African Americans, hypertension therapy

Patients with asymptomatic left ventricular systolic dysfunction and hypertension should be treated with P-blockers and ACE inhibitors. Those with heart failure secondary to left ventricular dysfunction and hypertension should be treated with drugs proven to also reduce the morbidity and mortality of heart failure, including P-blockers, ACE inhibitors, ARBs, aldosterone antagonists, and diuretics for symptom control as well as antihypertensive effect. In African-Americans with heart failure and left ventricular systolic dysfunction, combination therapy with nitrates and hydralazine not only affords a morbidity and mortality benefit, but may also be useful as antihypertensive therapy if needed.66 The dihydropyridine calcium channel blockers amlodipine or felodipine may also be used in patients with heart failure and left ventricular systolic dysfunction for uncontrolled blood pressure, although they have no effect on heart failure morbidity and mortality in these patients.49 For patients with heart failure and preserved ejection fraction, antihypertensive therapies that should be considered include P-blockers, ACE inhibitors, ARBs, calcium channel blockers (including nondihydropyridine agents), diuretics, and others as needed to control blood pressure.2,49... 

Hydralazine, a hydrazine derivative, dilates arterioles but not veins. It has been available for many years, although it was initially thought not to be particularly effective because tachyphylaxis to its antihypertensive effects developed rapidly. The benefits of combination therapy are now recognized, and hydralazine may be used more effectively, particularly in severe hypertension. The combination of hydralazine with nitrates is effective in heart failure and should be considered in patients with both hypertension and heart failure, especially in African-American patients. 

Essential hypertension is a symptom of modem society, and its treatment accounts for a sizeable portion of global prescriptions. As a result, there is a great interest in reported ethnic and racial differences reported in the literature. The use of appropriate therapy in Black patients has been best studied. As monotherapy, calcium channel blockers and diuretics appear to be most effective in Blacks, whereas P-blockers and ACE inhibitors produce smaller reductions in blood pressure (Kiowiski et al, 1985 Freis, 1986 Hall, 1990). However, this may more reflect the lower plasma renin, salt and water retention and intercellular sodium and calcium in Blacks, compared to other groups (Kiowiski et al., 1988). There are individual exceptions amongst patients and among drugs, even within these classes for example labetalol, a combined a-blockers and P-blockers, can be equally effective in both African-Americans and Caucasians and, as mentioned previously, the Chinese appear twice as sensitive to propranolol as Caucasians (Oster etal., 1987 Zhou etal., 1990). 

THERAPEUTIC USES When given in adequate doses, the ATj receptor antagonists appear to be as effective as ACE inhibitors in the treatment of hypertension. As with ACE inhibitors, these drugs may be less effective in African Americans and patients with low-renin hypertension. The full effect of AT receptor antagonists on blood pressure typically is not observed until 4 weeks after initiation of therapy. If blood pressure is not controlled by an ATj receptor antagonist alone, a low dose of a thiazide or other diuretic may be added. In patients with mild-to-severe hypertension, the... 

Toxicity The principal adverse reactions to cyclosporine therapy are renal dysfunction, tremor, hirsutism, hypertension, hyperhpidemia, and gum hyperplasia. Hyperuricemia may lead to worsening of gout, increased P-glycoprotein activity, and hypercholesterolemia. Nephrotoxicity occurs in the majority of patients treated and is the major indication for cessation or modification of therapy. Hypertension occurs in -50% of renal transplant and almost all cardiac transplant patients. Combined use of calcineurin inhibitors and glucocorticoids is particularly diabetogenic, although this apparently is more problematic in patients treated with tacrohmus see below). Especially at risk are obese patients, African American or Hispanic recipients, or those with family history of type 2 diabetes or obesity. Cyclosporine, as opposed to tacrolimus, is more hkely to produce elevations in low-density lipoprotein (LDL) cholesterol. 

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