Acknowledgment

This activity is supported by a grant from Daiichi-Sankyo, Inc. , Parsippany, New Jersey.

Disclosures

Dr. Friedewald has received honoraria for speaking from Novartis, East Hanover, New Jersey. Dr. Friedewald is a consultant for NiCox, Warren, New Jersey; and AstraZeneca, Wilmington, Delaware. Dr. Nesbitt has received honoraria for speaking from Novartis; Daichii-Sankyo, Parsippany, New Jersey; Boehringer-Ingelheim, Ridgefield, Connecticut; Forest Laboratories, New York, New York; and Sanofi-Aventis, Bridgewater, New Jersey. Dr. Nesbitt has received honoraria for consulting from Novartis and Daiichi-Sankyo. Dr. Ram has received honoraria for consulting from Daichii-Sankyo; Forest Laboratories; and GlaxoSmithKline, Triangle Park, North Carolina. Dr. Ram is a member of the advisory board of Pfizer, New York, New York. Dr. Roberts has received honoraria for speaking from Merck, Whitehouse Station, New Jersey; and AstraZeneca.

Disclosures

Dr. Friedewald has received honoraria for speaking from Novartis, East Hanover, New Jersey. Dr. Friedewald is a consultant for NiCox, Warren, New Jersey; and AstraZeneca, Wilmington, Delaware. Dr. Nesbitt has received honoraria for speaking from Novartis; Daichii-Sankyo, Parsippany, New Jersey; Boehringer-Ingelheim, Ridgefield, Connecticut; Forest Laboratories, New York, New York; and Sanofi-Aventis, Bridgewater, New Jersey. Dr. Nesbitt has received honoraria for consulting from Novartis and Daiichi-Sankyo. Dr. Ram has received honoraria for consulting from Daichii-Sankyo; Forest Laboratories; and GlaxoSmithKline, Triangle Park, North Carolina. Dr. Ram is a member of the advisory board of Pfizer, New York, New York. Dr. Roberts has received honoraria for speaking from Merck, Whitehouse Station, New Jersey; and AstraZeneca.

Introduction

African-Americans are more seriously affected by cardiovascular (CV) disease (CVD) than the overall population in the United States. In 2006, the death rates (per 100,000 persons) from CVD were 433 among African American men and 298 among African American women, compared to 262 for the overall United States population. The most important reason for the increased incidence of CVD in African Americans is a high prevalence of CVD risk factors, particularly hypertension. The high prevalence of hypertension in individuals of African ethnicity is not confined to the United States, affecting >40% of all non-Hispanic blacks globally.

Dr. Friedewald: What is the prevalence of hypertension among African-Americans?

Dr. Nesbitt: According to the most recent NHANES (National Health and Nutrition Examination Survey) survey in 2005 to 2006, the prevalence of hypertension in African Americans is 39.1%, which is well above the 28.5% prevalence in non-Hispanic whites and the 28% figure for the entire population. African Americans continue to have a high CVD prevalence despite improved access to care and better treatment modalities. The rates also continue to be very high in young African Americans. Among African American men aged 18 to 21 years—the youngest group studied for prevalence in NHANES—the hypertension prevalence is 10%, far higher than in other demographic groups, where the prevalence rates are 1% to 2%. Although there is little prevalence data for hypertension in children, 1 analysis found that the prevalence of hypertension and prehypertension among adolescents was 24.5% for African Americans and 17.5% for European Americans. Thus, hypertension occurs earlier for African Americans than it does for other ethnic populations. There are no good data for prevalence in Hispanic adolescents.

Dr. Friedewald: How is hypertension defined in NHANES?

Dr. Nesbitt: In the NHANES database, hypertension is defined as a systemic pressure >140 and/or a diastolic pressure >90 mm Hg, the same as all for all current prevalence data. In children and adolescents in other data sets, it is defined as the 95th percentile for height, gender, and age, which is complicated because such measurement standards change as children grow faster, bigger, and with higher prevalence of obesity. Thus, the question whether 140/90 mm Hg is the right number for African Americans needs to be answered, as we may want to redefine hypertension to an even lower number in this population because we see complications of that blood pressure (BP) level is much higher compared to other populations.

Dr. Friedewald: If you were to redefine the criteria for hypertension in African Americans, what would it be?

Dr. Nesbitt: The answer is difficult, because African American must first be defined. At this time, it is a self-definition (“How do you see yourself?”) rather than a true genetic determination. As much as 90% and as little as 2% of the genetic variations derive from an African origin, so this is a complex question that should be taken into account when the question arises.

Dr. Ram: The genetics also vary according to different areas of Africa in which people originate.

Dr. Friedewald: Dr. Nesbitt, what complications of elevated BP are greater in African Americans?

Dr. Nesbitt: For every level of blood pressure, the rate of stroke, kidney failure, and heart failure is higher for African Americans than for other groups.

Dr. Friedewald: Dr. Roberts, is there more coronary atherosclerosis at necropsy in young African Americans compared to other populations?

Dr. Roberts: I do not know if that has been studied. The coronary arteries are a little bigger in hypertensive persons than in normotensive people, and the size of the coronary arteries is proportional to myocardial mass. Thus, a greater quantity of atherosclerotic plaque is needed to cause an acute coronary event in hypertensive patients, who have larger coronary arteries, than would be necessary in normotensive patients.

Dr. Ram: A therosclerosis is particularly aggressive among African American youth. The high degree of morbidity and mortality at the same level of BP among adult African Americans is probably due to a longer duration of hypertension. African Americans tend to have a longer duration of exposure to the hemodynamic stresses of elevated BP, so when a plateau of BP is reached that is comparable to non–African Americans, the BP at that cross-sectional point may not be truly indicative of the underlying disease process. It is the duration of hypertension that appears to be killing African Americans at much higher rates than European Americans. Prevalence is a complex statistic because it depends both on disease incidence and duration , and something unleashes CV disease early in the lives of many African Americans, unlike other populations, and increased BP is 1 of the reasons. I strongly believe that the current target treatment BP is too high in African Americans and that it should be the same as in patients with chronic kidney disease, diabetes mellitus, and coronary artery disease. The treatment must be much more aggressive than achieving a goal of ≤140/90 mm Hg. Rather, a BP of ≤130/80 mm Hg is real hypertension that should be treated . Many people in clinical practice have the unfortunate and tragic perception that if the systolic BP is even close to 140 mm Hg, or even a few millimeters higher, the high pressure is tolerated, but unfortunately, patients’ organs do not tolerate such levels in the long run.

Dr. Roberts: How do lipid levels of African Americans compare to European Americans?

Dr. Nesbitt: Serum total cholesterol levels tend to be lower, and high-density lipoprotein cholesterol levels and serum triglyceride levels tend to be slightly higher in African Americans than in European Americans in all age groups.

Dr. Friedewald: What is known about BP levels in native Africans?

Dr. Nesbitt: Richard Cooper studied populations of urban and rural-dwelling Africans, Africans residing in the Caribbean, and in Africans who migrated to the United States. He found that rural Africans had BPs that were within the range we regard as normal. Africans who lived in African urban environments, however, had BPs comparable to African Americans living in the USA. Those who lived in the Caribbean had even higher BPs than African Americans in the USA. These differences appear to be due in part to an environmental effect, with a westernized environment having an elevating effect on BP. Cooper’s data among native Africans have been duplicated by other investigators who have suggested that their lower BP was likely due to exercise: the rural residents are more likely to walk than to ride. Rural Africans also have a diet higher in potassium and lower in sodium than urban Africans.

Dr. Roberts: Plant-derived foods are produced and eaten locally in rural areas, whereas animal-based foods are more often eaten in urban areas.

Dr. Nesbitt: That is correct.

Dr. Ram: Cooper also studied the Zulu population, who live in Natal, and found a significant BP difference between rural Zulus and urban Zulus, who are genetically almost the same population, one of the purest genetic populations that can be studied, due to inbreeding. Thus, the only thing that differs when people move to urban areas is that they encounter new environmental factors that turn on the “switch” of hypertension. Our traditional thinking about rural areas is changing rapidly, however, as even persons remaining in rural areas are developing urban uses of technology that require less physical effort. Thus, although they may remain rural in terms of physical location, they are becoming very urban in terms of behavior. I fear that these rural-urban differences will merge unfavorably due to the rapid development in areas that previously provided natural protection.

Dr. Nesbitt: That is an unfortunate side effect of “progress.”

Dr. Friedewald: What is known about hypertension prevalence in rural compared to urban African Americans?

Dr. Nesbitt: I am not aware of any specific studies that have compared rural with urban African Americans.

Dr. Ram: NHANES has not addressed this question.

Dr. Friedewald: Should “hypertension” and “prehypertension” be redefined in African Americans?

Dr. Nesbitt: I do not like the term “prehypertension.” Rather, we should view BP as a continuum in which there are no absolute separations between “normal,” “toxic,” or “elevated” blood pressures. Both caregivers and patients need to be aware of this approach to BP control. The way BP is currently classified presents problems for all populations, not just African Americans. There is a big difference in outcomes between persons with “prehypertensive” systolic pressures of 120 to 130 mm Hg and those with systolic pressures of 130 to 139 mm Hg over a period of only 4 years. Although studies have not addressed this issue, I believe there is >10- to 15-year difference in the onset of target organ disease between those 2 groups. Thus, we need to either (1) change our initiating treatment threshold down, from 140 mm Hg systolic to 130 mm Hg systolic as well as treat people at higher risk to lower levels of BP, a group that includes African Americans, or (2) break out populations into smaller increments for treatment indications, something considered but not implemented in past hypertension guidelines.

Dr. Friedewald: When do you recommend first measuring BP in African Americans?

Dr. Nesbitt: I think that we should start measuring the BP in children by age 6 to 7 years, particularly children who have family members with hypertension.

Dr. Friedewald: Is BP measured when children begin school?

Dr. Ram: In Dallas, the BP is simply “checked”; no number is recorded, but it should be. Only immunizations and allergies are specified.

Dr. Nesbitt: A great problem among pediatric patients is taking into consideration the weight and height to correctly determine when BP is truly elevated, especially with the increasing prevalence of childhood obesity.

Dr. Friedewald: Many physicians appear reluctant to treat younger people with antihypertensive medications, even when hypertension is definite.

Dr. Nesbitt: I believe that is true for at least 2 reasons. Until only a few years ago, most of our hypertensive medications were not tested in pediatric populations. The Food and Drug Administration only recently required that drug companies test newer drugs in pediatric patients. Thus, many physicians are not comfortable using antihypertensive drugs in that population, particularly the newer drugs. Another reason is that hypertension is regarded primarily as an adult disease whose complications relate to the heart, kidney, and the brain, organs that are seldom problem areas in children. The most common problem in children with hypertension is kidney disease, so if kidney disease is absent, elevated BP is often not a concern to the physician, who tends to “watch it” and advise the child’s parents to wait for the child to reach adulthood before taking steps to control the BP. Another issue is that there are more and more children prescribed methylphenidate and other stimulant drugs, which elevate the blood pressure, for behavioral disorders. Thus, pediatricians are seeing more drug-induced elevated BPs, which they also do not treat. The rapidly growing problem of obesity and diabetes mellitus in children also is associated with hypertension, which raises another area of neglect.

Dr. Ram: Our treatment inertia for elevated BP is amazing. For example, even in the schools, tobacco use is taken seriously, but elevated BP is relegated to a simple phenomenon of aging. Diabetes mellitus also is taken more seriously. Unless we sensitize the public about hypertension, such as the way we did for smoking in the 1960s and early 1970s with the surgeon general’s warning on packs of cigarettes, we will be talking about this for a long time. There is always an excuse not to treat hypertension, and Dr. Nesbitt gave a classic example when she suggested that physicians who prescribe methylphenidate or other drugs that elevate the BP are excused for not treating hypertension. Hypertension is an “equal-opportunity killer” that does not forgive the source from which the BP increases. This is a very dangerous philosophy. I see many patients who are on corticosteroids and other blood pressure–elevating drugs but not receiving treatment for hypertension because they are told it is caused by these other drugs. Hypertension is hypertension, and hypertension begets hypertension, so whatever the cause is, and regardless whether it is transient or permanent, high BP should not be allowed to persist. There is always an excuse not to treat, and there is always an excuse to delay unless there is some kind of a mandate to do otherwise. I hate to call for more regulation, but unless there is some kind of a bureaucratic regulation, as in northern Scandinavian countries, we will continue to neglect hypertension.

Dr. Friedewald: At what age does hypertensive secondary nephropathy first become clinically manifest in African Americans who develop hypertension at a young age?

Dr. Ram: The natural course of renal dysfunction among African Americans has not been determined. African American patients with chronic hypertension often have detectable renal dysfunction—glomerular filtration rate of 55 to 60 ml/min and serum creatinine of 1.5 mg/dl—before age 30 years. Thus, renal insufficiency starts early, and there are many African American patients only 30 to 40 years of age. Renal nephropathy in African Americans is a devastating disease.

Dr. Friedewald: Dr. Ram, do you believe that regardless of age, when hypertension is first diagnosed, treatment should be started at that time?

Dr. Ram: Yes. The need to treat and the general pharmacologic and nonpharmacological approaches to hypertension treatment are the same regardless of age, unless a secondary form of hypertension is present, which is not part of this discussion. The most important point is that treatment should not be delayed because, for some mistaken reason, the physician believes that it is going to go away as the patient gets older. That does not happen. A study performed many years ago of African American medical students found that 30% of them were diagnosed with hypertension by age 40 years, and most of them had increased BP while in medical school. Thus, if an educated group such as physicians is detected with hypertension but not treated, we can assume that this gross undertreatment is commonplace among persons who have much less access to care than physicians themselves!

Dr. Friedewald: Let’s discuss treatment, starting with the lifestyle. Are the lifestyle recommendations, such as the DASH (Dietary Approaches to Stop Hypertension) diet for the overall population for patients with hypertension the same for African Americans?

Dr. Nesbitt: I recommend the DASH diet to everybody, but we need to be honest about to what expect in the real world. If all persons with hypertension consumed foods prepared every day according to DASH, BPs would decline significantly. Furthermore, in African Americans an even more robust reduction in blood pressure would occur, because the typical African American diet does not contain a significant amount of potassium or fiber, and the DASH diet is largely made up of low-sodium, high-fiber, and potassium-containing foods. In the real world, such as was shown in the PREMIER study, in which people had to follow such a diet on their own, the same level of BP reduction could not be achieved as with the DASH diet. Thus, while DASH adherents experience BP reduction, DASH followers are not representative of “the real world.”

Dr. Friedewald: Why does DASH not work in “the real world”?

Dr. Nesbitt: African American communities, where hypertension is truly rampant, are “deserts” for fresh food. For example, in South Dallas, a largely African American community, there is only one grocery store selling fresh fruits and vegetables, the mainstays of the DASH diet. There are many similar communities throughout the USA. Fresh food also is more expensive. Thus, use of the DASH diet and other diets that are also effective in reducing the BP are of limited use by a social situation that must be fixed first. Exercise also works just as well for African Americans as for other populations, and may even work better, in helping lower the BP.

Dr. Friedewald: In view of these limitations, what practical advice about lifestyle do you give African American patients with hypertension?

Dr. Nesbitt: I advise African Americans based on what they typically eat, like canned vegetables. Canned green beans are served a lot; it is a dish commonly served at African American church meals. For example, I tell them that merely pouring off the water from the can does not get rid of the salt, which has already been absorbed into the vegetables. Thus, they should use either fresh or frozen green beans. Other examples of popular, high-salt foods among African Americans are hot dogs and other preserved meats. They also need to know that not using the salt shaker is important but, by itself, is inadequate to avoid high salt intake.

Dr. Friedewald: Your advice about exercise?

Dr. Nesbitt: Many African Americans live in communities without access to health clubs, and in many communities the residents do not feel safe walking outside. For such persons, we provide ideas about how to utilize what is available to them, like walking inside their own homes and using stairs when possible.

Dr. Ram: African Americans, like most Americans, eat a lot of fast food, which is usually loaded with salt. There is a popular “double cheeseburger” that contains 2,300 mg of sodium. It would take a diuretic infusion to correct that amount of salt intake! Research on fast food sodium intake, however, is not being conducted, which is a sad commentary about the state of public health research in the USA. The amount of so-called convenience foods has increased tremendously in the past 2 years due to the recession, and we can only hope that this trend reverses after our economy recovers. As Dr. Nesbitt said, the DASH diet is difficult to routinely follow. The DASH trial itself was performed by transporting patients to facilities specializing in such food preparation, or the DASH-compliant food was transported to them. The DASH trial provided, however, excellent proof of the concept that moderation of salt intake lowers the BP, in African Americans by almost 7 mm systolic pressure, which is highly significant. This was a study of dietary feeding , not dietary instruction . According to the PREMIER study, when the DASH diet was simply recommended (“This is the DASH diet, for you to follow”), a reflection of the “real world,” the results were disappointing.

Dr. Friedewald: DASH content is high in potassium, low in sodium, and high in fiber. What is the effect of dietary fiber on the BP?

Dr. Ram: This has not been studied, because such a study would be difficult, given that the contents of fiber are so heterogenous. Fiber and fruit, which is high in potassium, are commonly together in food. The BP effect of fiber in isolation, if any, is unknown.

Dr. Roberts: Rural Africans were studied after World War II and were found to have very fast transit times from initial oral intake through the intestinal tract. It is possible that the faster the transit time, the lower the BP. This also lowers the serum lipoproteins.

Dr. Friedewald: There may be significant ethnic differences in patient adherence to lifestyle recommendations. A recent study related to such differences in BP stated, “Among persons advised to follow exercise, alcohol restriction, smoking cessation, tension reduction, or diet modification, non-Hispanic blacks and Mexican Americans were more likely than Caucasians to report adherence.” Thus, it is important to emphasize that diet and exercise are no less important to discuss with African Americans than members of other ethnic groups. Even with better adherence, however, hypertension is still more prevalent among African Americans.

Dr. Ram: This is an important reason to improve access to health care by African Americans, because they are so compliant with recommendations, and need to follow both lifestyle and pharmacologic strategies for successful treatment of hypertension.

Dr. Roberts: Although canned foods are generally high in salt, canned foods can be obtained that are low in salt, especially in food stores that specialize in the use of natural ingredients.

Dr. Friedewald: What about pharmacologic treatment of hypertension in African Americans?

Dr. Nesbitt: Let’s start with the issue of mono antihypertensive agents, which rarely work in either African Americans or in the general population. Thus, an important question is, Which antihypertensive drug combination is best for individual patients compared to patient groups ? In actual practice, we treat individual patients, not patient groups, so what science tells us is best for various populations is only a starting point for when prescribing for individual patients. Further, populations are not only defined by ethnicity, but also by specific diseases or disease combinations, such as patients with diabetes mellitus, kidney disease, and the metabolic syndrome.

Renin-aldosterone-angiotensin system (RAAS) blockers are particularly protective of the kidneys, especially in patients with diabetes mellitus, so they are a first choice in patients with renal disease. Whether a patient is African American does not affect their use. However, calcium channel blockers and diuretics may provide better BP reduction in African Americans, independent of their renal protection, shown in studies such as ALLHAT (Antihypertensive Lipid-Lowering Treatment to Prevent Heart Attack Trial).

Combination trials like ACCOMPLISH (Avoiding Cardiovascular Events in Combination Therapy in Patients Living With Systolic Hypertension) show that the combination of a calcium channel blocker with a RAAS blocker is better than a RAAS blocker with a diuretic in terms of overall mortality and BP reduction. My approach is to look at treatment based on the initial presentation, and then add ethnicity as an additional factor.

Dr. Ram: RAAS inhibitors are effective but may require higher than usual doses in African Americans. I find it impossible to control hypertension in African American patients without also prescribing a diuretic in any multiple drug regimen. The only exceptions to using diuretics in African Americans are drug allergy—and allergy to diuretics is rare—and in patients who are volume depleted. I also believe that regardless of how the target BP is reached, that it be attained within 6 months from the time of diagnosis.

Dr. Friedewald: Is not the issue of whether multiple drugs are required a function of the baseline BP? Perhaps we are not starting treatment until the BP is too high. If a systolic BP of 130 mm Hg were set as the trigger for beginning treatment, single drug therapy might suffice in many persons.

Dr. Ram: That is possible. In many such patients, the BP would go down immediately. There is, however, some kind of an escape phenomenon, although we do not recognize a true pharmacological tachyphylaxis to antihypertensive drugs but rather a type of “clinical tachyphylaxis.” With age and also with added body weight, the BP tends to go up to the same level as before treatment. In the ALLHAT study, which is the largest prospective therapeutic trial in hypertension, the percentage of patients who responded to initial monotherapy was very high, but as the patients were followed up to 40 years, the patients who required multiple drugs to maintain the same level of BP reciprocally increased. In other words, to keep the same level of BP attained with a single drug required other drugs to be added to avoid a resurgence or escape of hypertension. Thus, patients on monotherapy need to be followed carefully. In addition, I am sure there is a pharmacogenomic coding that some antihypertensive drugs might have greater efficacy due to the genomic background. For example, for diuretics, there is a genetic basis by which African Americans might respond particularly well to diuretics involving a polymorphism of one of the gene alleles called C825T, which encodes the G protein into the kidney, where they may be more responsive to diuretics. I believe pharmacogenetics will be the next frontier that will provide the ability to select optimal drug therapy based upon patients’ genomic profiles.

Dr. Roberts: For the patient with a systolic pressure >160 mm Hg at the time of initial diagnosis, guidelines recommend starting treatment with 2 drugs. Does the same multidrug approach also apply to some patient groups, such as African Americans, when the systolic BP is elevated but <160 mm Hg?

Dr. Nesbitt: Yes, African Americans patients in the 150 to 160 range should start with dual therapy. We should be more aggressively managing African Americans, because their risk is similar to the general population with diabetes mellitus and chronic kidney disease than it is to the overall general population.

Dr. Friedewald: What is your target blood pressure when you begin treatment?

Dr. Ram: Until new guidelines state otherwise, the treatment goal for uncomplicated hypertension is <140/90 mm Hg. For patients with chronic kidney disease, proteinuria, coronary artery disease, and diabetes mellitus, the goal is <130/80 mm Hg. I would like to see African American ethnicity added to this treatment goal of <130/80 mm Hg.

Dr. Roberts: Let us assume you have a 50-year-old African American patient with a blood pressure of 150/80 mm Hg and no evidence of renal disease or diabetes mellitus. What antihypertensive combination do you start with?

Dr. Ram: A suitable combination is a diuretic and a calcium channel blocker, but there is no fixed-dose combination of a calcium channel blockers with a diuretic. If you prefer to prescribe a fixed-dose combination, you can start with an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB) plus a diuretic. Or you could prescribe a calcium channel blocker and a diuretic separately.

Dr. Roberts: If medication costs were not a consideration, what combination would you start with?

Dr. Nesbitt: Based on the ACCOMPLISH trial, a RAAS blocker plus a calcium channel blocker would be my first choice, because mortality outcome is better than with diuretics. There are, however, reasons that a diuretic plus a RAAS blocker is also a reasonable choice, so there is not an absolute answer to the best starting combination. Either a calcium channel blocker plus a diuretic or a RAAS blocker plus a diuretic is acceptable, although I generally prefer the RAAS blocker because of its protective effect on the vasculature and the kidney over the long term.

Dr. Ram: Even if you choose a RAAS blocker plus calcium channel blocker as the initial choice, many patients still require a third agent at some point, which should be a diuretic.

Dr. Nesbitt: I agree.

Dr. Friedewald: Another reason for being aggressive at the outset of treatment involves medication adherence, which is enhanced when the patient sees fast results. Thus, a multiple drug combination at the outset will cause a quicker significant fall in the BP, increasing the likelihood of at least short term adherence.

Dr. Roberts: The same principle is true for lipid-modifying drugs.

Dr. Ram: Self-monitoring, immediate feedback also helps drug treatment adherence, which is excellent in patients with diabetes mellitus when using glycated hemoglobin for self-monitoring. Unfortunately, BP is not nearly as accurate because it is so unstable under varying times and conditions.

Dr. Friedewald: What is the role of self-monitoring of BP at home in your approach to treating hypertension?

Dr. Nesbitt: I am a fan of teaching patients how to do take their own BP for at least a couple of reasons: first, patients are much more adherent when they are active participants in their own care. When they understand more about BP, they are more aware of how they feel and how the medication actually affects their BP. If the office BP is their only indicator of how they are doing, they are disconnected completely and their hypertension is more the doctor’s problem than their own problem. When they take their own BP, however, they get a sense for how much variation there is in BP and what happens to the BP under various circumstances, such as eating high-salt-containing foods. This has a positive effect on their behavior, especially as it relates to diet and medication adherence. I tell patients to get a BP monitor, including recommended brands, and I show them how to measure the BP in my office. I ask them to bring their monitors with them so that we can compare their readings with the office readings. We also have electronic charting for them to transmit their blood pressures to us, so it is a very active involvement for them.

Second, patients’ taking their own BP helps address the problem of “white coat hypertension.” Many patients believe that their BP is lower at home than it is in the office, when it actually is not. The prevalence of white coat hypertension is around 15% to 20%. When home BP self-monitoring does not suffice for attaining adequate control, we use 24-hour ambulatory BP monitoring.

Dr. Roberts: What BP monitor for home use do you recommend?

Dr. Nesbitt: I recommend the Omron devices. There is also a wrist device, but patients must be carefully instructed how to use the wrist device, such as using it at heart level.

Dr. Roberts: Wrist devices are not nearly as accurate as the others, correct?

Dr. Nesbitt: They are not as accurate, so we prefer that patients use the arm devices. Some persons, however, such as for surgical reasons and persons with very obese upper arms, cannot use an arm device. Such persons really need a thigh cuff, but they are not commercially available.

Dr. Ram: Wrist devices have not been properly studied, and the radial artery often cannot be compressed to the same degree as the brachial artery.

Dr. Friedewald: Does your approach to the use of initial medications differ in patients with diabetes mellitus, obesity, or metabolic syndrome?

Dr. Nesbitt: In diabetes, at least 1 of the antihypertensive agents should be a RAAS blocker, just as in patients with chronic kidney disease. RAAS blockade is not necessarily part of the regimens for other patients. In patients with metabolic syndrome, a diuretic may not be a first choice because of its effects on glucose metabolism. Even though they may not be a first choice, however, many patients still may need them to gain optimal BP control as part of a multidrug regimen.

Dr. Ram: A paradox of all the guidelines is that when complications occur, these preferred choices really do not mean as much. Further, especially among African Americans, a single complication seldom persists. Rather, coexisting complications—hypertension, diabetes mellitus, chronic kidney disease—become more prevalent with aging. The role of RAAS blockers in African American patients has been nicely substantiated by the AASK (African American Study of Kidney Disease) study in black patients without diabetes mellitus, only hypertension and atherosclerosis, who received an ACE inhibitor, with less progression of renal disease compared to patients who received β blockers. Ethnicity itself, however, should not point to a particular drug class.

Dr. Friedewald: How so you treat the hypertensive patient with obesity but without diabetes?

Dr. Ram: That is probably the most common clinical problem among all races and both genders. They are often individuals in their 40s who have gained a lot of weight. They should be encouraged to lose it. However, weight loss is seldom sustained. These are the same individuals who often develop the metabolic syndrome. There is activation of the sympathetic nervous system in obesity, which probably relates to the elevated BP. Thus, the obese patient with hypertension, from a pathophysiological point of view, might benefit from blockade of the sympathetic nervous system, although that does not appear to be easily achievable in practice. It is not known whether weight gain or sympathetic activation comes first. Another factor promoting hypertension in obese patients is obstructive sleep apnea, which is common in these patients. No treatment, however, is better than weight loss itself. When obese individuals are able to lose weight, and keep it off, the BP is also measurable with greater accuracy.

Dr. Roberts: For weight control, I like to recommend the drug orlistat, which acts by increasing bowel transit time and reduces fat absorption by 30%. This is a neglected but useful agent for maintaining weight.

Dr. Friedewald: What dose do you recommend?

Dr. Roberts: Over the counter, it is available at 60 mg. I recommend 120 mg/day. In the original studies with orlistat, the dose recommended was 120 mg with each meal. That regime in my view is impossible to follow. I recommend 60 mg during each of 2 daily meals, or 120 mg with 1 daily meal.

Dr. Friedewald: What is the normal bowel transit time?

Dr. Roberts: The transit time of the average American adult is about 48 hours. The average transit time of rural Africans is about 18 hours.

Dr. Friedewald: What is the role of lipid-modifying drugs in African American hypertensive patients?

Dr. Ram: Hypertension and dyslipidemia often coexist, and both conditions should be aggressively treated in African Americans, no differently from other ethnic groups.

Dr. Roberts: Both of you mentioned RAAS inhibitors. Where does aliskiren, the direct renin inhibitor, fit into your treatment schemes?

Dr. Nesbitt: We do not yet have mortality data available on direct renin inhibition. So far, tolerability and BP reduction is similar to that of ARBs. Angioedema occurs the same or perhaps a little less often than with ARBs. In terms of proteinuria and left ventricular mass, the direct renin inhibitor appears to augment the effects of ARBs and ACE inhibitors. I have not seen data that are specific for the African American population, so I do not know whether it offers an advantage. I do not believe that we should limit use of direct renin inhibitors in African Americans because their renin levels are slightly low, similar to use of ACE inhibitors and ARBs. Thus, it appears that aliskiren is similar to the other 2 RAAS categories, although with a little less BP reduction. I have used it in my African American patients with success.

Dr. Ram: The efficacy of a direct renin inhibitor is the same as with ACE inhibitors and ARBs. The difference is mechanistic, raising the question of whether renin inhibition is the same, better, or worse whether upstream or downstream. There are no major outcome trials to date that address this question.

Dr. Nesbitt: One possible role for direct renin inhibition is when cough and angioedema due to either an ACE (or, less commonly, an ARB) develops in a patient with proteinuria, in whom maximum RAAS inhibition is indicated. Because both cough and angioedema are more common in African Americans, the direct renin inhibitor may be better tolerated than an ACE inhibitor and can be used in combination with an ARB.

Dr. Friedewald: Do you have any comments you would like to make about other ethnic groups in regard to hypertension?

Dr. Ram: People of Asian descent are at a very high risk of premature CV disease. The average age of first clinical acute myocardial infarction in south Asians is about 10 years earlier than in Caucasian counterparts, with all confounding variables taken into account. Thus, the image that Asians may have inherent CV protection is no longer true, perhaps due to urbanization, similar to observations in African Americans. The World Health Organization is very much concerned about an epidemic of CV disease in Asia as well as in Asians who have migrated to other countries. This could have a large, global effect. There is now a lot of interest in Asian countries to control CV risk factors such as hypertension, particularly as part of the metabolic syndrome due to increasing prevalence of obesity. Among Asians, the body mass index can be very misleading compared to other populations. Waist circumference might be a better indicator. Waist circumference is less obvious among many Asians because they often wear saris, which are draped, which masks waist size.

Dr. Friedewald: What about Hispanics?

Dr. Ram: Hispanics are another large and growing segment of our population with a high prevalence of the metabolic syndrome and diabetes mellitus. The prevalence of hypertension is between that of European Americans and African Americans. Diabetic vascular disease, however, is very high in Mexican Americans, so there are a lot of additional issues that we must contend with in this population. Many Mexican Americans, for example, eventually require renal dialysis.

Dr. Friedewald: We need more research into ethnic specificity with respect to hypertension.

Dr. Ram: I agree.

Dr. Nesbitt: Definitely.

Dr. Friedewald: Are there any other areas of research that need to be addressed?

Dr. Nesbitt: We need a better understanding of health care delivery and how we can better utilize what we currently have available. Studies like ACCOMPLISH help in many different ways. All of the data from ACCOMPLISH has not yet been collected, but we should study how we can better use the data for specific patient groups. Rather than the competition of “which one is better,” which combinations are optimal to specific demographic patient profiles would be more helpful to clinicians and their patients. We also need much more information about how to improve patient compliance, both in terms of lifestyle and medications.

Dr. Friedewald: Who is responsible for making patients more compliant? Physicians themselves do not get reimbursed well, or sometimes at all, for their efforts to enhance patient compliance.

Dr. Nesbitt: Our biggest mistake is to make this only the physician’s responsibility. Rather, this is a health care system responsibility. Physicians cannot do it all. They need partners to improve patient adherence, such as in our offices. We need partners within health care plans, such as dietitians and exercise physiologists, as well as from society and employers for assistance at home and in the work environment. Support in all arenas possible is what physicians need to improve lifestyle and medication compliance, not just for hypertension but for better control of all CV risk factors. We can provide advice for our patients, but there has to be these additional layers of support beyond what we provide in the office.

Dr. Roberts: If every American could lose 10 to 20 pounds, our health would skyrocket. That is the kind of marketing that is needed to encourage everyone to grab control of their own health. The medical profession alone cannot do it all.

Dr. Friedewald: Thank you.