Hypertension is the leading cause of the life-threatening and debilitating effects of cardiovascular disease. It affects most adults in the U.S. with incidence distressingly increased among the African American population than any other racial ethnicities. Multifactorial contributions such as vascular dysfunction, salt sensitivity, Renin-Angiotensin System dysregulation, obesity, biological, environmental, and health behaviors will be examined to help healthcare providers tailor interventions specific to them. Recognizing the need to address the issue of hypertension in this population as well as utilizing practice guidelines and recommendations will help resolve the problem.
Problem and PopulationHypertensionAccording to the Centers for Disease Control and Prevention (2019), about 1 of 3 U.S. adults”or about 75 million people”have high blood pressure and only about half (54%) of these people have their high blood pressure under control. Hypertension is prevalent in the U.S. and most people have difficulty controlling it. The 2017 American Heart Association/American College of Cardiology (AHA/ACC) treatment guidelines for hypertension defines normal blood pressure as < 120/80 (Davis, 2019).
It's been determined that individuals with unmet criteria should be identified as having hypertension and requires further investigation. Furthermore, more than 360,000 American deaths in 2013 included high blood pressure as a primary or contributing cause, which is almost 1,000 deaths each day (Centers for Disease Control and Prevention, 2019). Neglect in controlling elevated blood pressure can lead to severe complications resulting in death. In addition, the Centers for Disease Control and Prevention (2019) demonstrates that 69% of people who have a first heart attack, 77% who have a first stroke, and 74% with chronic heart failure have high blood pressure. When blood pressure is high, an individual is 4 times more likely to die from stroke and 3 times more likely to die from heart disease.Hypertension is a condition that if left untreated or undetected can result in life-threatening complications.Impact on African AmericansHypertension is a condition seen more in African Americans than any other ethnic groups. The prevalence of hypertension in African Americans is ~45%, significantly higher than in other ethnicities, including ~32% among non-Hispanic whites and ~30% among Hispanics (Zilbermint, Hannah-Shmouni, & Stratakis, (2019). The incidence of hypertension distressingly increased among the African American population than other racial ethnicities. Moreover, the annual rate of first heart attacks and first strokes is higher for African Americans than White Americans (Boston Scientific, 2019). The burden of hypertension and the risk of heart disease, stroke, and death are significantly greater among African Americans. In addition, studies found by Musemwa and Gadegbeku (2017) showed thatCompared to other racial groups, it is well recognized that African Americans have earlier onset and greater severity of hypertension. As a result, they have 30% greater rate of nonfatal strokes, 80% more fatal strokes, 50% more CVD, and a 4-fold more kidney disease. Another study determined that African Americans have a 20-fold higher rate of incident heart failure before age 50 compared to White Americans, which is considered directly related to hypertension. The effect of hypertension is found to be more severe in African Americans compared to White Americans. Contributing factors Multifactorial contributions have been reviewed that explains the higher prevalence of hypertension in African Americans. The hypertension burden and its consequences are likely due to a host of inter-related biological and environmental factors superimposed on a genetically-susceptible background (Musemwa & Gadegbeku, 2017). These risk factors include vascular dysfunction, salt sensitivity, Renin-Angiotensin System dysregulation, obesity, biological, environmental and health behaviors. Examining each risk factor will help healthcare providers understand and tailor interventions specific to hypertension in the African American population. Endothelial Vascular DysfunctionEndothelial vascular dysfunction has been found to be a contributing factor to hypertension in African Americans. A study found by Musemwa and Gadegbeku (2017) demonstrated thatIn comparison to normotensive white individuals, African Americans have enhanced adrenergic vascular reactivity and attenuated vasodilatory responses. The vasodilatory impairment is thought to be due to both endothelium-dependent and independent mechanisms. A growing body of literature suggests that reduced Nitric Oxide bioavailability contributes to endothelial dysfunction. Dysregulation of endothelin-1, a potent vasoconstrictor also derived from endothelial cells, may potentiate the imbalance of vasoactive hormones that leads to elevated blood pressure and vascular remodeling. Premature occurrence of vascular dysfunction in African Americans is important to consider in identifying the cause of hypertension. In addition, endothelial dysfunction reflects a vascular phenotype prone to atherogenesis and may therefore serve as a marker of the inherent atherosclerotic risk in an individual (Hadi, Carr, & Al Suwaidi, 2005). Vascular dysfunction in African Americans is an independent predictor of heart attack and stroke. Salt-sensitivitySalt sensitivity is another contributing factor to hypertension in African Americans. Musemwa and Gadegbeku (2017) found that salt-sensitivity is more common in normotensive and hypertensive African Americans than in the general population. It appears that African Americans have an inevitable fate of acquiring hypertension as adults or even earlier. Furthermore, studies found by Zilbermin et al. (2019) speculated that Several genes implicated in the regulation of sodium reabsorption in the kidneys were likely selected as an adaptation to high temperature environments, particularly in people from Sub-Saharan Africa. These includes genes regulating RAAS that alter sodium retention from the kidneys and possibly armadillo repeat containing 5 (ARMC5) that might be responsible for increased aldosterone production from the adrenal cortex. This demonstrates that African Americans are more vulnerable to developing hypertension than the general population. Renin-Angiotensin SystemRenin-Angiotensin System dysregulation has also been found to be a contributing factor to hypertension in African Americans. Low-renin hypertension is well described in African Americans and initially interpreted as feedback inhibition to volume excess (Musemwa & Gadegbeku, 2017). As mentioned earlier, African Americans have the tendency to readily absorb sodium in the body. However, as a result of this volume excess, renin is suppressed to prevent overload. Moreover, studies found by Zilbermint et al. (2019) shows thatAfrican Americans excrete a sodium more slowly and less completely than whites. This results in suppression of the renin-aldosterone-angiotensin system (RAAS) due to volume-loading that typically begins in childhood. Ultimately, a low-renin state, which compensates for the relative tendency to retain sodium, ensues. Low-renin hypertension is a frequent cause of hypertension, with a prevalence of 20%-30%, and higher in African Americans. Understanding the unique pathogenesis of hypertension in this special population helps healthcare providers choose interventions appropriate for them. ObesityAnother contributing factor to hypertension in African Americans is obesity. African Americans have a 51% higher prevalence of obesity compared with Hispanics and whites (US Cardiology Review, 2019). Hereditary factors and an unhealthy diet places them at even greater risk for hypertension. Obesity is caused by an imbalance between food intake, absorption, and energy expenditure (Domino, 2019). Unhealthy food choices and sedentary lifestyle results in abdominal obesity which increases the risk for hypertension and other comorbidities such as insulin resistant diabetes and dyslipidemia which have additive cardiovascular risk. Health Behaviors and Environmental FactorsHealth behaviors and environmental factors also contribute to hypertension in African Americans. A study by Espejo, Magabo, Rivera-Castro, Faiz, Ramirez, Robles, Shabarek, Shariff, & Kanna (2018) showed that African Americans chose food based on family tradition and cost more than nutritional value and the lack of exercises was explained as a lack of will-power or not having access to a gym facility. In general, lack of access to care can be a barrier to the prevention of hypertension. Uninsured or underinsured individuals often had tremendous wait times and were not able to be seen for a condition until it had worsened (Der Ananian, Winham, Thompson, & Tisue, 2018). Lack of access to care can have a negative effect on African Americans with hypertension. ReferencesBoston Scientific. (2019). What black americans need to know about heart disease. Heart disease facts. Retrieve from for Disease Control and Prevention. (2019). Blood pressure: make control your goal. High blood pressure. Retrieved from for Disease Control and Prevention. (2019). High blood pressure. Retrieved from for Disease Control and Prevention. (2019). High blood pressure facts. High blood pressure. Retrieved from L. L. (2019). Hypertension: How Low to Go When Treating Older Adults. Journal for Nurse Practitioners, 15(1), 1"6. Ananian, C., Winham, D., Thompson, S., & Tisue, M. (2018). Perceptions of Heart-Healthy Behaviors among African American Adults: A Mixed Methods Study. International Journal of Environmental Research and Public Health, 15(11), 2433. doi:10.3390/ijerph15112433Domino, Frank J. The 5-Minute Clinical Consult 2019 (The 5-Minute Consult Series). Wolters Kluwer Health. Kindle Edition.Egan, B. M., Bland, V. J., Brown, A. L., Ferdinand, K. C., Hernandez, G. T., Jamerson, K. A., Saunders, E. (2015). Hypertension in african americans aged 60 to 79 years: statement from the international society of hypertension in blacks. Journal of Clinical Hypertension, 17(4), 252"259. M., Magabo, S., Rivera-Castro, A., Faiz, M., Ramirez, L., Robles, C., Kanna, B. (2019). Qualitative Study of Knowledge, Perception, and Behavior Related to Hypertension and Cardiovascular Disease Risk Reduction Among Hypertensive African-Americans in Urban Inner City of South Bronx, New York. Journal Of Racial And Ethnic Health Disparities, 6(1), 197"206. H. A., Carr, C. S., & Al Suwaidi, J. (2005). Endothelial dysfunction: cardiovascular risk factors, therapy, and outcome. Vascular health and risk management, 1(3), 183"198.Journal of The American College of Cardiology. (2019). The 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the american college of cardiology. Retrieved from J. D., & Walsh, R. F. (2016). Team-Based Hypertension Management to Improve Blood Pressure Control. Journal of Primary Care & Community Health, 7(4), 272"275. N., & Gadegbeku, C. A. (2017). Hypertension in African Americans. Current Cardiology Reports, 19(12), 129. M. (2015). Perceived Barriers to and Facilitators of Hypertension Management among Underserved African American Older Adults. Ethnicity & Disease, 25(3), 329"336. K. A. (2018). Hypertension management options: 2017 guideline. Nurse Practitioner, 43(6), 33"37. Preventative Task Force. (2015). Final recommendation statement: high blood pressure in adults screening. Retrieved from PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, et al. (2017). 2017 ACC/AHA/AAPA/ABC/ACPM/ AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology, 71 (19), e127-e248. doi: 10.1016/j.jacc.2017.11.006Zilbermint, M., Hannah-Shmouni, F., & Stratakis, C. (2019). Genetics of Hypertension in African Americans and Others of African Descent. International Journal of Molecular Sciences, 20(5), 1081. doi:10.3390/ijms20051081
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