Literature Review – Improving Hypertensive Therapy Outcomes Among African Americans

Literature Review

Over 40% of Americans have hypertension (CDC, 2021). The hypertension prevalence is high in African Americans than Caucasians (CDC, 2018). Furthermore, Blacks are more likely to develop hypertension at an earlier age, to have more severe hypertension, and to experience greater rates of consequences such as kidney damage, stroke, and kidney failure. Blood pressure regulation is especially uneven among underprivileged populations, notably African Americans. The high prevalence of hypertension among African Americans this population is partly influenced by social determinants of health. As a result, increasing hypertension knowledge and access to health care among the African American population, particularly in underprivileged regions, is crucial. Healthcare personnel, particularly nurses, should be culturally competent. This paper will utilize a literature review on improving hypertensive therapy outcomes among African Americans.

There is a high incidence of hypertension and health-related complications such as stroke among African Americans (Zilbermint et al., 2019). Gene variants, including ACE and AGT, are linked to hypertension in some populations, including Blacks (Zilbermint et al., 2019). Alpha-adducing and beta-2 adrenergic receptors are linked to a higher prevalence of hypertension in this population. Social factors, including diet and stress, contribute to changes in genetic makeup that contribute to high blood pressure. Social determinants of health, including unemployment and poverty are strongly linked to disparities in hypertension prevalence in America. Chronic diseases that are associated with hypertension like obesity are more common in African American adults (Howard et al., 2018). Still, social factors including income, poverty, unemployment, and living environment do not explain the higher prevalence of hypertension risk among African American adults.

Hypertension and associated health complications in African Americans are often undertreated with hypertension medications (Holt et al., 2022). Therefore, they do not receive effective or optimal hypertensive therapy compared to Whites. Some hypertension medication classes, including ACE inhibitors and beta blockers, may be less effective in reducing blood pressure in African Americans than in other populations (Holt et al., 2022). Genetic differences are associated with disparities in response to hypertensive therapy outcomes among African Americans. Holt et al. (2022) added that African Americans are less likely to receive certain hypertension medications, including diuretics and ACE inhibitors, and more likely to receive calcium channel blockers and alpha-blockers. Thus differences in medication prescribing practices are associated with disparities in hypertension prevalence. Holt et al. (2022) found that African Americans who received diuretics and ACE inhibitors had better blood pressure control and medication adherence than those who did not. Those who received calcium channel and alpha blockers had higher rates of hypertension-related emergency department visits and hospitalizations (Holt et al., 2022).

Healthcare professionals must develop and implement strategies for addressing racial/ethnic disparities in hypertensive therapy, including medication prescribing practices. Holt et al. (2022) emphasized that healthcare professionals must consider an individual’s clinical characteristics when selecting hypertension medications rather than relying on a one-size-fits-all method. Odion-Omonhimin et al. (2022) reported a high prevalence of treatment-resilient hypertension among Blacks, including a continuing elevation of blood pressure despite treatment with antihypertensive medications. Thus, it leads to high morbidity and mortality among African Americans with hypertension.

Genetic factors, such as the renin-angiotensin-aldosterone system, influence the prevalence of drug-resistant hypertension (Odion-Omonhimin et al., 2022). Still, factors like unhealthy lifestyle choices and obesity can contribute to drug-resistant high blood pressure in this population. Managing drug-resistant high blood pressure in this population is fundamental to achieving and maintaining optimal health outcomes. Thus, clinicians must implement a comprehensive approach that comprises hypertensive therapy, lifestyle modifications, and patient education. Nurses should educate patients, especially those from vulnerable populations, about necessary lifestyle changes, including staying active and adopting a healthy dietary pattern to manage their blood pressure and achieve optimal health outcomes effectively. Furthermore, hypertensive therapy should be personalized according to the patient’s preferences and values. Antihypertensive medications help maintain healthy blood pressure by removing excess water from the body. Furthermore, antihypertensive medications can be combined to ensure optimal blood pressure management.

The research (Boulware et al., 2019) analyzed the effectiveness of self-management strategies, part of hypertensive therapy, and found that the strategy to achieving blood pressure control together program significantly reduced systolic blood pressure. The achieving blood pressure control together program included home blood pressure monitoring, self-titration of medication based on monitoring results and provider-approved algorithms, behavioral coaching to enhance adherence to the program, and individualized support from a pharmacist (Boulware et al., 2019). Boulware et al. (2019) reported that the achieving blood pressure control together program led to hypertensive therapy adherence and improved quality of life among African Americans. The program is an effective strategy for managing blood pressure levels in marginalized African Americans with hypertension. The program’s multifaceted approach comprising self-monitoring, medication titration, behavioral coaching, and pharmacist support, appears to be particularly effective in improving medication adherence and quality of life (Boulware et al., 2019).

Implementing self-management strategies can help African Americans incorporate physical activity into their daily routines by setting achievable goals, tracking progress, and seeking support from friends and family members to reduce hypertension prevalence. Nurses must educate their patients about the significance of maintaining a healthy diet, including low-fat and whole grains, to manage their blood pressure effectively (Boulware et al., 2019). Thus, nurses must help this population make healthy lifestyle choices to manage their blood pressure levels effectively and ensure optimal health outcomes. Stress reduction approaches, including meditation and deep breathing exercises, can help African Americans manage their hypertension and related health complications to reduce morbidity and mortality. Therefore, self-management strategies help African Americans manage hypertension by addressing risk factors through lifestyle modifications. By promoting regular physical activity, healthy eating habits, and stress reduction techniques, self-management strategies can help individuals take control of their health and reduce the risk of developing hypertension or other chronic health conditions.

According to the research (Adinkrah et al., 2020), adherence to hypertension medications and lifestyle modifications was low among marginalized African American middle-aged and older adults. Adinkrah et al. (2020) noted a significant relationship between medication adherence and lifestyle modification adherence. For instance, individuals adherent to hypertensive therapy are more likely to adhere to lifestyle modifications and healthy behaviors. Adinkrah et al. (2020) identified factors affecting adherence to hypertension medications and lifestyle modification among marginalized African American middle-aged and older adults, including socioeconomic status, health literacy, social support, and health beliefs. Therefore, healthcare providers must collaborate with policymakers to address factors affecting adherence to hypertensive therapy and lifestyle modifications among marginalized African Americans.

According to Adinkrah et al. (2020), most underinsured or uninsured African Americans face challenges accessing quality care. Therefore, most may not have regular medical care, including regular medical screening and medication management. Moreover, this population may not access healthcare services, including patient education about the significance of maintaining a healthy diet, staying active, and adhering to the recommended therapy. This population may not afford antihypertensive medications or medications for hypertension-related complications due to social determinants of health, including a high prevalence of poverty and unemployment. Most individuals from this population have a history of experiencing discrimination and racism within the healthcare system, leading to mistrust of healthcare providers, a reluctance to seek medical care and poor adherence to the recommended hypertensive therapy (Adinkrah et al., 2020). Some African American cultural practices may conflict with modern medicine or therapy, discouraging adherence to the recommended hypertensive therapy. This population may also lack satisfactory social support and relationships necessary to help them manage their hypertension and adhere to their medication regimen.

Still et al. (2020) reported that technological innovations toward effective hypertension management help educate patients about effective self-management strategies, including education management, healthy lifestyle choices, and self-monitoring. The technology-based also comprised a web-based platform that enabled patients to communicate with healthcare providers and access educational resources. Additionally, community-based programs help create awareness, promote change, and increase knowledge on effective hypertension management. They also inform community-based organizations about available community resources to help improve the health outcomes of marginalized populations. The use of technology in delivering care for this population underscores the potential of technology-based approaches in improving access to healthcare and self-management support for individuals with chronic conditions.

The technology-based self-management program can enable African Americans with hypertension to access online resources, including mobile applications, websites, and social media platforms for disseminating information on hypertension prevention, management, and lifestyle modifications (Still et al., 2020). Clinicians can utilize technological resources to check blood pressure levels and track the advancement toward achieving health goals in African Americans with hypertension. For example, wearable devices, including smartwatches and fitness monitors, help nurses monitor blood pressure and provide real-time responses to patients. They can utilize technological resources to personalize hypertensive treatment by considering the patient’s preferences and values to build a patient-focused care plan.

Sessoms et al. (2015) maintained that healthcare providers must adhere to the national guidelines for managing hypertension in African Americans to reduce disparities in hypertension prevalence. Sessoms et al. (2015) found a connection between healthcare provider adherence to the national hypertension treatment and national guidelines for patient outcomes management. Therefore, clinicians must follow the recommended hypertension treatment and management guidelines for effective and quality healthcare delivery. Thus, nurses must follow hypertension treatment and national management guidelines to deliver evidence-based, quality care for African Americans with hypertension to improve their health outcomes. They can help nurses classify hypertension patients based on their health statuses to identify those at high risk of developing health-related to implement appropriate interventions to prevent morbidity or mortality. They ensure hypertension patients receive appropriate treatment, including proper medication dosages and patient follow-up, such as monitoring potential side effects of antihypertensive medications.

Following hypertension treatment and national management guidelines help clinicians address health disparities associated with social determinants of health. Notably, social determinants of health, including unemployment, poor living conditions, and poverty, increase the risks of developing chronic conditions, such as hypertension, in marginalized groups. Therefore, clinicians must adhere to these guidelines to ensure patients receive appropriate and equitable care regardless of their socioeconomic status or race. Ojji et al. (2019) reported that combining benazepril and amlodipine is safe and tolerable for African Americans. Adherence and tolerance to antihypertensive medications are useful in managing hypertension among this population. Poor adherence to antihypertensive medications increases the risk of developing health-related complications.

ACE inhibitors and ARBs work by preventing angiotensin II production and reducing its action to avoid the narrowing of blood vessels. On the other hand, diuretics help remove excess water and salt from the body to reduce the amounts of fluid passing through arteries and veins. Calcium channel blockers relax the blood vessels, making it easier for blood to flow through them and reducing blood pressure. Ojji et al. (2019) noted that dual therapy effectively controls blood pressure in African Americans with hypertension. For instance, ACEi ramipril and diuretic metoprolol are more effective than either medication alone in blood pressure management in African Americans with chronic kidney disease and hypertension. An ACEi and a diuretic are more efficient or effective in reducing blood pressure in African Americans than combining an ACEi and a CCB (Ojji et al., 2019). Still, dual therapy for hypertension in African Americans should be personalized based on an individual’s medical history, blood pressure level, and other risk factors.

Conclusion

The literature review shows a higher prevalence of hypertension in African Americans than in Whites. Genetic factors, lifestyle behaviors, and social determinants of health contribute to disparities in hypertension prevalence in African Americans. It is often undertreated in African Americans due to disparities in hypertensive therapy practices, leading to poor outcomes. Drug-resistant hypertension incidence is high in this group, contributing to high morbidity and mortality rates. Self-management strategies, including lifestyle adjustments and medication adherence, can improve hypertension outcomes among African Americans. Still, access to affordable care is challenging for many African Americans. Therefore, technology-based approaches may be useful in addressing these barriers. Adhering to national guidelines for managing hypertension in African Americans is critical to reducing disparities in hypertension prevalence. Dual therapy regimens, including ACE inhibitors or ARBs plus a diuretic or CCB, can be safe and effective in controlling blood pressure in African Americans. However, treatment should be personalized based on individual characteristics.

References

Adinkrah, E., Bazargan, M., Wisseh, C., & Assari, S. (2020). Adherence to hypertension medications and lifestyle recommendations among underserved African American middle-aged and older adults. International Journal of Environmental Research and Public Health, 17(18), 6538. https://doi.org/10.3390/ijerph17186538

Boulware, L. E., Ephraim, P. L., Hill-Briggs, F., Roter, D. L., Bone, L. R., Wolff, J. L., Lewis-Boyer, L., Levine, D. M., Greer, R. C., Crews, D. C., Gudzune, K. A., Albert, M. C., Ramamurthi, H. C., Ameling, J. M., Davenport, C. A., Lee, H.-J., Pendergast, J. F., Wang, N.-Y., Carson, K. A., & Sneed, V. (2019). Hypertension self-management in socially disadvantaged African Americans: The achieving blood pressure control together (ACT) randomized comparative effectiveness trial. Journal of General Internal Medicine, 35(1), 142–152. https://doi.org/10.1007/s11606-019-05396-7

CDC. (2018, October 2). High blood pressure publications – African American men sourcebook | cdc.gov. Www.cdc.gov. https://www.cdc.gov/bloodpressure/aa_sourcebook.htm

Centers for Disease Control and Prevention. (2021, September 27). High blood pressure facts. Centers for Disease Control and Prevention. https://www.cdc.gov/bloodpressure/facts.htm

Holt, H. K., Gildengorin, G., Karliner, L., Fontil, V., Pramanik, R., & Potter, M. B. (2022). Differences in hypertension medication prescribing for Black Americans and their association with Hypertension Outcomes. The Journal of the American Board of Family Medicine, 35(1), 26–34. https://doi.org/10.3122/jabfm.2022.01.210276

Howard, G., Cushman, M., Moy, C. S., Oparil, S., Muntner, P., Lackland, D. T., Manly, J. J., Flaherty, M. L., Judd, S. E., Wadley, V. G., Long, D. L., & Howard, V. J. (2018). Association of clinical and social factors with excess hypertension risk in Black compared with White US adults. JAMA, 320(13), 1338. https://doi.org/10.1001/jama.2018.13467

Odion-Omonhimin, L. O., Marwizi, F. M., Chive, M., Obasi, N. B., Akinrinmade, A. O., Obitulata-Ugwu, V. O., Victor, F., & Obijiofor, N. B. (2022). Etiology and management of treatment-resistant hypertension in African American adults ≥18 Years: A literature review. Cureus. https://doi.org/10.7759/cureus.29566

Ojji, D. B., Mayosi, B., Francis, V., Badri, M., Cornelius, V., Smythe, W., Kramer, N., Barasa, F., Damasceno, A., Dzudie, A., Jones, E., Mondo, C., Ogah, O., Ogola, E., Sani, M. U., Shedul, G. L., Shedul, G., Rayner, B., Okpechi, I. G., & Sliwa, K. (2019). Comparison of dual therapies for lowering blood pressure in Black Africans. New England Journal of Medicine, 380(25), 2429–2439. https://doi.org/10.1056/nejmoa1901113

Sessoms, J., Reid, K., Williams, I., & Hinton, I. (2015). Provider adherence to national guidelines for managing hypertension in African Americans. International Journal of Hypertension, 2015, 1–7. https://doi.org/10.1155/2015/498074

Still, C. H., Margevicius, S., Harwell, C., Huang, M.-C., Martin, L., Dang, P. B., & Wright Jnr, J. T. (2020). A community and technology-based approach for hypertension self-management (COACHMAN) to improve blood pressure control in African Americans: Results from a pilot study. Patient Preference and Adherence, 14, 2301–2313. https://doi.org/10.2147/PPA.S283086

Zilbermint, M., Hannah-Shmouni, F., & Stratakis, C. (2019). Genetics of hypertension in African Americans and others of African descent. International Journal of Molecular Sciences, 20(5), 1081. https://doi.org/10.3390/ijms20051081