New recommendations for treating hypertension in black patients: evidence and/or consensus?
New recommendations for treating hypertension in black patients: evidence and/or consensus?
复制标题
治疗黑人患者高血压的新建议：证据和/或共识？
DOI：
10.1161/hypertensionaha.110.159566
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发表时间：
2010
期刊：
影响因子：
--
通讯作者：
Reed,James
中科院分区：
文献类型：
--
作者：
WrightJr,JacksonT;Agodoa,LawrenceY;Appel,Lawrence;Cushman,WilliamC;Taylor,AnneL;Obegdegbe,GbengaG;Osei,Kwame;Reed,James
Hypertension is the major cause of morbidity, mortality, and disability in black populations in the United States and increasingly worldwide. Its greater severity, resistance to treatment, and more frequent financial challenges to achieve control in this population make it critical that populationspecific recommendations for hypertension management be based on the very best evidence. In 2003, the International Society of Hypertension in Blacks (ISHIB) published its first consensus statement. 1 The 2003 Statement has been widely promoted as the authoritative guideline for managing hypertension in black patients. The consensus statement2 in this issue of Hypertension updates the 2003 statement, and, although the authors are careful not to call it a guideline, it may become viewed similarly. Thus, it could dramatically impact the management of hypertension in this population. The ISHIB statement has a number of commendable features. Written by a very impressive group of experts, it is a well-organized, comprehensive document providing an excellent update on the epidemiology, significance, and pathophysiology of hypertension in the black population, as well as substantial practical advice on its management. A particularly worthwhile feature is the discussion of psychosocial factors influencing blood pressure (BP) control in this population, including those related to patient-provider interaction. However, it makes several sweeping recommendations that are both unsupported by randomized clinical trial evidence and, moreover, are inconsistent with the most recent results of large randomized clinical outcome trials in black hypertensive patients.While acknowledging that less than one third of black hypertensive patients are controlled to 140/90 mm Hg, the ISHIB statement recommends substantially lower BP goals in patients already 140/90 mm Hg. In uncomplicated hypertensive patients without target organ damage, preclinical cardiovascular disease (CVD), or history of CVD, it recommends lowering the target BP from 140/90 to 135/85 mm Hg. The selection of this new BP target appears both arbitrary and unfounded. To support the new lower goal, the authors cite evidence from observational studies and the results from 3 clinical trials: the Treatment of Mild Hypertension Study (TOMHS)(n902 with 177 blacks); Cardio-Sis, a European trial (n1111, no blacks identified); and the Trial of Preventing Hypertension (TROPHY)(n772, 79 blacks). 3–5 Only the TOMHS and CardioSis reported clinical outcomes; more than half of the outcomes in the TOMHS were based on a screening questionnaire for angina (the Rose questionnaire). In CardioSis, the primary outcome was ECG evidence of left ventricular hypertrophy. The ISHIB statement also references end-of-study, achieved BP data from the Antihypertensive and Lipid Lowering Heart Attack Prevention Trial (ALLHAT) to support the 135/85-mm Hg target in uncomplicated hypertensive patients. However, the ALLHAT BP goal was 140/90 mmHg, and trial participants were, by trial design, extremely high risk patients: mean age was 67 years, more than half had CVD, 25% had coronary heart disease, 35% had diabetes mellitus, and 60% met criteria for the metabolic syndrome. 6 Entry into CardioSis also required 1 additional risk factor. Thus, both CardioSis and the ALLHAT studied populations substantially different from the low-risk patients for which the lower BP target is recommended. Even more problematic is the recommendation for a BP goal of 130/80 mm Hg in those with diabetes mellitus, prediabetes, high Framingham risk, left ventricular hypertrophy, metabolic syndrome, or glomerular filtration rate 60. This …
