SUPPLEMENT 1 VOL. V NO. I JANUARY/FEBRUARY 2003 THE JOURNAL OF CLINICAL HYPERTENSION 3

African Americans have one of the highest ratesof hypertension in the world. They develop

hypertension earlier in life than the general popu-lation, and their rates are higher than whites forstage 3 hypertension and target organ damage,including heart failure, end-stage renal disease, andfatal and nonfatal stroke. Blood pressure loweringwith a wide range of agents, especially diuretics,has been shown to be effective in controllinghypertension and reducing cardiovascular risk inall patients regardless of their race or ethnicity.Angiotensin-converting enzyme (ACE) inhibitorshave also been demonstrated to be effective in con-trolled clinical trials in treating hypertension andpreventing the mortality and morbidity associatedwith hypertension-related target organ damage.However, until recently, African American patientshave been underrepresented in clinical trials, andthere is a question regarding the efficacy of ACEinhibitors as monotherapy in these individuals inreducing blood pressure and cardiovascular events.Nevertheless, while we await the results of ongoinginvestigations that will address questions regardingoutcome with ACE inhibitors in different racialgroups, there is a need to make reasonable recom-mendations based on available data for the use ofthese medications in African American patients.

This supplement to The Journal of ClinicalHypertension will define some of the uniqueaspects of hypertension in African Americans,including epidemiology of hypertension and car-diovascular disease, the increased prevalence oftype 2 diabetes mellitus and heart failure, and the

increased incidence of left ventricular dysfunctionin this population.

Drs. John Flack and Keith Ferdinand and Ms.Samar Nasser review the epidemiology of hyperten-sion and other cardiovascular risk factors in AfricanAmericans, including diabetes, obesity, dyslipidemia,and renal disease. The adverse consequences associ-ated with elevated blood pressure, both alone and incombination with other risk factors, are described.The importance of geography, lifestyle, and socioe-conomic factors are highlighted.

Drs. Elijah Saunders and James Gavin discussthe role of the renin-angiotensin-aldosterone sys-tem in African Americans and how it impactshypertension and cardiovascular disease. Theauthors focus on the underutilization of ACEinhibitors in minority populations, as well as othertherapeutic strategies for treating hypertension andpreventing cardiovascular events. It is noted thatparticular care must be taken to ensure appropriatedosing of ACE inhibitors in high-risk populations.

The optimal treatment of hypertension and car-diovascular risk in African Americans is reviewedby Drs. Jackson Wright and Janice Douglas.Results from older studies that showed the impor-tance of lowering blood pressure are reviewed,including the Systolic Hypertension in the ElderlyProgram (SHEP)1 and the Hypertension Detectionand Follow-Up Program (HDFP).2 The authorsalso explain newer outcome trials evaluating theeffect of hypertension treatment on minoritypatients, such as the African American Study ofHypertension and Kidney Disease (AASK),3 whichstudied the benefit of ACE inhibition (usually witha diuretic) in this high-risk population. The impor-tance of recent data from the Antihypertensive andLipid-Lowering Treatment to Prevent HeartAttack Trial (ALLHAT)4 will be noted, as well asclinical findings in the African American cohorts in

I n t r o d u c t i o n

Management of Hypertension and CardiovascularRisk Factors in African Americans

Keith C. Ferdinand, MD Guest Editor

Keith C. Ferdinand, MDFrom the Heartbeats Life Center, New Orleans, LA Address for correspondence: Keith C. Ferdinand, MD, Heartbeats Life Center, 1201Poland Avenue, New Orleans, LA 70117

the Losartan Intervention for Endpoint Reductionin Hypertension study (LIFE).5 Based on the evi-dence, the authors discuss treatment approachesfor minority outpatients with hypertension, withan emphasis on target organ risk reduction.

Drs. Rohit Arora, Luther Clark, and MalcolmTaylor then examine the treatment benefits of ACEinhibitors in the treatment for high-risk hyperten-sive patients, with specific recommendations on theuse of ACE inhibition in African American patientswith left ventricular dysfunction, renal disease,heart failure, stroke, and acute myocardial infarc-tion. The authors further discuss use of ACE inhi-bition in high-risk patients, including those whoare hospitalized post-myocardial infarction.

Finally, Drs. Karol Watson and Kenneth Jamersonreview the importance of lifestyle modification in thetreatment of hypertension and cardiovascular risk inAfrican Americans.6 Their paper reviews the resultsfrom studies evaluating the effect of hypertensiontreatment in these individuals, such as the diet inter-ventions in the Dietary Approaches to StopHypertension (DASH)7 and DASHing With Less Salt8and discusses the use of statins and other medications.

Considering the disproportionate target organ dam-age, death, and disability associated with hypertensionin African Americans, this supplement as a whole andin part should help clinicians better understand how toapproach this difficult-to-treat population. Specifically,intensive blood pressure lowering using diuretic thera-py as the initial step and the appropriate utilization ofACE inhibitors should help to minimize racial dispari-

ties in cardiovascular disease. Although diuretics con-tinue to be the proven therapy for lowering blood pres-sure in all patients, including African Americans, ACEinhibitors also provide protective benefits for reducingcardiovascular risk and target organ damage.

REFERENCES1 SHEP Cooperative Research Group. Prevention of stroke

by antihypertensive drug treatment of older persons withisolated systolic hypertension. Final results of the SystolicHypertension in the Elderly Program (SHEP). JAMA. 1991;265:3255–3264.

2 Hypertension Detection and Follow-Up Program Co-operative Group. Five-year findings of the HypertensionDetection and Follow-up Program: mortality by race, sexand blood pressure level. A further analysis. J CommunHealth. 1984;9:314–327.

3 Agodoa LY, Appel L, Bakris GL, et al. Effect of ramipril vs.amlodipine on renal outcomes in hypertensive nephroscle-rosis. A randomized controlled trial. JAMA. 2001;285:2719–2728.

4 Grimm RH, Margolis KL, Papademetriou V, et al. Baselinecharacteristics of participants in the Antihypertensive andLipid-Lowering Treatment to Prevent Heart Attack Trial(ALLHAT). Hypertension. 2001;37:19–27.

5 Dahlof B, Devereaux RB, Kjeldsen SE, et al. Cardiovascularmorbidity and mortality in the Losartan Intervention forEndpoint reduction in hypertension study (LIFE): a randomizedtrial against atenolol. Lancet. 2002;359:995–1003.

6 National Heart, Lung, and Blood Institute. New recom-mendations to prevent high blood pressure. Available at:www.nhlbi.nih.gov. Accessed October 17, 2002.

7 Appel LJ, Moore TJ, Obarzanek E, et al. A clinical trial of theeffects of dietary patterns on blood pressure. DASHCollaborative Research Group. N Engl J Med. 1997;336:1117–1124.

8 Sacks FM, Svetky LP, Vollmer WM, et al. Effects on blood pres-sure of reduced dietary sodium and the Dietary Approaches toStop Hypertension (DASH) diet. DASH-Sodium CollaborativeResearch Group. N Engl J Med. 2001;344:3–10.

THE JOURNAL OF CLINICAL HYPERTENSION SUPPLEMENT 1 VOL. V NO. I JANUARY/FEBRUARY 20034