Despite important advances in knowledge related to prevention of hypertension and improvements in awareness treatment and control of hypertension in African Americans, much remains to be done. The following list provides recommendations that were felt to represent some of the most important research needs to facilitate improvements in prevention, treatment and control of hypertension among African Americans. The recommendations are grouped into broad categories. The order of the list is not intended to convey priority.
Surveillance, assessment and causes of high BP
- There is a need for surveys that are more relevant to day-to-day clinical practice settings, including clinical practices that predominantly serve African Americans. An important focus should be to determine the adequacy of BP measurements and their use in diagnosis and management of hypertension.
- There is a need for additional study of environmental, psychosocial and behavioral factors (social determinants) that can prevent hypertension and improve BP control.
- Strategies to improve identification and management of masked hypertension in African Americans should be developed.
- The physiologic factors that contribute to altered diurnal variation and visit-to-visit variability of BP should be studied.
Lifestyle change and other nonpharmacological interventions
- Population-based studies that promote adherence to lifestyle and other non-pharmacological interventions and antihypertensive drug therapy are warranted, especially studies that explore the use of mobile and technology-based solutions. This is an area for potential collaboration with the OBSSR in the broader context of improving health in African Americans across their lifespan.
- A broad portfolio of research, including mechanistic studies and clinical trials, to test the main and interactive effects of increasing potassium intake and reducing sodium intake is warranted in African Americans. For potassium, there are several unresolved issues, including dose response relationship, long-term beneficial effects, safety, and the role of non-chloride anions.
- Given the increasing recognition that antecedents of hypertension in adults begin early in life, the efficacy and effectiveness of lifestyle and other non-pharmacological interventions to prevent and delay the onset of hypertension in African American children should be a high priority.
Treatment and adherence
- The ALLHAT findings suggest chlorthalidone is the preferred agent for first-step antihypertensive drug therapy in most adults, especially in African Americans, but chlorthalidone is used infrequently in practice. Clinician and patient barriers to use of chlorthalidone and other recommended antihypertensive treatments should be explored. Understanding the mechanism of the clinical effects of chlorthalidone, especially in African Americans, could facilitate greater use of this agent in clinical practice.
- Additional study of albuminuria as an effect modifier during BP-lowering and pharmacotherapy in African Americans with hypertension and CKD is warranted.
- Trials comparing different combination therapies in African Americans are needed to optimize long term clinical outcomes, improve adherence, and prevent or delay the onset of treatment resistant hypertension.
- Trials should be conducted to determine whether treatment strategies targeting reduction in visit-to-visit BP variability or nocturnal hypertension can reduce the CVD risks associated with these conditions in African Americans.
- Strategies to enhance management and improve outcomes in African Americans with resistant hypertension should be developed and tested, including targeting of barriers to treatment adherence with nonpharmacological and drug interventions.
Genetics, genomics and pharmacogenetics
- There is need for additional pharmacogenomic studies in patients with hypertension, especially in African Americans, including utilization of ALLHAT and GenHAT resources.
- Whole genome (and exome) sequencing are now affordable and practical for use in RCTs. Consideration of African ancestry may be a useful approach to study modification of response to antihypertensive treatment on CVD outcomes.
- Further study of APOL1 variants may improve our understanding of the relationship between CKD and hypertension, and whether affected patients require alternative treatment approaches.
- There is a need to study strategies for implementation of successful hypertension quality improvement interventions in clinical practice settings (including patient, provider, clinic/system, team, and multilevel approaches), and to assess performance measures that are intended to meet the needs of organizations and providers who care for a diverse range of patients, including those with practices that have a high percentage of African Americans.
- Scaling up best practices and trial-tested effective interventions will require interactions with a broad constituency that includes regulatory authorities, patient advocacy groups, and multi-sectorial partnerships outside of the health care delivery system. Evaluation using RCT designs, the current gold standard, may not be feasible. Whatever the study design, such evaluations need to include detailed investigation of factors influencing successful implementation as well as rigorous assessment of short- and long-term individual- and population-level beneficial and adverse effects.
- Performance measures that facilitate achievement of quality improvement goals in patient care settings with a high proportion of African American patients should be developed.
Building the workforce capacity
- In addition to research studies, there is a need for training programs that cover the full spectrum of hypertension, from etiology to clinical and public health practice. They should underscore proficiency in technical skills, such as BP measurement issues, and how to investigate and address racial disparities in hypertension. Training program teams should be interdisciplinary with inclusion of social scientists, policy makers and clinicians who do not plan to make research the focus of their careers. They should emphasize the value of multi-sectorial models for enhancing care. Fostering networking for trainees and junior investigators is also warranted. Existing programs have the potential to accommodate many of these requirements. New initiatives, such as focused scientific workshops, should be developed to specifically concentrate on hypertension in African Americans, addressing both the health disparities and clinical needs of this population.