Current Cardiology Reports

, Volume 14, Issue 6, pp 660–666 | Cite as

Should African Americans Have a Lower Blood Pressure Goal than Other Ethnic Groups to Prevent Organ Damage?

  • John M. Flack
  • Tochukwi Okwuosa
  • Rajeev Sudhakar
  • Brian Ference
  • Phillip Levy
Hypertension (MJ Sorrentino, Section Editor)


African Americans manifest an inordinately high burden of hypertension, pressure-related target-organ injury (eg, left ventricular hypertrophy, stroke), and sub-optimal hypertension control rates to conventional levels (<140/90 mm Hg). A substantive proportion of the excessive premature mortality in African Americans relative to Whites is pressure-related. Randomized prospective pharmacologic hypertension end-point trials have shown invariable cardiovascular disease (CVD) risk reduction across a broad range of pre-treatment BP levels down to 110/70 mm Hg with the magnitude of CVD risk reduction across the 5 major antihypertensive drug classes being directly linked to degree of blood pressure (BP) lowering. Pooled endpoint data from pharmacologic hypertension trials in African Americans showed that CVD risk reduction was the same with major antihypertensive drug classes when similar levels of BP were achieved. A lower than conventional BP target for African Americans seems justified and prudent because attainment of lower BP should incrementally lower CVD risk in this high-risk population


Hypertension Hypertension control rates Target-organ injury Target blood pressure Cardiovascular disease African Americans 



Conflicts of interest: J.M. Flack has received grant support from the NIH, Novartis, Medtronic and Daiichi Sankyo. He serves as a consultant to Medtronic, Back Beat Hypertension, NIH and Novartis; T. Okwuosa, R. Krishamoorthi, B. Ference: none; P. Levy has received grant support from The Robert Wood Johnson Foundation Physician Faculty Scholars Program-Grant #64319.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Prospective Studies Collaboration. Age-specific relevance of usual pressure to vascular mortality: a meta-analysis of individual data for 1 million adults in 61 prospective studies. Lancet. 2002;360:1903–13.CrossRefGoogle Scholar
  2. 2.
    •• Law MR. Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomized trials in the context of expectations from prospective epidemiologic studies. BMJ. 2009;338:1–19. An aggregation of hypertension clinical trial endpoint data that provides relative risk estimates for CHD and stroke across a broad range of pre-treatment BPs. CrossRefGoogle Scholar
  3. 3.
    Flack JM, Gardin JM, Yunis C, Liu K. Static and pulsatile blood pressure correlates of left ventricular structure and function in black and white young adults: the CARDIA study. Am Heart J. 1999;138(5 Pt 1):856–64.CrossRefPubMedGoogle Scholar
  4. 4.
    Hefferman KS, Jae SY, Wilund KR, et al. Racial differences in central blood pressure and vascular function in young men. Am J Physiol Heart Circ Physiol. 2008;295:H2380–7.CrossRefGoogle Scholar
  5. 5.
    Guo F, He D, Zhang W, Walton RG. Trends in prevalence, awareness, management and control of hypertension among United States adults, 1999 to 2010. J Am Coll Cardiol. 2012;xx:xxxx.Google Scholar
  6. 6.
    Drazner MH, Dries DL, Peshock RM, et al. Left ventricular hypertrophy is more prevalent in blacks than whites in the general population: the Dallas Heart Study. Hypertension. 2005;46:124–9.CrossRefPubMedGoogle Scholar
  7. 7.
    Dyer AR, Liu K, Walsh M, et al. Ten-year incidence of elevated blood pressure and its predictors: the CARDIA study. Coronary Artery Risk Development in (Young) Adults. J Hum Hypertens. 1999;13:13–21.CrossRefPubMedGoogle Scholar
  8. 8.
    Cowie CC, Rust KF, Byrd-Holt DD, et al. Prevalence of diabetes and high risk for diabetes using A1C criteria in the U.S. Population in 1988–2006. Diabetes Care. 2010;33:562–8.CrossRefPubMedGoogle Scholar
  9. 9.
    Liao Y, Cooper RS, McGee DL, et al. The relative effects of left ventricular hypertrophy, coronary artery disease, and ventricular dysfunction on survival among black adults. JAMA. 1995;273:1592–7.CrossRefPubMedGoogle Scholar
  10. 10.
    Lloyd-Jones D, Adams R, Carnethon M, et al. Heart disease and stroke statistics– 2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2009;119:e21–e181.CrossRefPubMedGoogle Scholar
  11. 11.
    Flack JM, Neaton JD, Daniels B, Esunge P. Ethnicity and renal disease: lessons from Multiple Risk Factor Intervention Trial and the Treatment of Mild Hypertension Study. Am J Kidney Dis. 1993;21(Suppl):31–40.PubMedGoogle Scholar
  12. 12.
    Mensah GA, Mokdad AH, Ford ES, et al. State of disparities in cardiovascular health in the United States. Circulation. 2005;111:1233–41.CrossRefPubMedGoogle Scholar
  13. 13.
    •• Bibbins-Domingo K, Pletcher MJ, Lin F, et al. Racial differences in incident heart failure among young adults. N Engl J Med. 2009;360:1179–90. An important prospective epidemiologic longitudinal epidemiologic study showing the strikingly higher risk of heart failure in middle-aged African Americans relative to Whites. The study also highlights the importance of blood pressure in causing heart failure. CrossRefPubMedGoogle Scholar
  14. 14.
    Zhang X, Saaddine JB, Chou C-F, et al. Prevalence of diabetic retinopathy in the United States, 2005-2008. JAMA. 2010;304:649–56.CrossRefPubMedGoogle Scholar
  15. 15.
    UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ. 1998;12(317):703–13.CrossRefGoogle Scholar
  16. 16.
    • Fiscella K, Holt K. Racial disparity in hypertension control: tallying the death toll. Ann Fam Med. 2008;6:497–502. A sobering analysis of national probability data showing the thousands of deaths from stroke and CHD that could be prevented by equalizing the SBP in hypertensive African Americans and Whites. CrossRefPubMedGoogle Scholar
  17. 17.
    Centers for Disease Control. Compressed mortality file: underlying cause-of-death. National Center for Health Statistics. 2008. Available at:
  18. 18.
    •• Flack JM, Sica DA, Bakris G, et al. Management of high blood pressure in Blacks: an update of the International Society on Hypertension in Blacks Consensus Statement. Hypertension. 2010;56:780–800. An update of the first ISHIB Consensus Statement (2003) on the treatment of hypertension in Blacks. This Consensus Statement recommended a target BP < 135/85 mm Hg for African Americans without pre-clinical CVD, target-organ injury, or known vascular disease. CrossRefPubMedGoogle Scholar
  19. 19.
    Wright Jr JT, Agodoa LY, Appel L, et al. New recommendations for treating hypertension in black patients: evidence and/or consensus? Hypertension. 2010;56:801–3.CrossRefPubMedGoogle Scholar
  20. 20.
    Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure. Hypertension. 2003;42:1206–52.CrossRefPubMedGoogle Scholar
  21. 21.
    Brewster LM, van Montfrans GA, Kleijnen J. Systematic review: antihypertensive drug therapy in black patients. Ann Intern Med. 2004;141:614–27.PubMedGoogle Scholar
  22. 22.
    • Tricoci P, Allen JM, Kramer JM, et al. Scientific evidence underlying the ACC/AHA clinical practice guidelines. JAMA. 2009;302:831–41. This analysis shows the relatively low level of data used to make the majority of Class I recommendations in AHA/ACC clinical guidelines. This precedent is important when considering the strength of the data used to recommend the lower target BP (< 135/85 mm Hg) for African Americans in the ISHIB Consensus Statement. CrossRefGoogle Scholar
  23. 23.
    Weir MR, Bakris GL, Weber MA, et al. Renal outcomes in hypertensive Black patients at high cardiovascular risk. Kidney Int. 2012;81:568–76.CrossRefPubMedGoogle Scholar
  24. 24.
    Neaton JD, Grimm Jr RH, Prineas RJ, et al. Treatment of mild hypertension study: final results. JAMA. 1993;270:713–24.CrossRefPubMedGoogle Scholar
  25. 25.
    Verdecchia P, Staessen JA, Angeli F, et al. Usual vs tight control of systolic blood pressure in non-diabetic patients with hypertension (Cardio-Sis): an open-label randomized trial. Lancet. 2009;374:525–33.CrossRefPubMedGoogle Scholar
  26. 26.
    Lopes AA, Andrade J, Noblat AC, Silveira MA. Reduction in diastolic blood pressure and cardiovascular mortality in nondiabetic hypertensive patients. A reanalysis of the HOT study. Arg Bras Cardiol. 2001;77:132–7.Google Scholar
  27. 27.
    Schrier RW, Estacio RO, Esler A, Mehler P. Effects of aggressive blood pressure control in normotensive type 2 diabetic patients on albuminuria, retinopathy, and strokes. Kidney Int. 2002;61:1086–97.CrossRefPubMedGoogle Scholar
  28. 28.
    Estacio RO, Jeffers BW, Gifford N, Schrier RW. Effect of blood pressure control on diabetic microvascular complications in patients with hypertension and type 2 diabetes. Diabetes Care. 2000;23(Suppl):B54–64.PubMedGoogle Scholar
  29. 29.
    ACCORD Study Group. Effects of intensive blood pressure control in type 2 diabetes mellitus. N Engl J Med. 2010;362:1575–85.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  • John M. Flack
    • 1
  • Tochukwi Okwuosa
    • 2
  • Rajeev Sudhakar
    • 3
  • Brian Ference
    • 4
  • Phillip Levy
    • 5
  1. 1.Department of Medicine, Division of Translational Research and Clinical Epidemiology and Division of Endocrinology, Metabolism, and HypertensionWayne State University and the Detroit Medical CenterDetroitUSA
  2. 2.Department of Medicine, Division of CardiologyWayne State University and the Detroit Medical CenterDetroitUSA
  3. 3.Department of Medicine, Division of General Medicine, Academic Hospitalist SectionWayne State University and the Detroit Medical CenterDetroitUSA
  4. 4.Department of Medicine, Division of Translational Research and Clinical Epidemiology and CardiologyWayne State University and the Detroit Medical CenterDetroitUSA
  5. 5.Department of Emergency MedicineWayne State University and the Detroit Medical CenterDetroitUSA

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