Systematic review: antihypertensive drug therapy in patients of African and South Asian ethnicity

Abstract

Despite the large differences in the epidemiology of hypertension across Europe, treatment strategies are similar for national populations of white European descent. However, hypertensive patients of African or South Asian ethnicity may require ethnic-specific approaches, as these population subgroups tend to have higher blood pressure at an earlier age that is more difficult to control, a higher occurrence of diabetes, and more target organ damage with earlier cardiovascular mortality. Therefore, we systematically reviewed the evidence on antihypertensive drug treatment in South Asian and African ethnicity patients. We used the Cochrane systematic review methodology to retrieve trials in electronic databases including CENTRAL, PubMed, and Embase from their inception through November 2015; and with handsearch. We retrieved 4596 reports that yielded 35 trials with 7 classes of antihypertensive drugs in 25,540 African ethnicity patients. Aside from the well-known blood pressure efficacy of calcium channel blockers and diuretics, with lesser effect of ACE inhibitors and beta-blockers, nebivolol was not more effective than placebo in reducing systolic blood pressure levels. Trials with morbidity and mortality outcomes indicated that lisinopril and losartan-based therapy were associated with a greater incidence of stroke and sudden death. Furthermore, 1581 reports yielded 16 randomized controlled trials with blood pressure outcomes in 1719 South Asian hypertensive patients. In contrast with the studies in African ethnicity patients, there were no significant differences in blood pressure lowering efficacy between drugs, and no trials available with mortality outcomes. In conclusion, in patients of African ethnicity, treatment initiated with ACE inhibitor or angiotensin II receptor blocker monotherapy was associated with adverse cardiovascular outcomes. We found no evidence of different efficacy of antihypertensive drugs in South Asians, but there is a need for trials with morbidity and mortality outcomes. Screening for cardiovascular risk at a younger age, treating hypertension at lower thresholds, and new delivery models to find, treat and follow hypertensives in the community may help reduce the excess cardiovascular mortality in these high-risk groups.

Underuse of hydralazine and isosorbide dinitrate for heart failure in patients of African ancestry: a cross‐European survey

“…16 With a focus on European countries within the EU with relatively large African populations, European national bodies were requested for drug registration and utilization data, and demographic data of AA populations, excluding dependent territories, overseas departments, and collectivities (please view the Appendix for contact details). In line with existing literature, 4,5,[9][10][11][12] AA is defined as sub-Saharan African descent, either self-defined or as defined by the consulted authorities. With a non-response, at least one e-mail reminder was sent, and with a second non-response, bodies were contacted through the telephone.…”

“…37 African populations may require special health care, such as screening for cardiovascular disease, adjusted guidelines, and performance measures. [2][3][4][5][6][7][8][9][10][11]29 On the other hand, many scholars argue that 'Blackness' is a sociologically constructed identity that has historically been imposed on people. 36 This matter is circumvented through self-identification of AA, 10,11 but a biomarker to identify individuals who might benefit from H and ISDN therapy would be helpful.…”

“…9 Also, G-protein beta-3 subunit genotype was reported to predict the response to H and ISDN, 38 but to date, no biomarker has been validated for clinical use, and self-identified AA remains the best available predictor for benefit from H and ISDN therapy. 4,5,[8][9][10][11] The lack of consensus on categories based on ancestry and inconsistent data collection are major hindrances for European health outcome assessments by AA. This difficulty in assessing data extends the problem of a significant evidence-practice gap in the care of AA patients with HF.…”

“…2 HF in AA is of predominantly nonischaemic aetiology, and the more severe natural history is largely explained by a greater risk factor burden of obesity, hypertension, diabetes, and chronic kidney disease. [1][2][3][4][5][6][7] In addition, a distinct response to pharmacotherapy is noted, with low efficacy of angiotensin-converting enzyme inhibitor therapy, 4,8,9 which is thought to be associated with compromised bioavailability of nitric oxide (NO). 5,9 In line with this notion, a retrospective analysis of the Vasodilator-Heart Failure Trial I indicated a significant survival benefit in AA but not European men when a combination of vasoactive drugs, hydralazine (H), an antioxidant that inhibits destruction of NO, and the NO donor isosorbide dinitrate (ISDN) was added to conventional therapy.…”

Chronic disease in the ethnic minority and migrant groups: time for a paradigm shift in Europe

“…Judging from the important accepted papers that we attracted from all over the world, we surmise that they are both topical and timely, and that they are likely to have a significant impact on the field of treatment and prevention of chronic disease in minority groups. In particular, four main aspects are covered for a better understanding of (1) detection and control of risk factors in the low-and middle-income countries and their current health needs [16]; (2) the epidemiology of the two most prevalent chronic diseases, hypertension and diabetes, in the ethnic minority and migrant groups living in Europe, and differences between migrants and localborn populations to identify potential drivers predisposing ethnic minorities to CV disease [17][18][19][20]; (3) available data on the most appropriate strategies for treatment recognition and prevention of at-risk sub-populations [21,22] to tailor health services according to needs; and finally, (4) the perspective of specific interventions in low-and middleincome countries especially focused on kidney disease [23].…”