Cardiovascular Disease in African Americans

SUPP. 1 VOL. VI NO. IV APRIL 2004 54 Cardiovascular disease (CVD) in African Americans remains a clinical problem that requires investigation. This supplement to The Journal of Clinical Hypertension presents a comprehensive summary of the hypotheses, dilemmas, data, and problems that confound our ability to adequately address the cardiovascular health needs of African-American patients. The increase in CVD in African Americans has traditionally been attributed to the high prevalence of hypertension. The group of authors presented here embraces this observation as one of paramount importance. However, newer perspectives, primarily from the field of genomic medicine, have emerged that also appear to be important if we are to fully understand the burden of CVD in this population. Given the number of described polymorphisms in the renin-angiotensin-aldosterone, sympathetic nervous, cytochrome P450, nitric oxide, and inflammatory cytokine systems, it is plausible that a genotype of risk that contributes to CVD in African Americans will ultimately emerge. It should be noted, however, that the interpretation of genomic markers of disease is contextual; that is, gene–environment interactions will ultimately serve as a better platform to explain CVD. Thus, obesity, dietary preferences, and other lifestyle issues remain important. In addition, ongoing care and caution must be exercised as we continue to explore not only gene–environment interactions, but also any specific race-based reference to CVD. The assignment of race is self-selected, nonphysiologic, arbitrary, and heterogeneous. Race cannot be a proxy for genetics or disease. Despite these cautionary statements, it is clear that those who may be described as African American are indeed at increased risk for CVD. The prevalence of hypertension in African Americans is the highest in the world and 80% of persons in this group are likely to become hypertensive. CVD is the most common cause of death in African Americans and they experience death due to CVD and stroke at rates higher than other groups in the United States. Long-held beliefs regarding best treatment strategies for hypertension in African Americans are largely rhetorical and not well grounded in evidence-based medicine. The more contemporary databases (the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial [ALLHAT]1 and the African American Study of Kidney Disease and Hypertension [AASK],2 for example) demonstrate that thiazide diuretics are preferred agents for all patients with hypertension and when other compelling indications exist, the use of neurohormonal antagonists (e.g., angiotensin-converting enzyme [ACE] inhibitors, angiotensin-receptor antagonists, and β blockers) is preferred. The treatment algorithm generated by the Working Group on Hypertension in African Americans3 is embraced by the authors in this publication as an appropriate and effective means of treating this population and reducing morbidity and mortality due to CVD and stroke. Although not stated as such by the guidelines of the seventh report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure,4 we suggest that African Americans with hypertension should be treated aggressively with targeted, tighter blood pressure control. C o n c l u s i o n