Hypertension in Minority Populations: New Guidelines and Emerging Concepts Fatima Rodriguez and Keith C. Ferdinand Persistent disparities in hypertension, CKD, and associated cardiovascular disease have been noted in the United States among racial/ethnic minority groups. Overall, these disparities are largely mediated by social determinants of health. Yet, emerging data suggest additional biologic factors in racial/ethnic disparities in hypertension prevalence, complications, particularly CKD, and responses to treatment. Nevertheless, race is a social construct and not a physiologic concept, and ethnicity, federally defined as the binary “Hispanic/Latino” or “not Hispanic/Latino,” is also imprecise. However, race/ethnicity categories may help interpret health-related data, including surveillance and research, and are important in ensuring that clinical trials remain generalizable to diverse populations. There is significant heterogeneity among prespecified groups and, perhaps, greater genetic differences within than between certain racial/ethnic groups. This review will explore hypertension epidemiology, pathophysiology, and management among the diverse and growing US minority groups, specifically African Americans and Hispanics because much less data are available across the wide spectrum of diverse populations. We will highlight the intersection of hypertension and increasingly prevalent CKD, particularly in African Americans. Finally, we propose multidimensional treatment approaches to hypertension among diverse populations, encompassing population, community, health system, and individual-based approaches. Q 2015 by the National Kidney Foundation, Inc. All rights reserved. Key Words: Hypertension, Chronic kidney disease, Guidelines, Racial/ethnic minorities, Disparities

Hypertension Epidemiology Hypertension is the most common risk factor for cardiovascular disease (CVD) affecting nearly 78 million adults in the United States.1,2 Moreover, this important and modifiable contributor to excess CVD morbidity and mortality affects approximately one-third of US adults,1 and the prevalence is even higher among African Americans and adults with CKD at 60%.3 In the most recent National Health and Nutrition Examination Survey data from 2011 to 2012, the prevalence of hypertension was highest among non-Hispanic black adults (42.1%), compared with non-Hispanic white (28.0%), Hispanic (26.0%), and non-Hispanic Asian (24.7%) adults.4 Furthermore, even mild elevations of systolic blood pressure of 130 mm Hg or more and/or diastolic blood pressure of 85 mm Hg or more pose an increased risk for the development of CVD5 and CKD, including ESRD.6-8 Hypertension-associated adverse cardiovascular events include stroke, coronary heart disease, peripheral vascular disease, myocardial infarction, and heart failure.9-11 Most adults have hypertension with no identifiable cause, also known as primary or essential hypertension. Secondary or identifiable causes of hypertension include sleep apnea, CKD, medication related (particularly steroids), thyroid disease, pheochromocytoma, primary hyperaldosteronism, and Cushing syndrome. Hypertension is intimately linked with CKD, as both a cause and consequence of CKD,12 across a continuum, with higher CKD prevalence even among individuals with undiagnosed or prehypertension (Fig 1).13 It is estimated that approximately 10% of US adults (20 million people) have CKD, with hypertension and diabetes representing the leading causes of ESRD.14 Furthermore, in nondiabetic hypertensive adults, measurement of cystatin C and the presence of albuminuria may identify 25% cases of occult CKD, otherwise missed by simple creatinine evaluation, most notably among younger African American and Hispanic adults.15 Therefore, CKD prevalence among hyperten-

sive adults may be underdiagnosed in certain minority populations.16 For African Americans, hypertension confers the highest CKD risk among all racial/ethnic groups, with a 4-fold increase in progression to ESRD,17,18 and Hispanics are approximately 1.5 times as likely to progress to ESRD compared with non-Hispanic whites.14 Despite decreasing ESRD cases among all groups, disparities persist, particularly among younger African Americans. Additionally, because both African Americans and Hispanics experience significantly longer wait times for kidney transplantation,19 prevention and early detection of CKD are essential to reduce these disparities and associated health care costs.

Hypertension in Diverse Populations The burden of hypertension and CKD is not distributed equally.20 Compared with non-Hispanic whites, African Americans develop hypertension at an earlier age and experience higher rates of stroke and end-stage kidney disease.10,11,21-24 Rates of hypertension-related ESRD are approximately 4.2 times higher among African Americans.1 For Hispanic adults, the data have been inconsistent— with some studies showing a higher prevalence of hypertension and others suggesting lower rates compared with non-Hispanic whites.25,26 Recent data from the Department of Cardiovascular Medicine, Stanford University, Palo Alto, CA; and Heart and Vascular Institute, Tulane University School of Medicine, New Orleans, LA. Financial Disclosure: The authors declare that they have no relevant financial interests. Address correspondence to Keith C. Ferdinand, MD, Professor of Clinical Medicine, Tulane University School of Medicine, 1430 Tulane Avenue, SL-48, New Orleans, LA 70112. E-mail: [email protected] Ó 2015 by the National Kidney Foundation, Inc. All rights reserved. 1548-5595/$36.00 http://dx.doi.org/10.1053/j.ackd.2014.08.004

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Hispanic Community Health Study/Study of Latinos Pathophysiology: Genetic and Environmental estimates an overall prevalence of hypertension of 25% Contributors among Hispanics, with the lowest rates among South American women (17.2%) and the highest rates in African Americans Dominican men (34.3%).27 The prevalence of hypertension Potential physiologic determinants of increased hypertension and CKD among African Americans, include increases more rapidly with age among Hispanics obesity,40 low levels of plasma renin,41 vitamin D deficompared with non-Hispanic whites.26 Similarly, less is known about CKD prevalence among ciency,42 and sympathetic overactivity.43 Moreover, in the Jackson Heart Study, isolated nocturnal hypertension in Hispanics, with poor representation in large prospective African Americans was shown to correlate with increased studies and some data suggesting lower overall CKD prevalence but, similar to African Americans, higher left ventricular mass, with a greater tendency toward proteinuria compared with those who were normotensive.44 rates of microalbuminuria and more rapid disease Interestingly, polymorphisms encoding apolipoprotein 1 progression to ESRD compared with non-Hispanic (APOL1) may explain some of the variation in the high whites.28-30 In 2 large cohorts of patients with CKD, Hispanics disproportionately had higher rates of diabetes, rates of nondiabetic kidney disease among African Amerworse blood pressure control, and were less likely to be icans.45 Recent data from the African American Study of 31 Kidney Disease and Hypertension (AASK) and from the on an angiotensin-converting enzyme inhibitor (ACE-I). These participants tended to be of lower socioeconomic staChronic Renal Insufficiency Cohort (CRIC) help elucidate tus and experience more severe CKD and associated comthe role of APOL1 high-risk alleles in kidney disease proplications compared with their white counterparts. gression. Interestingly, the progression of CKD by Among Hispanics, higher acculturation (English language APOL1 status was found to be independent of blood presuse and increasing years in sure control. the United States) has been There is a strong association associated with higher between social determinants CLINICAL SUMMARY prevalence of self-reported of health and hypertension hypertension and CKD.32-35 in African Americans. For  Hypertension is a highly prevalent risk factor for Furthermore, there is example, data from the cardiovascular and kidney disease, and disproportionately significant heterogeneity Multiethnic Study of Atheroaffects minority populations. among Hispanics by sclerosis cohort showed sig There are persistent disparities in the prevention and country of origin, and rates nificant associations between treatment of hypertension among diverse populations, of age-adjusted hypertension hypertension prevalence and particularly African Americans and Hispanics. are higher among Puerto geography, with higher rates  There are potential genetic and environmental determinants Ricans and Dominicans of hypertension in the Southof increased hypertension and kidney disease risk, which compared with Mexican ern United States.46 Similarly, 36 may partly explain the observed disparities. recent findings from the Americans and Cubans. Data from Hispanic ComReasons for Geographic and  Prevention of the adverse consequences of hypertension in munity Health Study/Study Racial Differences in Stroke minority populations should involve population, community, of Latinos identify significant cohort demonstrate an associhealth system, and individually based approaches. heterogeneity in CVD risks ation between long-term resiand disease prevalence by dence in the southeastern country of origin, suggesting United States with ESRD that previous Hispanic risk factor data, largely obtained among African Americans.47 Geographic disparities may be because of differences in healthy food availability, social from Mexican Americans, may underestimate the true hypertension, CKD, and other cardiometabolic risk factors cohesion, perceived neighborhood safety, and greater prevalence of cardiovascular risk clustering. among certain US Hispanics.37 Finally, differences in acculturation, health literacy, and social support may partially explain the rapid progression of CKD among Hispanics Hispanics Few studies have specifically explored the pathophysiologwith hypertension and diabetes.28 Among the growing Asian American population, adult ical basis of hypertension and CKD among Hispanics. hypertension prevalence is estimated at 25.6%, with However, the Multiethnic Study of Atherosclerosis study higher prevalence with age and lower educational demonstrated that left ventricular hypertrophy and attainment level.38 However, similar to Hispanics, adverse LV remodeling was higher among CaribbeanAsians are heterogeneous and subgroup differences origin Hispanics compared with other Hispanic subgroups, among South Asians, Chinese, and Japanese patients even after controlling for a greater prevalence of hypertenshould be considered, with possible variation attributed sion.48 Similar to African Americans, Hispanics have a higher prevalence of other comorbid diseases, particularly to differences in dietary sodium intake and physical activity patterns. Race-specific data for pharmacologic diabetes and cardiorenal metabolic syndrome,26 are more likely than non-Hispanic whites to have heart failure therapies for hypertension control and CKD prevention and ESRD,49 and are at higher risk of CKD, irrespective of are limited for this patient subgroup, other than increased ACE-I-induced cough and possibly angioeblood pressure.13 Nevertheless, although Hispanics have 39 dema in East Asians. been mostly under-represented in landmark hypertension

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sion using multiple effective approaches and evidencebased guidelines, including prioritizing blood pressure control, working as a team (physicians, nurses, nurse practitioners, pharmacists, care co-ordinators, and the patients themselves). Electronic health records track successes and assist with adjustment of medications when needed, along with publicly recognizing or using financial incentives to reward high-performing clinicians or teams.

Community-Based Interventions

Figure 1. Population prevalence of CKD by hypertension status: results from National Health and Nutrition Examination Survey 1999 to 2006. Source: Crew et al.13

studies, available clinical trial evidence suggests responses to antihypertensive therapy similar to non-Hispanic whites. Similar to African Americans, it is likely that most of the differences in blood pressure control among Hispanics are a result of socioeconomic factors including lifestyle factors and access to adequate health resources. Hispanics in National Health and Nutrition Examination Survey data (mostly Mexican American) have the lowest rates of awareness, treatment, and control of hypertension, perhaps, related to language and other cultural barriers.50-52

Treatment Population-Based Interventions

Public health interventions, unlike our medical model of individual-level care, seek to create the greatest reduction in risk by shifting the population distribution toward greater overall health.53 Because many people are unaware of their hypertension risk and many events occur in those who are perceived to be at low or only mildly elevated risk, population-based approaches can complement current individually based medical strategies. For example, reducing additive sodium in the processed foods may ultimately result in the greatest impact on population health, particularly among AfricanAmericans, obese individuals, and those who may be particularly “salt sensitive.”54 A major public health population-based approach is the Million Hearts (MH) campaign sponsored by the Centers for Disease Control and Prevention (CDC) and the Centers of Medicare and Medicaid Services. Through multifaceted approaches, MH seeks to prevent 1 million heart attacks and strokes by 2017, with a special early focus on hypertension control.55 In 2014, the MH initiative recognized 9 public and private clinical settings and health systems that achieved blood pressure control rates ranging from 73% to more than 90%. These diverse practices, including urban and rural areas, an Indian Health Center, the Veterans Health Administration, and Kaiser Permanente care for more than 8.3 million diverse patients and control hyperten-

Community-based hypertension programs seek to achieve behavioral change, and these may prove particularly advantageous among members of racial/ethnic minorities who experience more disparate cardiovascular outcomes.56 Racial/ethnic disparities in hypertension and other CVD outcomes are largely mediated by social determinants of health that are unique to communities.57-60 The 2013 CDC Community Guide highlights positive examples of community-based interventions, and the prevention task force recommends a team-based approach to blood pressure control including the patient, the patient’s primary care provider, nurses, pharmacists, dietitians, social workers, and community health workers.61 One example of a successful community-based intervention to improve hypertension awareness and control among black men is the Barber-Assisted Reduction in Blood Pressure in Ethnic Residents-1 study, a cluster, randomized control trial, using barbers trained to screen for hypertension control among African American male barbershop patrons.56 Over a 10-month study period, there was a statistically significant improvement in hypertension control, suggesting the importance of community partnership for health promotion in minorities. Additionally, lay culturally and linguistically concordant community health workers, known as Promotores de Salud in Hispanic communities, have also been shown to help reduce cardiovascular risk and improve hypertension awareness.56

System-Based Approaches

Electronic medical records (EMRs) can be leveraged to reduce disparities in integrated health systems by incorporating clinical decision support tools for providers.2 For example, the successful large-scale hypertension program conducted by the Kaiser Permanente includes development, sharing, and incorporation of performance metrics, evidence-based guidelines, medical assistant visits for blood pressure measurement, and generic single-pill combination therapies.57 This program achieved high rates of hypertension control improvement (upto 80.4%) compared with state and national control rates. Similarly, using EMR decision support tools, the Department of Veterans Affairs has seen a dramatic improvement in blood pressure control over a decade, with hypertension control rates approaching 77% in a cohort comprising almost 50% African American and Hispanic patients.58 Therefore, EMR and collection of performance measures may prove particularly effective in improving cardiovascular risk factor control for diverse populations.

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Recent Guidelines and Hypertension Control: Lifestyle

The newly released guidelines by a hypertension control advisory board from the American Heart Association (AHA)/American College of Cardiology (ACC)/CDC emphasizes patient characteristics, preferences, and other factors to create an individualized approach to hypertension management.2 Providers must be attune to the unique needs of diverse populations and ensure that patient information is delivered at an appropriate linguistic and health literacy level. All providers should encourage their hypertensive patients to employ lifestyle modification of weight loss, the Dietary Approaches to Stop Hypertension diet59,60 (rich in fruits, vegetables, and low-fat dairy products), lower sodium intake, aerobic physical activity, and moderate alcohol consumption.2 The Dietary Approaches to Stop Hypertension diet, which is low in sodium, may assist in blood pressure reduction for diverse populations, including African Americans, women, and older adults.60 However, despite new lifestyle guidelines that emphasize dietary sodium reduction to control hypertension, a recent study found an association between higher intake of sodium and potassium with lower odds of CKD among US adults, after adjusting for comorbidities.62 Nevertheless, evidence-based pharmacotherapy is still needed to control hypertension and prevent CKD and CVD in most middle-aged and older patients with hypertension.

Recent Hypertension Guidelines: Pharmacotherapy

Antihypertensive pharmacotherapy reduces cardiovascular and kidney morbidity and mortality. Particularly in patients with early CKD, blood pressure lowering is associated with a significant reduction in CVD.63 Recommendations from the 2014 evidence-based guideline for the management of high blood pressure in adults, from the panel members appointed to the Eighth Joint National Committee (JNC 8), are outlined in Table 1.11 Unlike prior JNC reports, the 2014 guideline is not a product of the National Heart Lung and Blood Institute but uses evidence accumulated by National Heart Lung and Blood Institute and several key differences from the previous JNC 7 rec-

ommendations.10 The 2014 guideline emphasizes less stringent thresholds for persons with diabetes and CKD (now ,140/90 mm Hg) and even more lenient goals for adults of 60 years or older (,150/90 mm Hg). However, several panel members disagreed with the recommendation to increase the target systolic blood pressure to 150 mm Hg for older adults younger than 80 years because this recommendation may reduce the intensity of antihypertensive treatment in a large population with prevalent CVD64 and may have the unintended consequence of reversing decades of declining CVD rates. Notably, although the 2014 guideline recommends initial drug treatment with an ACE-I or an angiotensin II receptor blocker (ARB) for patients with hypertension and CKD, in the African American hypertensive population, a thiazide-type diuretic or a calcium channel blocker are recommended as the initial therapies, either alone or in combination.11 Early work from Saunders and colleagues65 suggested that African Americans do not respond to ACE-I or beta-blockade and that calcium channel blockers confer the greatest efficacy in controlling blood pressure. Because of the lower renin profile and greater tendency for higher peripheral and kidney vascular resistance in African Americans, studies have demonstrated a greater benefit in blood pressure reduction with calcium channel antagonism.65,66 Similarly, the most recent guidelines from the International Society of Hypertension in Blacks promote the use of either a calcium channel blocker or diuretic as first-line monotherapy for hypertension in African Americans, in the absence compelling indications for other drug classes.67 The 2014 AHA/ACC/CDC Scientific Advisory Board also developed an updated algorithm for effective blood pressure control (Fig 2).2 Similar to the 2014 report from prior JNC 8 members, the AHA/ACC/CDC recommends that for patients with CKD but without proteinuria, the target blood pressure should be less than 140/ 90 mm Hg.3,68 African Americans have a high prevalence of resistant hypertension (defined as blood pressure that remains above target despite the concurrent optimal use of 3 antihypertensive agents of different classes including a diuretic), and the 2008 AHA scientific statement recommends the use of a triple regimen of an ACE-I, calcium channel blocker, and a

Table 1. Summary of the Hypertension Management Recommendations for Adults 18 Years and Older by Population from the Panel Members Appointed to the JNC 8 Population General population ,60 y General population $60 y Diabetes, all ages, no CKD CKD, all ages, with or without diabetes

Target Blood Pressure

Initial Therapy

SBP , 140 mm Hg DBP , 90 mm Hg SBP , 150 mm Hg DBP , 90 mm Hg SBP , 140 mm Hg DBP , 90 mm Hg SBP , 140 mm Hg DBP , 90 mm Hg

Black: thiazide-type diuretic or CCB Nonblack: thiazide-type diuretic or ACEI or ARB

All races: ACEI or ARB, alone or in combination

Abbreviations: ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin-receptor blocker; CCB, calcium channel blocker; DBP, diastolic blood pressure; JNC 8, Eighth Joint National Committee; SBP, systolic blood pressure. Adapted from James et al.11

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Figure 2. An effective approach for high blood pressure control. Source: Go et al.2

long-acting thiazide.69 In resistant hypertension, the addition of aldosterone blockade with spironolactone, eplerenone, or amiloride can provide additional blood pressure reduction and reduce proteinuria. A 2-center study investigating the use of aldosterone antagonists for the treatment of resistant hypertension (with 82% of enrolled patients being African Americans) concluded that caution should be used in patients with greater than Stage 3 CKD with serum potassium levels greater than 4.5 mEq/L on appropriately dosed diuretics.70 The American Society of Hypertension and the International Society of Hypertension have also released 2013 guidelines, with an emphasis in simplifying recommendations to be employed for diverse patient populations in both low- and high-resource settings.54 Based on an expert opinion, the American Society of Hypertension/ International Society of Hypertension article endorses the less strict treatment goal of blood pressure under 140/90 mm Hg, including for patients with diabetes, CKD, and coronary artery disease. Nonpharmacologic treatments are recommended for all patients, including weight loss, salt reduction exercise, moderate alcohol consumption, and smoking cessation. For patients with CKD, the combination of ACEI-I and ARBs is not recommended and may have a deleterious effect on kidney function.54 A recent study testing the value of combined angiotensin inhibition for diabetic nephropathy was

terminated early because the combination of losartan and lisinopril significantly increased the risk of hyperkalemia and acute kidney injury without conferring any survival benefit.71 These findings are consistent with randomized clinical trials showing increased harms and no cardiovascular benefit or kidney disease progression prevention for combination therapies to block the reninangiotensin system.72,73

Clinical Trial Evidence for Diverse Populations

Several large studies have investigated pharmacotherapies among the general and African American populations with more limited data for Hispanics and other racial/ethnic subgroups. The AASK trial, which included 1094 African American adults with hypertensive kidney disease, prospectively investigated the role of aggressive blood pressure lowering and the progression of kidney disease.74 The rate of change of the glomerular filtration rate (GFR) was not affected by target systolic blood pressure lower than the “usual goal,” but ramipril-based regimen was more effective than amlodipine or metoprolol succinate regimens in slowing GFR decline. Similarly, the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack (ALLHAT) trial included 35% African American participants (15,094 blacks and 8100 Hispanics) and compared therapy on chlorthalidone, amlodipine, and lisinopril.75

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Figure 3. Multilevel approach to hypertension reduction and control in minority populations.

African Americans in ALLHAT on lisinopril had 40% more strokes and more overall CVD with less blood pressure lowering compared with chlorthalidone-based therapy. The ALLHAT investigators concluded that thiazide-type diuretics should be the initial therapy for all hypertensive patients without compelling indications. Similarly, in a subgroup analyses of 533 African Americans with hypertension and left ventricular hypertrophy in the Losartan Intervention For Endpoint Reduction trial, there was no benefit in CVD reduction with losartan plus diuretics as needed vs atenolol plus diuretics as needed, although the analysis was limited by the small number of events.76 The International Verapamil SR/Trandolapril Study also included over 8000 Hispanic participants.26,75,77 In both large trials, blood pressure control was equal or higher among Hispanics than other racial/ethnic groups.78 In the International Verapamil SR/Trandolapril Study, trandolapril-based therapy compared with the verapamil arm resulted in a lower incidence of type II diabetes. Although most major hypertension outcome trials have an under-representation of Asians, 2 studies exploring the role of ARBs for patients with type II diabetes and nephropathy, the Reduction of End Points in Noninsulin-Dependent Diabetes With the Angiotensin II Antagonist Losartan and the Irbesartan Diabetic Nephropathy Trial included 252 and 84 Asian participants, respectively. The studies found that ARBs confer significant protective effects on patients with type II diabetes by decreasing the incidence of diabetic nephropathy,79 doubling of serum creatinine, and progression to ESRD.80 Similarly, a recent prospective cohort study conducted in Taiwan showed that hypertensive adults with advanced CKD (predialysis, Stage 5) and anemia receiving ARBs or ACE-Is had lower risk for initiation of long-term dialysis or death.81 Figure 3 highlights the importance of a multilevel approach to hypertension prevention and management.

Future Considerations: Renal Artery Denervation

In view of the higher prevalence of resistant hypertension in African Americans and all patients with hypertension and kidney insufficiency, intervention with renal nerve denervation (RND), already approved and used clinically in Europe and Australia, was seen as a potentially significant tool to control hypertension in these difficult to treat patients. Nevertheless, although prior unblinded studies have demonstrated remarkable blood pressure lowering in resistant hypertension cohorts,82,83 recently published data from a prospective, single-blind, randomized, shamcontrolled trial, SYMPLICITY HTN-3 in 535 patients with resistant hypertension, did not show a significant difference in blood pressure with RND or a sham procedure.84 The mean (6standard deviation) change in systolic blood pressure at 6 months was 214.13 6 23.93 mm Hg with RND compared with 211.74 6 25.94 mm Hg in the sham procedure group (P , .001 for both comparisons of the change from baseline), for a difference of 22.39 mm Hg (95% confidence interval, 26.89 to 2.12; P ¼ .26 for superiority with a margin of 5 mm Hg). The RND change in the 24-hour ambulatory systolic blood pressure was 26.75 6 15.11 and 24.79 6 17.25 mm Hg in the sham procedure group, for a difference of 21.96 mm Hg (95% confidence interval, 24.97 to 1.06; P ¼ .98 for superiority with a margin of 2 mm Hg).84 Interestingly, approximately one-fourth of the SIMPLICITY HTN-3 cohort was self-reported as black, with about 70% white and small numbers of other racial/ ethnic groups; about 10% had kidney insufficiency, as defined by GFR less than 60 mL/min/1.73 m2. There was no greater benefit in subgroup analysis with either black race or CKD. Despite a P value for interaction of .09 in blacks compared with non-blacks, there was actually a significant systolic blood pressure reduction in the non-black subgroup only (P ¼ .01). Further studies with perhaps other approaches to RND are needed to determine if this

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intervention will have significant clinical utility in the United States, especially in high-risk minorities and patients with CKD.

Conclusions Hypertension and associated CVD and CKD are more prevalent in African Americans. Less is known about the precise epidemiology and pathophysiology of hypertension and CKD among Hispanics, the largest and fastest growing US minority group. Although the use of race/ethnicity to guide antihypertensive treatment may prove particularly problematic, increasing efforts have been made to increase minority participation in clinical trials. Recent hypertension management guidelines make specific recommendations for both African Americans and patients with CKD for target blood pressure and initial pharmacologic therapies. Ultimately, prevention of cardiovascular and kidney morbidity necessitates the implementation of population, community, health system, and individually based approaches to hypertension prevention, identification, and management.

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13. Crews DC, Plantinga LC, Miller ER III, et al. Prevalence of chronic kidney disease in persons with undiagnosed or prehypertension in the United States. Hypertension. 2010;55(5):1102-1109. 14. Centers for Disease Control and Prevention (CDC). National chronic kidney disease fact sheet: general information and national estimates on chronic kidney disease in the United States. 2014. Available at: http://www.cdc.gov/diabetes/pubs/factsheets/kidney.htm. Accessed April, 19, 2014. 15. Peralta CA, Weekley CC, Li Y, Shlipak MG. Occult chronic kidney disease among persons with hypertension in the united states: data from the National Health and Nutrition Surveys 1988-1994 and 1999-2002. J Hypertens. 2013;31(6):1196-1202. 16. Derose SF, Rutkowski MP, Crooks PW, et al. Racial differences in estimated GFR decline, ESRD, and mortality in an integrated health system. Am J Kidney Dis. 2013;62(2):236-244. 17. Whittle JC, Whelton PK, Seidler AJ, Klag MJ. Does racial variation in risk factors explain black-white differences in the incidence of hypertensive end-stage renal disease? Arch Intern Med. 1991;151(7):1359-1364. 18. Ferdinand KC, Townsend RR. Hypertension in the US black population: risk factors, complications, and potential impact of central aortic pressure on effective treatment. Cardiovasc Drugs Ther. 2012;26(2):157-165. 19. Joshi S, Gaynor JJ, Bayers S, et al. Disparities among blacks, Hispanics, and whites in time from starting dialysis to kidney transplant waitlisting. Transplantation. 2013;95(2):309-318. 20. Mensah GA, Mokdad AH, Ford ES, Greenlund KJ, Croft JB. State of disparities in cardiovascular health in the United States. Circulation. 2005;111(10):1233-1241. 21. Albert MA, Torres J, Glynn RJ, Ridker PM. Perspective on selected issues in cardiovascular disease research with a focus on black Americans. Circulation. 2004;110(2):e7-12. 22. Ferdinand KC, Ferdinand DP. Race-based therapy for hypertension: possible benefits and potential pitfalls. Expert Rev Cardiovasc Ther. 2008;6(10):1357-1366. 23. Rahman M, Douglas JG, Wright JT Jr. Pathophysiology and treatment implications of hypertension in the African-American population. Endocrinol Metab Clin North Am. 1997;26(1):125-144. 24. Howard G, Lackland DT, Kleindorfer DO, et al. Racial differences in the impact of elevated systolic blood pressure on stroke risk. JAMA Intern Med. 2013;173(1):46-51. 25. Borrell LN, Menendez BS, Joseph SP. Racial/ethnic disparities on self-reported hypertension in New York City: examining disparities among Hispanic subgroups. Ethn Dis. 2011;21(4):429-436. 26. Guzman NJ. Epidemiology and management of hypertension in the Hispanic population: a review of the available literature. Am J Cardiovasc Drugs. 2012;12(3):165-178. 27. Sorlie PD, Allison MA, Aviles-Santa ML, et al. Prevalence of hypertension, awareness, treatment, and control in the Hispanic Community Health Study/Study of Latinos. Am J Hypertens. 2014;27(6):793800. 28. Lora CM, Gordon EJ, Sharp LK, et al. Progression of CKD in Hispanics: potential roles of health literacy, acculturation, and social support. Am J Kidney Dis. 2011;58(2):282-290. 29. Lora CM, Daviglus ML, Kusek JW, et al. Chronic kidney disease in United States Hispanics: a growing public health problem. Ethn Dis. 2009;19(4):466-472. 30. Bryson CL, Ross HJ, Boyko EJ, Young BA. Racial and ethnic variations in albuminuria in the US Third National Health and Nutrition Examination Survey (NHANES III) population: associations with diabetes and level of CKD. Am J Kidney Dis. 2006;48(5):720-726. 31. Fischer MJ, Go AS, Lora CM, et al. CKD in Hispanics: baseline characteristics from the CRIC (Chronic Renal Insufficiency Cohort) and Hispanic-CRIC studies. Am J Kidney Dis. 2011;58(2):214-227. 32. Yi S, Elfassy T, Gupta L, Myers C, Kerker B. Nativity, language spoken at home, length of time in the united states, and race/ ethnicity: associations with self-reported hypertension. Am J Hypertens. 2014;27(2):237-244.

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Hypertension in minority populations: new guidelines and emerging concepts.

Persistent disparities in hypertension, CKD, and associated cardiovascular disease have been noted in the United States among racial/ethnic minority g...
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