Hypertension in Diverse Populations: a New York State Medicaid Clinical Guidance Document

 

Introduction

The purpose of this report is to summarize relevant current information to help clinicians optimize the treatment of hypertension in patients of varied racial and ethnic backgrounds. This advisory statement represents the collective effort of a working group of academic physicians and pharmacists, public health professionals, and other interested parties charged by the New York State Department of Health to respond to a clinical need. As with the Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7),1 the document is a science‐based expert consensus that integrates basic and clinical information.

Summary

  • The main risk factors for hypertension are age and obesity.
  • Disparities in hypertension risk and outcomes among diverse populations are likely a function of socioeconomic status and psychosocial factors rather than race, ethnicity, or genetic background.
  • All patients should be treated according to best practices; using race or ethnicity as a marker for goal‐setting or treatment options is not scientifically justified.
  • For most patients with hypertension, blood pressure should be maintained below 140/90 mmHg. In certain patient populations, such as those with diabetes, chronic kidney disease, or prior stroke, a lower target BP (below 130/80 mmHg) may be indicated; in patients with ischemic heart disease, the lower BP target is more controversial.
  • Non‐pharmacologic therapy should be routine practice in all patients, with emphasis on caloric restriction, dietary composition (DASH diet), and increased physical activity.
  • Drug therapy is recommended for patients with stage 1 hypertension (140‐159/90‐99 mmHg), especially those who fail to lower their BP with lifestyle modifications within 6 months.
  • Most patients will require more than one drug to control BP; combining drugs with different mechanisms of action is more effective than titrating monotherapy.
  • Preferred first‐line agents include ACE inhibitors, ARBs, thiazide‐type diuretics, and dihydropyridine calcium channel blockers.
  • In patients with stage 2 hypertension (≥160/100 mmHg), initial 2‐drug combinations are recommended; preferred combinations include an ACE inhibitor (or ARB) with either a DHP CCB or a thiazide‐type diuretic.
  • The importance of adherence to therapeutic recommendations (lifestyle modification and medication‐taking) should be stressed repeatedly. Regimens should be simplified when possible, including using single‐pill combination products when appropriate.
  • Providers should continually assess and reduce barriers to effective communication with patients.