Introduction

Hypertension (HTN) is the largest contributor to cardiovascular disease (CVD), including coronary heart disease, heart failure (HF), and stroke, among traditional risk factors, as recently confirmed among 13,541 participants (6 % Black) over 10 years in the Atherosclerosis Risk in Communities (ARIC) study [1]. Moreover, along with diabetes mellitus (DM), it is a major cause of chronic kidney disease (CKD) and end-stage renal disease (ESRD). Overall, the HTN control rate is only 53.3 % and prevalence differs by race/ethnicity. Hypertension is more common among Blacks or African-Americans (AAs) (40.4 %) compared with Whites (27.4 %) and Mexican-Americans (26.1 %) [2••]. For AAs, high blood pressure (BP) has an earlier onset, greater severity, and higher rates of target organ damage [3], leading to decreased longevity [2••].

Although race and ethnicity are often included in health-related data [4], they are not true scientific categories, but rather social constructs. Therefore, HTN burdens reflect adverse environments as much as, or even more so than true genetic diversity. This review will offer a better understanding of current concepts and new data to optimize care of HTN among various racial/ethnic patients. Epidemiology, pathophysiology, and responses to treatment are explored. In view of the disproportionate HTN-related complications and more documentation in AAs, this review will focus primarily on that population.

The Conundrum of Race/Ethnicity versus Environment-Causing Hypertension-Related Burden and Complications

According to the Food and Drug Administration (FDA) nomenclature for self-determined race, categories include American Indian or Alaska Native, Asian, Black or AA, Native Hawaiian or Other Pacific Islander, and White [4]. Subsequent to race self-determination, ethnicity is then accessed as Hispanic or Latino. Clearly, these somewhat arbitrary categories do not often accurately characterize a complex, heterogeneous, integrated society (e.g., White can include origins in Europe, the Middle East, or North Africa; Asian can be persons from areas ranging from India to Japan).

Conversely, the social determinants of health (SDOH), the circumstances in which people are born, grow up, live, work, and age, as well as the systems put in place to deal with illnesses, disproportionately affect HTN and CVD. Recently, Southern Black women with lower socioeconomic status (SES) were found to have worse cardiovascular health than White women [5•] and in Blacks, higher levels of psychological stress as racism-related vigilance was positively associated with HTN [6]. Nevertheless, even with SES similarities, among 69,211 participants in the Southern Community Cohort Study, both uncontrolled HTN and unreported HTN were twice as high among Blacks as Whites (OR, 2.13; 95 % CI, 1.68–2.69; and OR, 1.99; 95 % CI, 1.59–2.48 [7]. The prevalence of self-reported HTN was significantly higher among Blacks than Whites (59 % versus 52 %; P < 0.001), driven by the higher prevalence among Black women (64 %) compared with White women (52 %), whereas Black and White men had similar prevalences (51 %).

Hypertension has been shown to be associated with acculturation. In a recent New York City survey, US residency for ≥10 years was associated with higher self-reported HTN prevalence in Blacks and Hispanics [8]. There is significant heterogeneity among Hispanics by racial admixture, country of origin, CVD risks, and disease prevalence; age-adjusted HTN rates appear higher among Puerto Ricans and Dominicans as compared with Mexican-Americans and Cubans [9, 10]. Limited national data on HTN rates are available for Asians and Pacific Islanders, who are very diverse, and significant subgroup differences in HTN and CVD rates [11].

The majority of studies on the prevalence and incidence of CVD in US Hispanics have included primarily Mexicans. There is a greater availability of data on Mexican-Americans compared with other Hispanic groups; however, this data may not be generalizable to the other Hispanic groups. Accordingly, a recent American Heart Association scientific statement describing the diversity and complexity of the Hispanic population and assessing the multiple issues affecting CVD among all subgroups of Hispanics, CVD epidemiology and related personal beliefs and the social and health issues of US Hispanics are discussed, and it identifies potential prevention and treatment opportunities. Notably, Hispanics represent the fastest-growing racial/ethnic population in the USA and are expected to constitute 30 % of the total US population by the year 2050 [12].

In the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort, long-term suboptimal CVD risk factor control and unhealthy lifestyles were significantly greater in AAs compared to Whites and poor BP control conferred a three times higher stroke risk among Blacks, for every 10 mmHg increase in systolic BP (SBP) [13]. Paradoxically, despite a higher burden of risk factors for atrial fibrillation (AF) in Blacks than in non-Blacks, there is a widely noted lower AF prevalence and incidence of AF in Blacks among treated hypertensive patients [14].

In view of high CVD burden in AAs, especially for stroke, despite no higher risk for dyslipidemia, the recent 2013 American College of Cardiology (ACC)/American Heart Association (AHA) atherosclerotic cardiovascular disease (ASCVD) risk calculation adds additional points for AA status, primarily driven by more prevalent and severe HTN [15]. Unfortunately, these significant disparities have persisted and possibly worsened in the last two decades [2••,16, 17].

Hypertension as the primary reason for a hospitalization is an indicator of health care system failure to prevent and control HTN. In contemporary Medicare data, AAs had persistently higher and increasingly disparate, preventable hospitalizations than Whites. However, high rates for preventable HTN hospitalizations among Whites were found in Appalachia, a low SES area [18]. Addressing SDOH may assist in BP control and in one urban, bi-racial hypertensive cohort, after adjusting for multiple socioeconomic and demographic variables, race differences in HTN treatment and control were eliminated [19].

Current Hypertension Awareness, Treatment and Control Among Various Race/Ethnicities

Current National Health and Nutrition Examination Survey (NHANES) data confirm among adults aged <65 years, the prevalence of HTN was greater for Blacks (74.1 %) and Mexican-Americans (71.9 %) as compared to Whites (57.4 %). A greater proportion of Mexican-Americans and Blacks have stage 1 and stage 2 hypertension than Whites, and treated stage 1 hypertension was significantly lower for Mexican-Americans compared to non-Hispanics. Control for Whites was 48.6 %, Blacks 43.0 %, and Mexican-Americans 35.5 % [2••]. According to a recent longitudinal cohort study of 16,415 Hispanics/Latinos aged 18–74 years, the Hispanic Community Health Study/Study of Latinos demonstrated the total age-adjusted prevalence of hypertension was 25.5 % as compared with 27.4 % in non-Hispanic Whites in the NHANES. Furthermore, the prevalence of hypertension increased with increasing age groups and was highest in Cuban, Puerto Rican, and Dominican groups. Thus, there exists a significant deficit in treatment and control of hypertension among Hispanics/Latinos residing in the USA [20].

Lack of health care coverage is associated with lower rates of hypertension awareness, treatment, and control [20, 21], which contributes to poor control rates among Mexican-Americans. Health care coverage with uncontrolled hypertension was lowest for Mexican-Americans (59.3 %), compared with Blacks (77.7 %) and Whites (89.4 %). Furthermore, Mexican-Americans and Blacks with hypertension were significantly younger than their White counterparts [22]. Interestingly, as previously demonstrated, awareness and treatment was highest among Blacks, possibly reflecting efforts to identify hypertension among AAs [23, 24].

Unmasking Pathophysiology and Genetic Mechanisms for Hypertension in Blacks

In AAs, hypertension is generally considered related to high reabsorption of sodium (Na) and this low-renin, salt-sensitive hypertension may be, at least in part, genetically-based, with a more active Na, potassium (K), 2 chloride cotransporter (NKCC2), and its regulators in the thick ascending limb [25]. Although, urinary excretion of Na appears similar in Blacks and Whites, indicating similar dietary Na intakes, urinary excretion of K is generally lower in AAs [26]. Postulated hypertension mechanisms in Blacks may involve the intrarenal renin-angiotensin system (RAS), variations in angiotensinogen [27], and increased aldosterone sensitivity. Plasma renin activity (PRA) and aldosterone in 1021 participants in the Multi-Ethnic Study of Atherosclerosis not currently taking antihypertensives showed, compared with Whites, Blacks had 28 % lower PRA and 17.4 % lower aldosterone, and Hispanics had 20.1 % higher PRA but similar aldosterone levels, suggesting a different mechanism of hypertension with Hispanic ethnicity [28].

In a prospective observational study, Black children, but not Whites, had lower levels of plasma renin activity and plasma aldosterone, and their BP was positively associated with the plasma aldosterone concentration (P = 0.004). Intervening with 9-α fludrocortisone to simulate hyperaldosteronism increased BP in Blacks but not in Whites, pointing to aldosterone sensitivity as a significant determinant [27].

Diminished nitric oxide (NO) bioavailability in Blacks may affect both resting and stimulus-mediated vasodilator tone [29]. In addition, the four to five times greater risk for developing CKD or ESRD in hypertensive Blacks has been linked to unique genetic polymorphisms, including MYH9 and apolipoprotein L1 gene (APOL1), which is found primarily with African ancestry and associated with focal segmental glomerular sclerosis and hypertensive kidney disease [30]. Accordingly, APOL1 risk alleles in the African American Study of Kidney Disease and Hypertension (AASK) participants suggest CKD was unlikely to be related to high blood pressure alone [31].

Early hypertension onset and premature CVD in Blacks may be related to blunted nocturnal blood pressure declines, starting in childhood and exacerbated with age [32]. African-Americans have a higher prevalence of not only clinic-based HTN, but also masked (out-of-office-only) HTN, which may confound effective control and is independently associated with left ventricular hypertrophy, a potent risk factor for CVD morbidity and mortality [33].

The Importance of Therapeutic Lifestyle Interventions (Non-pharmacologic Therapy) in Racial/Ethnic Minorities

Therapeutic lifestyle interventions (TLC) are the bedrock of BP control and overall CVD risk reduction, regardless of race/ethnicity. Adverse lifestyles, including excess sodium intake, excess alcohol, obesity, and sedentary lifestyle may be causal to hypertension, in many patients, and can also blunt the beneficial effects of drug therapy for hypertension [34].

High body mass index (BMI), especially abdominal obesity, may explain much of the variation of hypertension and CVD among groups [35]. In a retrospective study of 150,753 California adults, Asians had the lowest BMI among all groups, but the impact of increasing BMI on the risk of hypertension and diabetes was significantly greater in Asians; for each one unit increase in BMI, Asians were significantly more likely to have hypertension (OR 1.15; 95 % CI 1.13–1.18) compared to non-Hispanic Whites, Blacks, and Hispanics [36]. Furthermore, in AA’s, stress-induced sodium retention and obesity may affect a higher nocturnal pressure to excrete the higher sodium load.

A higher BMI lowers 25-Hydroxyvitamin D (25[OH]D) levels and is a causal risk factor for vitamin D deficiency [37, 38]. A large contemporary meta-analysis including 283,537 participants, with 55,816 hypertension cases [39] noted the risk for HTN was reduced by 12 % per 10 ng/mL increment of 25(OH)D. Although vitamin D deficiency has been associated with HTN and incident stroke, among White and Black Atherosclerosis Risk in Communities (ARIC) participants with no stroke history; lower 25(OH)D levels were not significantly associated with white matter hyperintensity progression or subclinical brain infarcts [40]. Low vitamin D levels are common in Blacks and appropriate vitamin D supplementation may benefit hypertension therapy in African-Americans [41]. Hydrochlorothiazide (HCTZ) decreases urinary calcium excretion, but the risk for hypercalcemia was low among Blacks using up to 4000 IU vitamin D3 with HCTZ [42].

Especially in Blacks, there is strong evidence for the Dietary Approaches to Stop Hypertension (DASH) diet (high in fresh fruits and vegetables and low-fat dairy products), Mediterranean eating patterns, and sodium restriction [41, 43–45]. Despite persistent debates on the benefits of widespread sodium restriction, recently, Mozaffarian and colleagues reported that globally 1.65 million deaths (1 out of 10 deaths) from CVD in 2010 were due to sodium consumption of more than 2.0 g per day, with greater effects on BP among Blacks than among Whites [46]. Additional sodium restriction to 1500 mg/day may have a more significant BP reduction [45]. One small ambulatory blood pressure monitoring (ABPM) study confirmed rigorous sodium restriction, if successfully achieved, lowers BP even in drug-treated patients with resistant HTN [47].

In 2043 participants from the REGARDS study with treatment-resistant HTN, positive lifestyles were associated with a lower risk for CVD events [34] and in Black Seventh-day Adventists, compared with non-vegetarians, the vegetarian/vegans had lower odds ratios for hypertension, and other CVD risk factors [48]. Therefore, the preponderance of available data suggests the major approaches to non-pharmacologic therapy, if successfully applied are effective, or even more beneficial in Black patients as compared to Whites [49].

Pharmacogenetics and Pharmacotherapy: Potential Racial/Ethnic Differences Responses

Brewster and colleagues systematically reviewed the international contemporary literature on pharmacotherapy in persons of African ancestry and concluded the response was superior in Blacks for thiazide-like diuretics and calcium channel blockers (CCBs), as compared to β-adrenergic blockers and angiotensin converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs). Overall, as compared to genetic markers, self-defined ancestry appeared to be the best predictor of individual responses to antihypertensive drugs [50•]. Nevertheless, the same authors recently cautioned that there was also a large degree of overlap in BP lowering between Blacks and Whites, providing caution for making therapeutic decisions based solely upon ethnicity (race) [51]. Beyond genetics, responsiveness to specific BP agents may be influenced by environmental concerns including dietary sodium, physical inactivity, obesity, and stress and comorbidity.

Thiazide Diuretics

The thiazide-type diuretics effectively lower BP and CVD outcomes across all racial/ethnic groups, but the robust response in Blacks compared to Whites may be influenced by a functional single-nucleotide polymorphism in the G protein β3 subunit gene (GNB3) [52, 53].

In the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), with 35 % Blacks of over 35,000 subjects, chlorthalidone-based treatments (12.5 to 25 mg/day) produced fewer major cardiovascular complications than with lisinopril, especially in Blacks, and less heart failure than amlodipine-based therapy [54]. Moreover, HCTZ-induced adverse metabolic changes, specifically hypertriglyceridemia, in AAs were recently found to be associated with novel variant alleles [55].

Calcium Channel Blockers

Calcium channel blockers are effective antihypertensive agents across a wide spectrum of patients, regardless of race/ethnicity, salt sensitivity, or age, including extensively documented effectivenenss in Blacks [56, 57]. Although in ALLHAT, in Blacks amlodipine was associated with a higher risk of heart failure (RR 1.37, 95 % CI 1.24–1.51), overall, BP lowering and CVD outcomes were similar to chlorthalidone. In the International Verapamil SR and Trandolapril Study (INVEST), patients randomized to a calcium channel blocker or β-blocker strategy reported no differences in outcomes (composite of death, myocardial infarction, or stroke) by drug strategy for Blacks, Whites, or Hispanics [58].

Angiotensin Converting Enzyme Inhibitors and Angiotensin Receptor Blockers (ARBs)

In ALLHAT, lisinopril in Blacks showed a mean SBP approximately 4 mmHg higher than with chlorthalidone, and an increased relative risk for heart failure (RR 1.3), stroke (RR 1.4), and combined cardiovascular outcomes (RR of 1.19). Similarly, in the Losartan Intervention For Endpoint reduction in hypertension (LIFE) study, although losartan-based therapy was superior to atenolol in non-Blacks (hazard ratio 0.83, 95 % CI 0.73 to 0.94), there was increased risk in Blacks with losartan (hazard ratio 1.67, 95 % CI 1.04 to 2.66) [59]. Also, in the Valsartan Antihypertensive Long-term Use Evaluation (VALUE) trial, valsartan was associated with a 20 % increase in CVD (NS) in Blacks as compared to amlodipine [60]. For Blacks, higher doses of angiotensin converting enzyme inhibitors (ACEIs), as shown with trandolopril, or perhaps with angiotensin receptor blockers (ARBs) may increase efficacy, and assist with better BP control [61].

The circulating renin-angiotensin system (RAS) appears suppressed in salt-sensitive populations, but intrarenal RAS, shown as urinary angiotensinogen excretion, may be associated with BP in salt-sensitive, low-renin Blacks [62]. In hypertensive nephrosclerosis, ACEIs are indicated in Blacks similarly to the general population, as clearly demonstrated in the AASK study [63] of 1094 African-Americans with the ramipril-based therapy superior to metoprolol or amlodipine regimens for composite renal outcomes.

Despite less BP reduction with monotherapy with ACEIs and ARBs in Blacks [64], no causal candidate genes including ACE gene insertion/deletion (I/D) polymorphism or angiotensin type 1 receptor, AGTR1 gene, have been conclusively demonstrated [54, 65, 66]. Moreover, although angioedema with ACE inhibitors is more common in Blacks [67], no specific underlying genetic cause has been elucidated [62].

Beta-blockers

The lesser antihypertensive effects of β-blocker monotherapy in Blacks than diuretics or CCBs may be affected by genetic polymorphisms in the β1-adrenergic receptor gene (ADRB1), Ser49Gly, and Arg389Gly, where frequency of one of the two most BP responsive diplotypes were found in 54 % of Chinese and 44 % of Whites but only 23 % of Blacks, [68]. In a recent bi-racial ambulatory blood pressure monitoring (ABPM) trial [69], in Blacks, night BP responses to atenolol were absent and baseline higher night/day ratios increased significantly (P < 0.05). Given the prognostic significance of night-time BP, a beta-blocker, specifically atenolol, is not an optimal first-step therapy.

Heart failure prevalence is higher in Blacks as compared to non-Blacks and more often due to hypertension. In the Beta-Blocker Evaluation of Survival Trial (BEST) for heart failure, unlike in non-Blacks, no CVD mortality benefit was seen in Blacks with bucindolol [70]. Interestingly, GRK5-Leu41 polymorphism, consistent with non-responsive beta-adrenergic receptor signaling and less B-blocker benefits, is more common in Blacks, with a ∼35 % frequency in African-Americans and ∼1–2 % in Whites [71]. There may be more favorable BP lowering with vasodilating B-blockers, including carvedilol and labetalol in Blacks as compared to conventional B-blockers. Moreover, nebivolol, a vasodilating B-blocking agent associated with increased NO availability, has BP lowering in Blacks similar to Whites [72].

Potassium-Sparing Diuretics and Aldosterone Antagonists

In Blacks, increased aldosterone sensitivity and the aldosterone-sensitive epithelial sodium channel in the collecting tubule [73] supports using amiloride, spironolactone, or eplerenone for robust BP lowering with resistant hypertension. Despite the increased risk of hyperkalemia, with stage 1 or 2 nephropathy and baseline potassium >4.5 meq/dl, aldosterone antagonism appears safe and effective for lowering BP, especially in obese Black females [74].

The Benefits of Combination Therapy and Identifying and Addressing Non-adherence

Most middle-aged and older patients with HTN, across race/ethnic status, will need a combination of medications to effectively control hypertension and reduce CVD risk.

Furthermore, the combination of thiazide-type diuretics or CCBs eliminates observed racial responses to B-blockers, ACEIs, or ARBs. In the Avoiding Cardiovascular Events through Combination Therapy in Patients Living with Systolic Hypertension (ACCOMPLISH) trial, 11,506 (Blacks = 12.3 %) high-risk patients on benazepril-amlodipine, the primary cardiovascular endpoints were less, as compared with benazepril–hydrochlorothiazide. Overall, including Blacks, the absolute risk reduction was 2.2 %, and the relative risk reduction was 20 % (HR 0.80; 95%CI 0.72–0.90) [75].

In recognition of the need for multi-drug regimens, low SES, cultural and language barriers, and diminished health literacy in many minority patients, clinicians should take active steps to ensure adherence [49]. Patients with excessive daytime sleepiness, often due to insufficient sleep, sleep apnea, illicit substance use, and other medical and psychiatric conditions are more than twice as likely to be non-adherent (OR 2.28, 95 % CI 1.42–3.67, P < 0.001) [76]. In a retrospective study of 106,621 hypertensive patients, the percentage of hypertensives controlled at 1 year was significantly higher in Whites than Blacks, for monotherapy (BP control 65 versus 53 %; P < 0.001), free combinations (67 versus 51 %; P < 0.001), and single-pill combinations (73 versus 63 %; P < 0.001) [77].

Patient education may improve adherence, addressing misconceptions about hypertension and medications. Techniques include narrative storytelling, with the culturally relevant vignettes [78], self-monitoring with home BP measurements, behavioral counseling, alerts, and computerized clinical decision-support systems [49]. Unfortunately, in the recent Counseling African Americans to Control Hypertension cluster-randomized clinical trial, home BP monitoring and monthly lifestyle counseling was no better than usual care in improving BP control among hypertensive Blacks [79].

Recent Hypertension Guideline and Reports: Pharmacotherapy in Racial/Ethnic Minorities and Controversies in BP Goal Recommendations

As initial choice or monotherapy, the general present consensus among US and international guidelines is that for Black patients, thiazide-type diuretics or CCBs are the most effective agents as compared to beta-blockers, ACEIs, or ARBs. However, significant controversy has developed related to initiation of drugs and the goals of therapy for patients aged 60–79 years of age.

First of all, the UK National Institute for Health and Clinical Excellence (NICE) (2011) recommended step 1 antihypertensive treatment with a CCB in all patients aged over 55 years, and specifically for Black people of African or Caribbean family origin of any age (Table 1). If a CCB first is not suitable, for example because of edema or intolerance, or with HF or a high HF risk, a thiazide-like diuretic is suggested, preferably chlorthalidone or indapamide [80]. For step 2, in Black people of African or Caribbean family origin, NICE notes an ARB should be considered over preference to an ACE inhibitor, in combination with a CCB. More recently, in July of 2013, the European Societies of Hypertension and Cardiology (ESH/ESC) consensus guideline suggested a diuretic or calcium antagonist medications as first-line for Blacks [81].

Table 1 Hypertension guideline or report recommendations
Full size table

In November of 2013, the ACC/AHA/CDC consensus report does not describe specific medications based on race/ethnicity, but does mention tighter BP may be appropriate in Blacks and clearly notes the social determinants of heath and race/ethnicity should be taken into account by clinicians [82]. The May 2014 Canadian Hypertension Education Program (CHEP) notes beta-blockers are not recommended as first-line therapy for uncomplicated hypertension in patients 60 years of age or older (Grade A); and first step ACEIs are not recommended for uncomplicated hypertension in Black patients (Grade A). However, both agents may be used in patients with certain comorbid conditions or in combination therapy [83].

In January of 2014, the American Society of Hypertension and the International Society of Hypertension (ASH/ISH) consensus report notes Blacks (African ancestry) usually respond well to treatment with CCBs and diuretics but have smaller BP reductions with ACEIs, ARBs, and B-blockers [84]. However, ASH/ISH notes that combination therapies provide powerful antihypertensive responses that are similar in both Black and White patients, and most patients (stage 2) will require more than one antihypertensive drug to maintain BP control.

The latest major 2014 US report, published in The Journal of American Medical Association (JAMA) in January of 2014, from members originally appointed to the Eight Joint National Committee (JNC) on the Detection, Evaluation, and Treatment of High Blood Pressure, is not a true “JNC 8” report as often described. Although a rigorous, evidence-based review, the report was not endorsed by the National Heart, Lung, and Blood Institute (NHLBI), other federal agencies, nor any of over three dozen organizations promulgating the previous JNC 7 [85]. The JAMA 2014 HTN US Guideline recommends in Blacks, including those with diabetes, that initial antihypertensive treatment should include a thiazide-type diuretic or CCB (for general Black population: moderate recommendation—Grade B; for Blacks with diabetes: weak recommendation—Grade C).

Nevertheless, a major source of controversy and concern in the 2014 US Guideline has been loosening goals for initiation of antihypertensive therapy and goal attainment for persons greater than 60 years old. In the general population aged ≥60 years, the panel recommends to initiate pharmacologic treatment to lower BP at SBP ≥150 mmHg and treat to a goal SBP <150 mmHg. Interestingly, Wright and others, with 5 of the 17 JAMA US 2014 Panel published in the Annals of Internal Medicine a minority opinion against raising the target from <140 mmHg for persons >60 to 79 years of age [86••].

Since it may adversely and disproportionately affect African-Americans and women, a recent State-of-the-Art Review in the Journal of the American College of Cardiology [87••] points to the potential harm with less rigorous BP control in older women and AAs and the Association of Black Cardiologists (ABC) strongly opposes the 2014 HTN Guideline decision. This new paradigm shift would leave approximately half of the untreated hypertensive patients in this age range untreated and is a dangerous public health experiment that could potentially reverse the decades long decline in US CVD mortality, especially stroke, seen with decades of increasingly effective BP control. Blacks are disparately affected by the ravages of uncontrolled HTN, and female hypertensive patients commonly develop hypertension after menopause and remain otherwise healthy [87••].

In consideration of the need for combination therapy, the 2010 working group recommendations from the International Society of Hypertension in Blacks (ISHIB) de-emphasized stepped care in favor of combination therapy even for Blacks without target organ damage or concomitant CVD and suggested pharmacotherapy greater than 135/85 mmHg and, for those at higher risk, at blood pressures greater than 130/80 mmHg [64]. The ASH/ISH consensus report uses combination medications for stage 2 hypertension, and CHEP also supports combination therapy using two first-line agents as initial treatment of hypertension (Grade C), if SBP is 20 mmHg above target or if DBP is 10 mmHg above target. The use of these two classes of drugs as initial antihypertensive therapy is supported only as an optional alternative in the 2014 US Guideline [85], but noted as preferred in the ESH/ESC [81].

Future Considerations

Improved understanding of hypertension among racial/ethnic groups has vast implications for public health and individual clinicians treating a diverse patient population. Efforts are critically needed to increase HTN control, awareness, treatment, and control, especially in Mexican-Americans and more effective treatment in Blacks. The Million Hearts® (MH) initiative is designed to prevent 1 million heart attacks and strokes over 5 years and reduce disparities by implementing proven, effective, multifactorial interventions to reduce CVD [88]. The National Forum for Heart Disease and Stroke Prevention, a coalition of over 65 organizations, spearheads multi-sector collaboration to support the MH® goals [89]. Recently, the MH® announced its 2013 hypertension Control Challenge Champions, encompassing nine health systems and health care providers across the country (http://millionhearts.hhs.gov/index.html) who achieved 70 % control rates, including diverse populations and settings.

Conclusion

Racial/ethnic disparities are persistent, unacceptable, and potentially correctable, including CVD risk with effective antihypertensive therapy. An observed life-long lower 10 mmHg SBP level is associated with a 58 % lower coronary heart disease (CHD) risk, much greater than the 22 % reduction in CHD reported for the same magnitude of SBP reduction in clinical trials [90•]. Earlier, effective hypertension treatment should reap substantial benefits and high-risk minorities suffer disparate, devastating consequences from inadequate control of BP [91].

Multiple national efforts, including MH®, support heart-healthy lifestyles, evidence-based antihypertensive pharmacotherapy, adherence, universal access to effective care, and increasing attention to overall CVD prevention. Blacks respond as monotherapy and first step to thiazide-type diuretics and CCBs, but combination blunts or removes racial/ethnic differences in responses. Although the recent 2014 US Guidelines suggest loosened goals for older adults, other expert opinion cautions against potential adverse, unintended consequences, especially in Blacks and women.