Hypertension black patients

Julius S, Alderman MH, Beevers G, et al. Cardiovascular riskreduction in hypertensive black patients with left ventricular hypertrophy The LIEE smdy. J Am Coll Cardiol 2004 43 1047-1055. 

Nifedipine, verapamil, and diltiazem are all efficacious in the treatment of mild and moderate hypertension, but nifedipine is more efficacious than diltiazem and verapamil in the control of severe hypertension. Nifedipine does not cause significant reflex tachycardia or orthostatic hypotension. Nifedipine benefits the older and black patients and patients with low PRA. 

Hypertensive patients with ieft ventricuiar hypertrophy (iosartan) Used to reduce the risk of stroke in patients with hypertension and left ventricular hypertrophy, but there is evidence that this benefit does not apply to black patients. 

Thiazide diuretics are effective antihypertensive agents in black hypertensive patients and studies suggest that they cause a greater decrease in blood pressure in black patients than in whites. The better hypotensive response in black hypertensive patients is probably due to the fact that, in comparison with whites, more black patients have an expanded intracellular volume and low plasma renin activity. In developing countries, in which the majority of black people live, the cost of therapy is important. Thiazide diuretics are because of their low cost important baseline drugs in the treatment of hypertension. 

Studies with ACE inhibitors have shown that in black patients the response is poor. However, the response becomes the same as in whites when ACE inhibitors are combined with a low-dose thiazide diuretic. ACE inhibitors can be effective in black hypertensive patients but in higher doses compared to white and Indian peoples. 

There is only limited data available on the response to All (AT) receptor antagonists in black hypertensive patients. The magnitude of the fall in blood pressure with losartan in black patients appears to be less than in non-black patients. Data on... 

Potentially as effective as or more effective than ACE inhibitors, without cough no evidence for reduction in morbidity and mortality as first-line agents in hypertension yet whetherthey provide the same cardiac and renal protection also still tentative like ACE inhibitors, less effective in black patients... 

Hypertension (without diuretic) PO Initially, 1 mg once a day in nonblack patients, 2 mg once a day in black patients. Adjust dosage at least at 7-day intervals. Maintenance 2-4 mg/day. Maximum 8 mg/day. 

Subsets of the hypertensive population The (3-blockers are more effective for treating hypertension in white than in black patients, and in young patients compared to the elderly. [Note Conditions that discourage the use of 3-blockers (for example, severe chronic obstructive lung disease, chronic congestive heart failure, severe symptomatic occlusive peripheral vascular disease) are more commonly found in the elderly and in diabetics.]... 

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). 

Patients undergoing screening for participation in the African-American Study of Kidney Disease and Hypertension were evaluated for kidney function based on an estimated CLcr compared with the simultaneous CLcr and I-iothalamate, and 24-hour CLcr- The simultaneous CLcr provided the best estimate of GFR. The CG method was the preferred method for estimation of GFR, based on performance and ease of use. This method was noted to underestimate the GFR by 9%, perhaps because of the increased excretion rate of creatinine by black patients. ... 

Nifedipine (Table 3) is a potent vasodilator that selectively dilates resistance vessels and has fewer effects on venous vessels. It does not cause reflex tachycardia during chronic therapy. Nifedipine is one of the first-line choices for black or elderly patients and patients having concomitant angina pectoris, diabetes, or peripheral vascular diseases. Nifedipine, sublingually, is also suitable for the treatment of hypertensive emergencies. Nifedipine does not impair sexual function or worsen blood Hpid profile. The side effects are flushing, headache, and dizziness. 

A number of non-hormonal therapies have been studied for symptomatic management of vasomotor symptoms, including antidepressants [e.g., selective serotonin reuptake inhibitors (SSRIs) and venlafaxine], herbal products (e.g., soy, black cohosh, and dong quai), and a group of miscellaneous agents (e.g., gabapentin, clonidine, and megestrol). The choice of therapy depends on the patient s concomitant disease states, such as depression and hypertension, and the risk for potential adverse effects. 

T reatment is indicated for ocular hypertension if the patient has a significant risk factor such as IOP greater than 25 mm Hg, vertical cup-disk ratio greater than 0.5, or central corneal thickness less than 555 micrometers. Additional risk factors to be considered include family history of glaucoma, black race, severe myopia, and presence of only one eye. 

In summary, black hypertensive patients respond well to thiazide diuretics, CCB, vasodilators like prazosin, doxazosin or the vasodilating /3-blocker la-betalol. It is suggested that in black hypertensive patients a thiazide diuretic should be routinely added when a /3-blocker or an ACE inhibitor is used. This above information is summarized in Table 10. 

Black DM, Brand RI, Greenlick M, et al Compliance to treatment for hypertension in elderly patients The SHEP pilot study. Systolic Hypertension in the Elderly Program. J Gerontol 1987 42 552-557. 

Fig. 15.9. Combined MRA (left) and plaque imaging (right) in a hypertensive patient with symptomatic left ICA stenosis. Cross-sectional black-blood imaging demonstrates the severely narrowed lumen (A and B) as well as the extension of the plaque to the carotid bifurcation (E), appearing normal on angiography...

Therapeutic use in hypertension Labetalol is useful for treating the elderly or black hypertensive patient in whom increased peripheral vascular resistance is undesirable. [Note In general black hypertensive patients are not well controlled with (3-blockers.] Labetalol may be employed as an alternative to hydralazine in the treatment of pregnancy-induced hypertension (PIH). 

Therapeutic uses Thiazide diuretics decrease blood pressure in both the supine and standing positions postural hypotension is rarely observed, except in elderly, volume-depleted patients. These agents counteract the sodium and water retention observed with other agents used in the treatment of hypertension (for example, hydralazine). Thiazides are therefore useful in combination therapy with a variety of other antihypertensive agents including (3-blockers and ACE inhibitors. Thiazide diuretics are particularly useful in the treatment of black or elderly patients, and in those with chronic renal disease. Thiazide diuretics are not effective in patients with inadequate kidney function (creatinine clearance less than 50 mls/min). Loop diuretics may be required in these patients. 

Like p-blockers, ACE inhibitors are most effective in hypertensive patients who are white and young. However, when used in combination with a diuretic, the effectiveness of ACE inhibitors is similar in white and black hypertensive patients. Unlike p-blockers, ACE inhibitors are effective in the management of patients with chronic congestive heart failure (see p. 156). ACE inhibitors are now a standard in the care of a patient following a myocardial infarction. Therapy is started 24 hours after the end of the infarction. 

Curb JD, Pressel SL, Cutler JA, Savage PJ, Applegate WB, Black H, Camel G, Davis BR, Frost PH, Gonzalez N, Guthrie G, Oberman A, Rutan GH, Stamler J. Effect of diuretic-based antihypertensive treatment on cardiovascular disease risk in older diabetic patients with isolated systolic hypertension. Systolic Hypertension in the Elderly Program Cooperative Research Group. JAMA 1996 276(23) 1886-92. 

Consider, finally, the use of race as a criterion of allocating kidneys for transplantation.119 Three facts conspire to make American blacks bad ly placed in this allocative process. First, they are overrepresented as patients, partly because of the hypertensive problems mentioned... 

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