for Black hypertensives, a thus far unsuccessful strategy, offers no opportunity for improving hypertension control for all patients while eliminating racial disparities in the same. The evidence documenting racial disparities in drug responses is neither synonymous with the best practices nor is it a necessary component of exemplary hypertension control programs.Artcile InformationSources of FundingNone.DisclosuresJ.M. Flack reports Research: Bayer HealthCare Pharmaceuticals, GlaxoSmithKline, Indorsia, Novartis, Quantam Genomics, ReCor Medical, Vascular Dynamics; Consultant: Teva Pharmaceuticals American College of Physicians Board of Regents. The other author reports no conflicts.FootnotesThe opinions expressed in this article are not necessarily those of the American Heart Association.For Sources of Funding and Disclosures, see page 351.Correspondence to: John M. Flack, Department of Medicine, Southern Illinois University, 701 N. First St. Room D442, P.O. Box 19636, Springfield, IL 62794. Email [email protected]eduReferences1. Muntner P, Hardy ST, Fine LJ, Jaeger BC, Wozniak G, Levitan EB, Colantonio LD. Trends in blood pressure control among US adults with hypertension, 1999 – 2000 to 2017 – 2018.JAMA. 2020; 324:1190–1200. doi: 10.1001/jama.2020.14545CrossrefMedlineGoogle Scholar2. Egan B, Li J, Sutherland S, Rakotz MK, Wozniak G. Hypertension control in the U.S. 2009 to 2018: factors underlying falling control rates during 2015 to 2018 across age and race-ethnicity groups.Hypertension. 2021; 78:578–587. doi: 10.1161/HYPERTENSIONAHA.120.16418LinkGoogle Scholar3. James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, Lackland DT, LeFevre ML, MacKenzie TD, Ogedegbe O, et al.. 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).JAMA. 2014; 311:507–520. doi: 10.1001/jama.2013.284427CrossrefMedlineGoogle Scholar4. Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C, DePalma SM, Gidding S, Jamerson KA, Jones DW, et al.. 2017 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.Hypertension. 2018; 71:e13–e115. doi: 10.1161/HYP.0000000000000065LinkGoogle Scholar5. Egan BM, Yang J, Rakotz MK, Sutherland SE, Jamerson KA, Wright JT, Ferdinand KC, Wozniak GD. Self-Reported Antihypertensive Medication Class and Temporal Relationship to Treatment Guidelines.Hypertension. 2022; 311: 79:338–348. doi: 10.1161/HYPERTENSIONAHA.121.17102LinkGoogle Scholar6. Mokwe E, Ohmit SE, Nasser SA, Shafi T, Saunders E, Crook E, Dudley A, Flack JM. Determinants of blood pressure response to quinapril in black and white hypertensive patients: the Quinapril Titration Interval Management Evaluation trial.Hypertension. 2004; 43:1202–1207. doi: 10.1161/01.HYP.0000127924.67353.86LinkGoogle Scholar7. Wright JT, Dunn JK, Cutler JA, Davis BR, Cushman WC, Ford CE, Haywood LJ, Leenen FH, Margolis KL, Papademetriou V, et al.; ALLHAT Collaborative Research Group. Outcomes in hypertensive black and nonblack patients treated with chlorthalidone, amlodipine, and lisinopril.JAMA. 2005; 293:1595–1608. doi: 10.1001/jama.293.13.1595CrossrefMedlineGoogle Scholar8. Derrington CG, King JB, Herrick JS, Shimbo D, Kronish IM, Saseen JJ, Muntner P, Moran AE, Bress AP. Trends in antihypertensive medication monotherapy and combination use among US adults, NHANES 2005 – 2016.Hypertension. 2020; 75:973–981. doi: 10.116/HYPERTENSIONAHA.119.14360LinkGoogle Scholar9. Bartolome RE, Chen A, Handler J, Platt ST, Gould B. Population care management and team-based approach to reduce racial disparities among African Americans/Blacks with Hypertension.Perm J. 2016; 20:53–59. doi: 10.7812/TPP/15-052MedlineGoogle Scholar10. Fletcher RD, Amdur RL, Kolodner R, McManus C, Jones R, Faselis C, Kokkinos P, Singh S, Papademetriou V. Blood pressure control among US veterans: a large multiyear analysis of blood pressure data from the Veterans Administration health data repository.Circulation. 2012; 125:2462–2468. doi: 10.1161/CIRCULATIONAHA.111.029983LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Gleason-Comstock J, Calhoun C, Mozeb G, Louis C, Hill A, Locke B, Harrell V, Yasmin S, Zhang L, Flack J, Artinian N and Xu J (2022) Recruitment, Retention, and Future Direction for a Heart Health Education and Risk Reduction Intervention Led by Community Health Workers in an African American Majority City, Journal of Racial and Ethnic Health Disparities, 10.1007/s40615-022-01329-z Related articlesSelf-Reported Antihypertensive Medication Class and Temporal Relationship to Treatment GuidelinesBrent M. Egan, et al. Hypertension. 2022;79:338-348 February 2022Vol 79, Issue 2Article InformationMetrics © 2021 American Heart Association, Inc.https://doi.org/10.1161/HYPERTENSIONAHA.121.18545PMID: 35020461 Originally publishedJanuary 12, 2022 PDF download Advertisement