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6 Conclusions
Hypertension and its related morbidity and mortality affect a disproportionate number of black patients compared with white patients. Blacks, Hispanics/Latinos, and Asians especially need effective hypertension treatment and control, considering their high prevalence of comorbidities, including obesity, diabetes, and metabolic syndrome. Such high-risk patients are good candidates for RAAS-inhibitorbased combination therapy, including a thiazide-type diuretic or long-acting calcium channel blocker. Adherence and persistence to antihypertensive medication remain suboptimal, including in these non-white populations, with evidence suggesting improvement with the use of SPC therapy. Results of clinical trials in blacks, Hispanics/Latinos, and Asians with stage 1 or 2 hypertension show that treatment with the combination of a dihydropyridine calcium channel blocker plus RAAS blocker (e.g., amlodipine/valsartan) is a reasonable choice for initial therapy or in patients who fail to respond to monotherapy. These drug classes have complementary mechanisms of action and, when used concomitantly, the magnitude of BP lowering in these non-white populations is generally comparable with that seen in non-Hispanic white patients. Although the clinical trial evidence is not examined in this review, if necessary, a diuretic can be added to the amlodipine/valsartan combination to further reduce BP, without compromising safety and tolerability.
Although the focus of this article is on combination calcium channel blocker/RAAS blocker therapy (particularly, amlodipine/valsartan), treatment with a thiazide-type diuretic plus RAAS blocker is another effective approach for the treatment of hypertension, including in non-white hypertensive patients. The main concern with using thiazide-type diuretics has been tolerability, although lower doses are generally well tolerated. Some evidence suggests that calcium channel blockers may provide greater regression of organ damage than thiazide diuretics, when used in combination with RAAS blockers, and that combination calcium channel blocker/RAAS blocker therapy may reduce the risk of new-onset diabetes in hypertensive patients with metabolic syndrome. Furthermore, results of the Avoiding Cardiovascular events through COMbination therapy in Patients LIving with Systolic Hypertension (ACCOMPLISH) trial suggest that treatment with a calcium channel blocker plus RAAS blocker, relative to a thiazide diuretic plus RAAS blocker, may confer greater protection from cardiovascular events and renal disease progression in high-risk hypertensive patients. Although the majority of patients enrolled in ACCOMPLISH were white, they had a high incidence of cardiovascular risk factors (e.g., diabetes [60 %], dyslipidemia [74 %], obesity [mean BMI 31 kg/m]) that are common in blacks, Hispanics/Latinos, and Asians. Further comparative studies are needed to determine optimal antihypertensive combinations in these minority populations.
Our findings are not unique to combination amlodipine/valsartan therapy. Similar results have been reported with other amlodipine/angiotensin receptor blocker SPC therapies in blacks and Hispanics/Latinos (e.g., amlodipine/olmesartan, amlodipine/telmisartan), although data in Asians are lacking with these other combinations. Of note, because of acculturation and certain health behaviors (e.g., diet, physical activity), it is not known whether the literature findings reported in Asian patients can be generalized to the Asian American population. Kaplan and colleagues reported that the prevalence of hypertension among Asian immigrants increased with increasing length of residence in Canada, from 3 % (0–4 years) to 7 % (5–9 years) to 13 % (10 or more years). A similar association was reported in a multiethnic cohort (white, black, Latino, and Asian) living in the USA, independent of confounders such as age, gender, race/ethnicity, level of education, smoking, alcohol intake, physical activity, BMI, and history of diabetes. In addition, although BP reductions appear robust with combination amlodipine/valsartan, outcomes data comparing this treatment approach with other combination regimens are not available. Thus, the optimal cardiovascular outcome benefits during management of patients with amlodipine/valsartan and similar combinations cannot be determined at this time. Lastly, it is important to note that pharmacological therapy is not a substitute for lifestyle changes. Sodium restriction, smoking cessation, weight reduction, moderation of alcohol consumption, and a diet rich in fruits, vegetables, and low-fat dairy products have been shown to reduce BP, and should be implemented in all patients including those who require antihypertensive drug therapy.
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