Recommendations for the management of special populations: racial and ethnic populations

One of the current challenges in the treatment of hypertension is the variation in the incidence and morbidity among ethnic populations. For example, in the recent Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), in which 35% of the patients were African American, the diuretic chlorthalidone was associated with greater reductions in blood pressure (BP) than the angiotensin-converting enzyme (ACE) inhibitor lisinopril and was also associated with a relative risk reduction in stroke compared with lisinopril. However, the increased stroke risk associated with lisinopril was experienced among African American but not non-African American patients. ALLHAT did not permit combination therapy with ACE inhibitors plus diuretics; therefore, the benefits of such regimens in this patient population could not be assessed. In the Losartan Intervention For Endpoint reduction in hypertension (LIFE) study, in contrast to the overall study population, African American patients with left ventricular hypertrophy treated with atenolol were at lower risk of experiencing the primary composite end point (death, myocardial infarction, and stroke) than African Americans treated with losartan, with or without diuretics. On the other hand, in the African American Study of Kidney Disease and Hypertension, African American patients treated with the ACE inhibitor ramipril had a significantly lower incidence of the primary composite end point (glomerular filtration rate reduction, end-stage renal disease, or death) than African Americans treated with the calcium channel blocker amlodipine. Although the use of diuretics in African American patients may be a logical first-line choice for BP reduction, most patients will require combination therapy. African American patients with systolic BP > or =15 mm Hg above target level or a diastolic BP > or =10 mm Hg above target should be considered for first-line combination therapy. Although certain combinations have been shown to be effective in non-African American patients, the choice of drugs for combination therapy in African American patients may be different.