Black patients

Hypertension is more common in black than in white patients, and its course is distinctly more severe. Black patients have a three-times higher mortality rate from cardiovascular disease than do white patients, and their risk of end-stage renal disease is several times greater. These simple facts indicate that cardiovascular diseases, such as hypertension, hyperlipidemia, and diabetes, should be treated most aggressively in the black population. However, the impediments to aggressive therapy in this population are numerous and range from relative inefficacy of certain antihypertensive drug classes and ill-perceived adverse effects, to socioeconomic factors. No racial difference in antihypertensive efficacy has been documented for calcium antagonists and diuretics. In a meta-analysis, calcium antagonists were the only drug class showing efficacy in all BP strata [85]. In contrast, ACE inhibitors and ARBs, at a given dose, have distinctly less effect on BP in black patients than in white patients. The same seems to hold true for heart failure, but not for renal disease. For the same fall in BP, black patients experienced more nephroprotection with an ACE inhibitor than with a calcium antagonist, as demonstrated in the African-American Study of Kidney Disease and Hypertension (AASK) [86].

Importantly, the most dreaded, albeit rare, adverse effect of ACE inhibitor, namely angioedema, is several times more common in black than in white patients. Angioedema can occur after weeks or months ofACE inhibitor therapy and may account for several hundred fatalities per year worldwide. A report from one coroner's office highlights the concerns; it documents that six black patients died of asphyxiation secondary to angioedema ofthe tongue associated with ACE inhibitor therapy over a period of 3 years [87]. Once solid studies are published attesting to the similar (or, hopefully, even better) outcomes with ARBs in black patients, ACE inhibitors should be avoided all together. The only good news, with regard to the treatment ofhypertension in black patients, is that high doses of most antihypertensive drug classes are well tolerated. However, in general, the plateau of the dose-response curve in the black patient is often only reached at a higher dose level than in a white patient.

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