Tailoring treatment to minority patients.

The treatment of high blood pressure in black people is often complicated by a variety of factors. These include the tendency of black hypertensive patients to have three to five times the cardiovascular mortality of white hypertensive patients, black hypertensives' more frequent progression to end-organ damage and stroke, and socioeconomic conditions that impede access to proper health care. In addition, blacks have a unique hemodynamic profile, one that alters the efficacy of many antihypertensive drugs. In black hypertensives, for example, diuretics are more effective than they are in whites, whereas beta-blockers and angiotensin-converting enzyme (ACE) inhibitors are less effective. Although it is true that blacks are disproportionately represented in the hypertensive population--having up to seven times the prevalence of severe hypertension seen in whites--it is not true that they are relatively unresponsive to drug therapy. A number of long-term clinical trials have established that black hypertensives respond well to treatment. Specifically, blacks in stepped-care therapy achieve goal blood pressure at the same rate as their white counterparts, although the increased barriers to blood pressure control in blacks require practitioners to put increased effort into this therapy. Possibly because black hypertensives tend to have low plasma renin levels, beta-blockers and ACE inhibitors are not nearly as effective as diuretics when used as monotherapy. Diuretics, on the other hand, have established efficacy in blacks, and their selection for initial monotherapy is favored for two additional reasons. First, they present a better profile in terms of overall cost and compliance, thanks to their lower relative cost and once-a-day dosing. Second, when diuretics are combined with another antihypertensive therapy, such as an ACE inhibitor or a calcium-entry blocker, responsiveness may be further improved. This combination therapy may be especially important in black hypertensives, who exhibit a higher incidence of concurrent diseases such as left ventricular hypertrophy and congestive heart failure.