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Hypertension in blacks: a double disadvantage
Journal of the American Society of Hypertension
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(2015) 1
Hypertension Highlight HYPERTENSION IN BLACKS: A DOUBLE DISADVANTAGE Blacks in the U.S. have a higher prevalence of hypertension and suffer more hypertension-related morbidity and mortality, particularly from chronic renal disease than do nonblacks. The reasons for these racial disparities are largely environmental, as described by Margaret Hicken (Am J Epidemiology 2015, printed online before formal publication on July 21. Dr Hicken states:l). ‘‘Segregation is thought to be an important mechanism by which racial inequalities in health are produced and maintained through differential access to economic opportunities, differential access to health-related resources (eg, pharmacies and hospitals), increased psychosocial stress, and greater exposure to environmental hazards (eg, hazardous waste and air pollution)...Indeed, after accounting for neighborhood environment, researchers reported no racial inequalities in hypertension’’ (Morenoff JD, et al. Soc Sci Med. 2007; 65:1853). [At least one genetic mechanism is also involved in the much higher prevalence of chronic renal disease among blacks who originate from South or West Africa: a missense mutation in the APOL1 gene (Skoreck KL and Wasser WG. Kidney Int. 2013; 83:6)]. In keeping with Dr. Hicken’s summary, a searing indictment of the maltreatment of blacks in the U.S. has recently been published—‘‘Between the World and Me’’ by TaNehisi Coates (2015, Spiegel and Grau, publishers). Although sometimes seemingly emotionally overwrought Mr. Coates strikingly portrays the fears, anxieties, and heightened constant stress that most U.S. blacks endure. Manifestations of such high levels of stress have long
1933-1711/$ - see front matter http://dx.doi.org/10.1016/j.jash.2015.08.014
been recognized to be associated with hypertension (Julius S, et al. J Hypertens. 1991; 9:77). As noted, when the stresses of segregation are eliminated, the racial inequalities of hypertension are also eliminated (Morenoff JD, et al. Soc Sci Med. 2007; 65:1853).
Lesser Protection From Therapy Beyond the environmental inequities, blacks achieve lesser protection from cardiovascular diseases when treated with drugs that reduce the activity of the renin-angiotensin system (RAS). In a cohort study of more than 430,000 patients, those blacks treated with angiotensin converting enzyme inhibitors had 45% more cardiovascular morbidity and mortality than did those treated with calcium-channel blockers and 65% more than those treated with thiazide diuretics (Bangalore S et al. Am J Med. E published ahead of formal publication on 6/10/2015). Such lesser protection is likely related to the usually lesser activity of the RAS in blacks, in turn related to a number of environmental factors, for example, lower birth weight with fewer renal nephrons, and possibly genetic mechanisms. Improved socioeconomic status might also improve blacks’ responsiveness to RAS blockers, but that has not been tested. The prevention and improved control of hypertension are yet other reasons to correct the current maltreatment of blacks in the U.S. Norman M. Kaplan, MD Clinical Professor of Medicine U.Texas Southwestern Medical School, Dallas TX, USA [email protected]
-(-)
(2015) 1
Hypertension Highlight HYPERTENSION IN BLACKS: A DOUBLE DISADVANTAGE Blacks in the U.S. have a higher prevalence of hypertension and suffer more hypertension-related morbidity and mortality, particularly from chronic renal disease than do nonblacks. The reasons for these racial disparities are largely environmental, as described by Margaret Hicken (Am J Epidemiology 2015, printed online before formal publication on July 21. Dr Hicken states:l). ‘‘Segregation is thought to be an important mechanism by which racial inequalities in health are produced and maintained through differential access to economic opportunities, differential access to health-related resources (eg, pharmacies and hospitals), increased psychosocial stress, and greater exposure to environmental hazards (eg, hazardous waste and air pollution)...Indeed, after accounting for neighborhood environment, researchers reported no racial inequalities in hypertension’’ (Morenoff JD, et al. Soc Sci Med. 2007; 65:1853). [At least one genetic mechanism is also involved in the much higher prevalence of chronic renal disease among blacks who originate from South or West Africa: a missense mutation in the APOL1 gene (Skoreck KL and Wasser WG. Kidney Int. 2013; 83:6)]. In keeping with Dr. Hicken’s summary, a searing indictment of the maltreatment of blacks in the U.S. has recently been published—‘‘Between the World and Me’’ by TaNehisi Coates (2015, Spiegel and Grau, publishers). Although sometimes seemingly emotionally overwrought Mr. Coates strikingly portrays the fears, anxieties, and heightened constant stress that most U.S. blacks endure. Manifestations of such high levels of stress have long
1933-1711/$ - see front matter http://dx.doi.org/10.1016/j.jash.2015.08.014
been recognized to be associated with hypertension (Julius S, et al. J Hypertens. 1991; 9:77). As noted, when the stresses of segregation are eliminated, the racial inequalities of hypertension are also eliminated (Morenoff JD, et al. Soc Sci Med. 2007; 65:1853).
Lesser Protection From Therapy Beyond the environmental inequities, blacks achieve lesser protection from cardiovascular diseases when treated with drugs that reduce the activity of the renin-angiotensin system (RAS). In a cohort study of more than 430,000 patients, those blacks treated with angiotensin converting enzyme inhibitors had 45% more cardiovascular morbidity and mortality than did those treated with calcium-channel blockers and 65% more than those treated with thiazide diuretics (Bangalore S et al. Am J Med. E published ahead of formal publication on 6/10/2015). Such lesser protection is likely related to the usually lesser activity of the RAS in blacks, in turn related to a number of environmental factors, for example, lower birth weight with fewer renal nephrons, and possibly genetic mechanisms. Improved socioeconomic status might also improve blacks’ responsiveness to RAS blockers, but that has not been tested. The prevention and improved control of hypertension are yet other reasons to correct the current maltreatment of blacks in the U.S. Norman M. Kaplan, MD Clinical Professor of Medicine U.Texas Southwestern Medical School, Dallas TX, USA [email protected]