Antihypertensive Therapy in African Americans: Findings From an Inner‐City Ambulatory Clinic

J Clin Hypertens (Greenwich). 2010;12:187–192. ^©2010 Wiley Periodicals, Inc. African Americans bear a greater burden of hypertension. Understanding prevailing epidemiologic patterns can facilitate the implementation and successful outcome of community programs. The authors assessed practice patterns of antihypertensive drug utilization and blood pressure (BP) control in a predominantly African American population in Brooklyn, NY, from January 1 to January 31, 2008. A total of 416 (53.1%) had hypertension, with a mean age of 61 years, and 267 (64%) were women. In general, 212 (50.9%) were at goal BP and 59.9% of those at goal were taking at least 2 drugs. Patient age correlated with the number of drugs used (r=0.14; P=.004). Patients taking β‐blockers and calcium channel blockers were older: 63.6 vs 60.1 years (P=.01) and 62.7 vs 60.3 years (P=.07), respectively. The pattern of antihypertensive use was as follows: angiotensin‐converting enzyme inhibitors, 194 (46.6%); calcium channel blockers, 162 (38.9%); diuretics, 162 (38.9%); β‐blockers, 133(32%); and angiotensin receptor blockers, 93 (22.4%). The findings of age associated with the class of medications used and a predominance of angiotensin‐converting enzyme inhibitors usage highlight possible gaps in appropriateness of antihypertensive therapy. The application of age‐appropriate race‐based antihypertensive therapy might improve BP control rates. These results strengthen arguments for investing in community‐based programs to overcome possible provider‐related and local health system barriers to achieving BP control goals.

Hypertension is the most common primary diagnosis in America and is responsible for 35.7 million office visits per year. ¹ Overall, 1 in 3 American adults have high blood pressure (BP), while 2 in 5 African American adults have high BP. ² African Americans bear a greater burden of disease, ^{3 , 4} have a variable response to conventional antihypertensive medications, ^{5 , 6} and develop more severe end‐organ damage. ^{7 , 8} In addition to pharmacologic therapy and lifestyle modifications, community‐based interventions focusing on African Americans may improve outcomes. In this light, the Centers for Disease Control and Prevention (CDC) has initiated the Racial and Ethnic Approaches to Community Health Across the US (REACH US) program. ^{9 , 10 , 11 , 12} Similarly, the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) ¹³ recommends a 3‐pronged approach of pharmacologic therapy, lifestyle changes, and public health initiatives involving community participation and mobilization. Pharmacologic therapy remains a primary focus of care, however, as it prevents and reverses end‐organ damage and improves cardiovascular outcomes. ^{14 , 15} Correspondingly, to ensure a cost‐effective, sustainable, and successful community‐based intervention, the intensity and design of public health programs involving grassroots initiatives ought to be guided by a clear understanding of prevailing epidemiologic patterns of hypertension.As such, the CDC calls for continuous surveillance of health status in minority communities so that culturally sensitive prevention strategies can be tailored to these communities and program interventions evaluated. ¹⁶ Knowledge of existing prescribing patterns, antihypertensive drug utilization, and BP control rates in the index community can provide useful information for establishing community programs to combat hypertension and gauge their effectiveness. We assessed practice patterns and BP control in a predominantly African American population serviced by a community health clinic affiliated with an internal medicine residency program.     

Therapy of heart failure in African Americans: lessons from an urban public hospital

African-American patients with heart failure treated at urban public hospitals are at high risk for adverse outcomes likely due to complex socioeconomic factors. While establishing a heart failure disease management program at Parkland Memorial Hospital in Dallas, TX, the authors completed two studies that address the high rates of heart failure hospitalizations seen in this population. The first study found high rates of adverse outcomes following emergency department discharge for heart failure. The second identified important deficiencies in dietary sodium knowledge. Both 90-day outcomes (return emergency department visit or heart failure hospitalization) following an index emergency department discharge and dietary sodium knowledge represent new potential measures of quality of care of heart failure. Studies of this high-risk population of heart failure patients may offer insights that lead to improved outcomes both in the urban setting and elsewhere.     

Antihypertensive efficacy of night-time graded-release diltiazem versus morning amlodipine in African Americans

BACKGROUND: The effect of a once daily night-time (10 pm) graded-release diltiazem (GRD) on early morning blood pressure (BP), heart rate (HR), and rate-pressure product (RPP) were compared with the effect of morning (8 am) amlodipine in 262 African American individuals with hypertension. METHODS: The multicenter, randomized, double-blind, parallel-group, dose-to-effect trial evaluated changes from baseline in BP, HR, and RPP (HR x systolic BP) by ambulatory BP monitoring during the first 4 h after awakening (diastolic BP = primary), between 6 am and 12 noon, and over a 24-h period. Patients were randomized to night-time GRD 360 mg (n = 132) or morning amlodipine 5 mg (n = 130) for 6 weeks, and were titrated to GRD 540 mg or amlodipine 10 mg after 6 weeks if clinic systolic BP/diastolic BP (SBP/DBP) was > or = 130/85 mm Hg. RESULTS: Compared with amlodipine, GRD showed significantly greater DBP reductions of 3.5 mm Hg (P < .0049) and 3.2 mm Hg (P < .0019) during the first 4 h after awakening and between 6 am and 12 noon respectively, as well as comparable reduction for the 24-h mean DBP. The SBP reductions during the morning periods were comparable, but the reduction in the 24-h mean SBP was 3.4 mm Hg greater (P < .0022) for amlodipine. Mean reductions in HR and RPP were significantly greater (P < or = .0008) for GRD during all intervals; amlodipine increased whereas diltiazem reduced HR with mean differences of 6.7 to 9.3 beats/min. Both treatments were well tolerated. CONCLUSIONS: Night-time GRD was more effective than morning amlodipine in reducing early morning DBP, HR, and RPP, as well as 24-h HR and RPP in African American individuals with hypertension. Amlodipine was more effective in reducing SBP over the 24-h period.     

Assessing Adherence to Antihypertensive Therapy in Primary Health Care in Namibia: Findings and Implications

Introduction

Namibia has the highest burden and incidence of hypertension in sub-Sahara Africa. Though non-adherence to antihypertensive therapy is an important cardiovascular risk factor, little is known about potential ways to improve adherence in Namibia following universal access. The objective of this study is to validate the Hill-Bone compliance scale and determine the level and predictors of adherence to antihypertensive treatment in primary health care settings in sub-urban townships of Windhoek, Namibia.

Methods

Reliability was determined by Cronbach’s alpha. Principal component analysis (PCA) was used to assess construct validity.

Results

The PCA was consistent with the three constructs for 12 items, explaining 24.1, 16.7 and 10.8% of the variance. Cronbach’s alpha was 0.695. None of the 120 patients had perfect adherence to antihypertensive therapy, and less than half had acceptable levels of adherence (≥ 80%). The mean adherence level was 76.7 ± 8.1%. Three quarters of patients ever missed their scheduled clinic appointment. Having a family support system (OR = 5.4, 95% CI 1.687–27.6, p = 0.045) and attendance of follow-up visits (OR = 3.1, 95% CI 1.1–8.7, p = 0.03) were significant predictors of adherence. Having HIV/AIDs did not lower adherence.

Conclusions

The modified Namibian version of the Hill-Bone scale is reliable and valid for assessing adherence to antihypertensives in Namibia. There is sub-optimal adherence to antihypertensive therapy among primary health cares in Namibia. This needs standardized systems to strengthen adherence monitoring as well as investigation of other factors including transport to take full advantage of universal access.

     

Prevalence of Probable Mental Disorders Among Pediatric Asthma Patients in an Inner-City Clinic

Objective. To determine the screen-positive prevalence of anxiety disorders and depression among pediatric asthma patients in an inner-city asthma clinic and to investigate the association between probable diagnoses of anxiety disorders and depression and medical service use among inner-city pediatric asthma patients. Method. In this pilot study, a consecutive sample of pediatric asthma patients aged 5-11 in the waiting room of an inner-city asthma clinic was screened for mental disorders using the DISC Predictive Scales (DPS), which produces probable DSM-IV diagnoses. In addition, data on health service use for asthma were collected. Statistical analyses were performed to examine the relationship between probable anxiety disorders and depression and health service use for asthma among pediatric asthma patients. Results. Approximately one in four (25.7%) pediatric asthma patients in an inner-city asthma clinic met criteria for a probable diagnosis of current anxiety disorders or depression (past 4-week prevalence). Specifically, childhood separation anxiety disorder was common among 8.1%, panic among 14.9%, generalized anxiety disorder among 4.1%, agoraphobia among 5.4%, and 2.7% had depression. Having more than one anxiety disorder or depression diagnosis was associated with higher levels of inpatient and outpatient medical services, compared with patients who were negative on screening for anxiety or depressive disorders, although differences failed to reach statistical significance. Conclusions. These findings are the first to provide preliminary evidence suggesting that mental health problems are common among pediatric asthma patients in an inner-city clinic. The results also suggest that mental health problems in pediatric asthma patients may be associated with elevated levels of medical service use for asthma. Replication of this pilot study is needed with a larger sample, more precise diagnostic methodology, and a comparison group with chronic medical illness.     

Prevalence of Probable Mental Disorders Among Pediatric Asthma Patients in an Inner-City Clinic

Objective. To determine the screen-positive prevalence of anxiety disorders and depression among pediatric asthma patients in an inner-city asthma clinic and to investigate the association between probable diagnoses of anxiety disorders and depression and medical service use among inner-city pediatric asthma patients. Method. In this pilot study, a consecutive sample of pediatric asthma patients aged 5–11 in the waiting room of an inner-city asthma clinic was screened for mental disorders using the DISC Predictive Scales (DPS), which produces probable DSM-IV diagnoses. In addition, data on health service use for asthma were collected. Statistical analyses were performed to examine the relationship between probable anxiety disorders and depression and health service use for asthma among pediatric asthma patients. Results. Approximately one in four (25.7%) pediatric asthma patients in an inner-city asthma clinic met criteria for a probable diagnosis of current anxiety disorders or depression (past 4-week prevalence). Specifically, childhood separation anxiety disorder was common among 8.1%, panic among 14.9%, generalized anxiety disorder among 4.1%, agoraphobia among 5.4%, and 2.7% had depression. Having more than one anxiety disorder or depression diagnosis was associated with higher levels of inpatient and outpatient medical services, compared with patients who were negative on screening for anxiety or depressive disorders, although differences failed to reach statistical significance. Conclusions. These findings are the first to provide preliminary evidence suggesting that mental health problems are common among pediatric asthma patients in an inner-city clinic. The results also suggest that mental health problems in pediatric asthma patients may be associated with elevated levels of medical service use for asthma. Replication of this pilot study is needed with a larger sample, more precise diagnostic methodology, and a comparison group with chronic medical illness.     

Adrenergic Polymorphisms and Survival in African Americans With Heart Failure: Results From A-HeFT

BackgroundPolymorphisms in adrenergic signaling affect the molecular function of adrenergic receptors and related proteins. The β1 adrenergic receptor (ADRB1) Arg389Gly, G-protein receptor kinase type 5 (GRK5) Gln41Leu, G-protein β-3 subunit (GNB3) 825 C/T, and α2c deletion affect adrenergic tone, impact heart failure outcomes and differ in prevalence by ethnicity. Their combined effect within black cohorts remains unknown.Methods and ResultsWe analyzed subjects from the African American Heart Failure Trial (A-HeFT) by assessing event-free survival, quality of life, and gene coinheritance. Significant coinheritance effects on survival included GRK5 Leu41 among subjects co-inheriting GNB3 825 C alleles (n = 166, 90.4% vs 69.0%, P < 0.001). By contrast, the impact of ADRB1 Arg389Arg genotype was magnified among subjects with GNB3 825 TT genotype (n = 181, 66.3% vs 85.7%, P = .002). The lack of the α2c deletion (ie, insertion) led to a greater impact of the ARG389Arg genotype (n = 289, 76.4% vs 86.1%, P = .007).ConclusionsPolymorphisms in adrenergic signaling affects outcomes in black subjects with heart failure. Coinheritance patterns in genetic variation may help determine heart failure survival.     

Gout in African Americans

Purpose

African Americans have a substantially higher prevalence of risk factors for gout than Caucasians. The aim of the present study was to compare the risk for incident gout among African Americans and Caucasians.

Methods

Incidence rates of physician-diagnosed gout among 11,559 Caucasian men and 931 African American men aged 35 to 57 years and at high cardiovascular risk, observed for 7 years as a part of the Multiple Risk Factor Intervention Trial, were analyzed. Cox regression models were used to account for potential confounding by age, body mass index, diuretic use, hypertension and diabetes status, aspirin and alcohol consumption, and kidney disease.

Results

At baseline, after accounting for risk factors, African Americans had a 14% lower prevalence of hyperuricemia than Caucasians. Incidence of gout increased with increasing prevalence of risk factors in both Caucasians and African Americans. Ethnic disparities in incidence rates were most apparent among those without other risk factors for gout. In separate Cox regression models, after accounting for risk factors, African American ethnicity was associated with a hazard ratio of 0.78 (95% confidence interval [CI], 0.66-0.93) for physician-diagnosed gout and 0.88 (95% CI, 0.85-0.90) for incident hyperuricemia. Significant interactions were observed; the association was the strongest (hazard ratio 0.47; 0.37-0.60). These associations were unaffected by addition of serum urate as a covariate or by using alternate case definitions for gout.

Conclusions

After accounting for the higher prevalence of risk factors, African American ethnicity is associated with a significantly lower risk for gout and hyperuricemia compared with Caucasian ethnicity.     

高血压病人药物治疗期间动态血压变化

目的评价高血压病人药物治疗期间２４ｈ动态血压变化。方法２６例住院的高血压病人经药物治疗４周连续３ｄ随测血压，血压正常后进入本研究。治疗前后进行２４ｈ动态血压监测。结果患者随测血压（８～９ＡＭ，３～４ＰＭ）血压恢复到正常水平，但动态血压显示在一段时间内（６～８ＡＭ，６～１１ＰＭ）平均收缩和舒张压仍明显高于正常人平均水平（Ｐ＜０．０１），而该时间段易被临床医生忽视。结论随测血压不能实际全面反映高血压病人药物治疗的疗效，２４ｈ动态血压的监测可以正确评价高血压病人药物治疗的效果并根据高血压分布的时间来调整降压药的种类和剂量。     

Hepatitis C in African Americans

African Americans, with treatment failure rates at about 80%, remain one of the most difficult patient groups in which to eradicate hepatitis C. Infection morbidity in this patient population is compounded by limitations on access to specialist care. Preliminary data regarding liver transplantation even suggest that African Americans, relative to Caucasians, have worse outcomes after liver transplantation. Hence, a priority in hepatitis C research remains studying the immunologic mechanisms that affect host-virus interaction and their relevance to viral persistence and interferon response. In this review, we emphasize recent literature related to the sociologic, immunologic, and metabolic mechanisms that underlie the racial decrements in hepatitis C outcomes in African Americans.     

Colorectal cancer in African Americans

In the United States, African Americans have the highest incidence of colorectal cancer of any racial or ethnic group. Compared with whites, African Americans have a younger mean age at colorectal cancer diagnosis and a greater proportion have proximal cancers. Survival in African Americans with colorectal cancer is lower than in whites. Currently, there are no established biological explanations for these differences in colorectal cancer between African Americans and whites. As leaders in the prevention and early diagnosis of colorectal cancer in the United States, clinical gastroenterologists can play an important role in promoting colorectal cancer awareness and the need for screening in African Americans.     

Diabetes self-management in African Americans: an exploration of the role of fatalism

PURPOSE: This study was conducted to explore the concept of fatalism in relation to diabetes self-management behavior in African Americans with type 2 diabetes. METHODS: Participants (n = 39) were recruited from a clinic sample of African Americans with type 2 diabetes. Seven focus groups were conducted; the sessions were recorded, transcribed, and analyzed to identify themes related to fatalism and diabetes self-management. The ISAS paradigm (individual, symbols, audience, situation), a social psychology theory, provided the theoretical framework for the study. RESULTS: Four dimensions of fatalism were identified: the meaning of diabetes, the illness experience, the individual's coping response, and the individual's religious and spiritual beliefs. For the participants in this study, fatalism seemed to characterize the nature of the interaction between the individual with diabetes and others, the meanings they attached to such interactions, and the decision to adopt an effective or ineffective diabetes self-management behavior. CONCLUSIONS: Fatalism was associated with diabetes self-management in African Americans with diabetes and was multidimensional in this population; the construct appeared to differ conceptually from the perspective of current measures.     

Viral hepatitis in African Americans

Chronic liver disease is the 12th leading cause of death in the United States and a significant cause of productivity loss and morbidity. Viral hepatitis is an important public health concern with a disproportionate impact on the African American community. As a result, African Americans have the greatest incidence of hepatocellular carcinoma, the most devastating consequence of chronic liver disease. Data suggest that African Americans are less likely than other ethnic/racial groups to receive vaccinations for hepatitis A and hepatitis B, to receive antiviral therapy for chronic hepatitis B and hepatitis C, and to respond to antiviral treatment for hepatitis C. This report reviews the current literature regarding acute and chronic viral infections among African Americans and makes recommendations for future public health and research initiatives to improve outcomes in this population.