In African Americans with hypertension, therapy is best initiated with the low-sodium Dietary Approaches to Stop Hypertension (DASH) diet and a thiazide-type diuretic (strength of recommendation [SOR]: A, based on randomized controlled trials). If the blood pressure goal is not achieved with thiazide monotherapy, a calcium channel blocker, angiotensin-converting enzyme (ACE) inhibitor, angiotensin II receptor blocker (ARB), or a beta-blocker can be added. An initial combination treatment is recommended for patients with systolic blood pressure >15 mm Hg or diastolic blood pressure >10 mm Hg above target (SOR: C, expert opinion)

Cherukuri, Manjula

Mayo, Helen G.

Rao, Shobha

University of Missouri: MOspace

	 vol	56,	No	2	/	february	2007	 149www.jfponline.comCliniCal INquIrIes From the Family Physicians Inquiries NetworkShobha Rao, MD,  Manjula Cherukuri, MD,  and Helen G. Mayo, MlSUniversity of Texas  Southwestern, Dallasn Evidence summaryThree large cohort studies determined that African Americans have a higher prevalence of hypertension and worse cardiovascular and renal outcomes when compared with white Americans. For African American patients, the stan-dard blood pressure goals apply: below c l i n i c a l  c o m m e n t a r yAfrican Americans respond better to combination ACE inhibitor plus diureticTreat	 african	 american	 patients	 with	 hy-pertension	according	to	the	Joint	National	Committee	 on	Prevention,	Detection,	 and	Treatment	 of	 High	 blood	 Pressure	 (JNC	7)	 guidelines.	 These	 guidelines	 state	 that	patients	with	stage	1	hypertension,	regard-less	of	race,	should	be	treated	with	lifestyle	modification	(to	include	a	low-salt	diet	and	weight	loss)	for	3	months.	If,	after	a	trial	of	lifestyle	 modification,	 these	 patients	 still	have	hypertension,	then	start	diuretic	thera-py	while	continuing	lifestyle	modifications.				If	patients	present	with	stage-2	hypertension,	started	them	on	a	diuretic	plus	another	agent.	african	american	patients	do	not	respond	to	aCe	 inhibitor	monotherapy	well,	 but	do	 re-spond	to	the	combination	of	an	aCe	inhibitor	plus	diuretic.	 If	 patients,	 regardless	of	 race,	have	 comorbid	 conditions	 that	 lend	 them-selves	to	alternate	antihypertensive	treatment	(ie,	beta-blocker	therapy	post–myocardial	in-farction),	then	use	these	therapies	first-line.Mandi Sehgal, MDuniversity	of	Cincinnatie v i d e n c e - b a s e d  a n s w e rIn	 african	 americans	 with	 hypertension,	therapy	 is	 best	 initiated	 with	 the	 low-	sodium	 Dietary	 approaches	 to	 stop	 Hy-pertension	 (DasH)	 diet	 and	 a	 thiazide-type	diuretic	(strength	of	recommendation	[sor]:	A,	based	on	randomized	controlled	trials).	 If	 the	 blood	 pressure	 goal	 is	 not	achieved	 with	 thiazide	 monotherapy,	 a	calcium	 channel	 blocker,	 angiotensin-	converting	 enzyme	 (aCe)	 inhibitor,	angiotensin	II	receptor	blocker	(arb),	or	a	beta-blocker	 can	 be	 added.	 an	 initial	combination	 treatment	 is	 recommended	for	 patients	 with	 systolic	 blood	 pressure	>15	 mm	 Hg	 or	 diastolic	 blood	 pressure	>10	mm	Hg	above	target	(sor:	C,	expert	opinion).		 	 	african	americans	have	reduced	blood	pressure	 responses	 to	monotherapy	with	beta-blocker,	aCe	inhibitor,	or	arbs	when	compared	to	diuretics	or	calcium	channel	blockers	 (sor:	A,	 randomized	 controlled	trials).	However,	cardiac	and	renal	 indica-tions	 for	 prescribing	 these	 medications	should	be	equally	applied	to	african	amer-ican	patients	(sor:	C,	expert	opinion).What is the best treatment  for hypertension  in African Americans?Copyright® Dowden Heal h Media  For pers nal use onlyFor mass reproduction, content licensing and permissions contact Dowden Health Media.fast track150 vol	56,	No	2	/	february	2007		ThE JournAl of fAMily PrACTiCECliniCal INquIrIes140/90 mm Hg with uncomplicated hypertension and below 130/80 with diabetes or renal disease.1Dietary interventionsAn RCT compared the effects of con-suming the DASH diet (consisting of 4–5 servings of fruit, 4–5 servings of vegetables, 2–3 servings of low-fat dairy per day, and <25% fat) with a typical high-fat control diet among 459 adults with normal or elevated blood pressure.2 Among 133 patients with hypertension, the DASH diet reduced systolic and dia-stolic blood pressure by 11.4 mm Hg (97.5% confidence interval [CI], –15.9 to –6.9) and 5.5 mm Hg (97.5% CI, –8.2 to –2.7) respectively when com-pared with the control diet. Among African Americans with hypertension, the DASH diet was even more benefi-cial, reducing their systolic and diastolic blood pressure by 13.2 mm Hg and 6.1 mm Hg respectively.1 Another RCT studied the effect of different levels of dietary sodium in conjunction with the DASH diet.3 A total of 412 participants were ran-domly assigned to eat either a control diet or the DASH diet. Within the assigned diet, participants ate foods with high (150 mmol/d), intermediate (100 mmol/d), and low (50 mmol/d) levels of sodium in random order. In this study, low-sodium DASH diet was associated with additional lower-ing of blood pressure, an effect that was also found to be stronger for African Americans patients than oth-ers.3 When compared with the combi-nation of the control diet and a high level of sodium, the DASH diet and a low level of sodium lowered sys-tolic blood pressure by 11.5 mm Hg for participants with hypertension (12.6 mm Hg for blacks; 9.5 mm Hg for others), and by 7.1 mm Hg for participants without hypertension (7.2 mm Hg for blacks; 6.9 mm Hg for others).3 Medical interventionsThe Antihypertensive and Lipid-Lower-ing Treatment to Prevent Heart Attack Trial4 (ALLHAT) and African Ameri-can Study of Kidney Disease and Hy-pertension5 (AASK) have demonstrated the benefit of blood pressure reduction using specific classes of antihypertensive agents. The ALLHAT trial, a double-blind RCT of 42,448 high-risk hypertensive pa-tients aged >55 years, compared chlortha-lidone (a thiazide-type diuretic) with am-lodipine (Norvasc), lisinopril (Prinivil, Zestril), or doxazosin (Cardura). In this study, which included 36% African Amer-icans, chlorthalidone, lisinopril, and amlo-dipine did not differ in preventing major cardiovascular events. However, lisinopril was associated with an increased risk for heart failure (relative risk [RR] for African Americans=1.32; 95% CI, 1.11–1.58) and stroke (RR for African Americans=1.4; 95% CI, 1.17–1.68), and amlodipine was associated with a higher risk of heart failure (RR in African Americans=1.47; 95% CI, 1.24–1.74). Additionally, ACE inhibitor–induced angioedema or cough occurred more frequently among African American patients than white patients.4 Although a randomized controlled trial5 and a review of multiple studies6 demonstrated that African Americans may be less responsive to monotherapy with ACE inhibitors, the AASK trial con-firmed that ACE inhibitors can provide significant clinical benefits for African Americans with hypertensive renal dis-ease. AASK, a double-blind RCT of 1094 African American patients with renal insufficiency, compared the effects of an ACE inhibitor (ramipril [Altace]), a di-hydropyridine calcium channel blocker (amlodipine), or a beta blocker (meto-prolol [Lopressor]) on the progression of hypertensive renal disease. The study showed a 44% relative risk reduction (95% CI, 13%–65%; num-ber needed to treat [NNT]=25) in pro-gression to end-stage renal disease, and a significant decrease in the combined Start therapy  with a low-sodium DASH diet  and a thiazide diureticfast track	 vol	56,	No	2	/	february	2007	 151www.jfponline.comendpoints of glomerular filtration rate events (decrease >50%), end-stage renal disease, and death (decreased by 38%) in the ramipril group compared with the amlodipine group (95% CI, 13%–56%; NNT=56 per patient-year).5,7 Metopro-lol appeared to have intermediate out-comes.8Recommendations from othersBoth the International Society on Hy-pertension in Blacks (ISHIB) guidelines1 and the JNC 79 recommend therapeu-tic lifestyle modification that includes DASH diet, dietary sodium restriction, and weight reduction. Both guidelines recognize the importance of thiazide di-uretics and recommend its use as first-line therapy or as a part of combination therapy for hypertension among African Americans. They also recommend ini-tiating therapy with 2 agents for blood pressure significantly above target level (20/10 mm Hg above target per JNC 7, 15/10 mm Hg above target per ISHIB). The ISHIB report emphasizes the need for not overlooking renal protection with an ACE inhibitor for African Americans with renal disease. The American Diabetes Association recommends that all patients with diabetes and hypertension be treated with a regimen that includes either an ACE inhibitor or an ARB.10 nreferences	 1.	 	americans:	consensus	statement	of	the	Hyperten-sion	 in	 african	 americans	 Working	 Group	 of	 the	International	 society	 on	 Hypertension	 in	 blacks.	Arch Intern Med	2003;	163:525–541.	 2.	 	appel	lJ,	Moore	TJ,	obarzanek	e,	et	al.	a	clinical	trial	of	the	effects	of	dietary	patterns	on	blood	pres-sure.	DasH	Collaborative	research	Group.	N Engl J Med	1997;	336:1117–1124.	 3.	 	sacks	fM,	svetkey	lP,	vollmer	WM,	et	al.	effects	on	blood	pressure	of	reduced	dietary	sodium	and	the	Dietary	approaches	to	stop	Hypertension	(DasH)	diet.	DasH-sodium	Collaborative	research	Group.	N Engl J Med	2001;	344:3–10.	 4.	 	allHaT	officers	and	Coordinators	for	the	allHaT	Collaborative	research	Group.	 The	antihyperten-sive	and	lipid-lowering	Treatment	to	Prevent	Heart	attack	Trial.	Major	outcomes	in	high-risk	hyperten-sive	 patients	 randomized	 to	 angiotensin-convert-ing	enzyme	inhibitor	or	calcium	channel	blocker	vs	diuretic:	The	antihypertensive	and	lipid-lowering	Treatment	 to	Prevent	Heart	attack	Trial	 (allHaT).	JAMA	2002;	288:2981–2997.	 5.	 	agodoa	ly,	appel	l,	bakris	Gl,	et	al,	and	the	af-rican	american	study	of	Kidney	Disease	and	Hy-pertension	 (aasK)	study	Group.	effect	of	 ramipril	vs	amlodipine	on	 renal	outcomes	 in	hypertensive	nephrosclerosis:	 a	 randomized	 controlled	 trial.	JAMA	2001;	285:2719–2728.		 6.	 	richardson	aD,	Piepho	rW.	effect	of	race	on	hy-pertension	and	antihypertensive	therapy.	Int J Clin Pharmacol Ther	2000;	38:75–79.		 7.	 	McConaghy	J.	What	is	the	best	treatment	for	slow-ing	 the	 progression	 to	 end-stage	 renal	 disease	(esrD)	in	african	americans	with	hypertensive	ne-phropathy?	J Fam Pract	2001;	50:744.	 8.	 	Wright	JT,	bakris	G,	Greene	T,	et	al,	and	the	african	american	study	of	Kidney	Disease	and	Hyperten-sion	(aasK)	study	Group.	effect	of	blood	pressure	lowering	and	antihypertensive	drug	class	on	pro-gression	of	hypertensive	kidney	disease:	results	of	the	aasK	trial.	JAMA	2002;	288:2421–2431.	 9.	 	Chobanian	av,	bakris	Gl,	black	Hr,	et	al,	and	the	National	 Heart,	 lung,	 and	 blood	 Institute	 Joint	National	 Committee	 on	 Prevention,	 Detection,	evaluation,	and	Treatment	of	High	blood	Pressure;	National	High	blood	Pressure	education	Program	Coordinating	 Committee.	 The	 seventh	 report	 of	the	 Joint	National	Committee	 on	Prevention,	De-tection,	 evaluation,	 and	 Treatment	 of	High	blood	Pressure:	the	JNC	7	report.	JAMA	2003;	289:2560–2572.	10.	 	american	 Diabetes	 association.	 standards	 of	Medical	 Care	 in	 Diabetes—2006. Diabetes Care	2006;	29:s4–s42.Hypertension treatment in african americans pAfrican Americans have less blood pressure response to beta-blockers, ARBs, and ACE inhibitors

What is the best treatment for hypertension in African Americans?

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