ACCEL: Hypertension in Ethnic Minorities

The ACC's Coalition to Reduce Racial and Ethnic Disparities in CV Disease Outcomes (credo) was developed to provide the cardiovascular community with greater awareness of disparities as well as the tools to help close the gap in care and outcomes for all patient populations. As noted in a JACC White Paper, most cardiology practices are seeing an increasingly diverse patient population.1 This trend will continue given projected demographics changes in the U.S.

The U.S. Census Bureau projects that by 2042, Hispanic and Latino populations will rise to an estimated 30 percent of the population and African-American populations will rise to an estimated 15 percent. This growth is not limited to a few geographic regions: Asian- and Hispanic-origin populations are the fastest-growing populations in every region of the U.S.

A Heart Challenge

A 2011 supplement to Morbidity and Mortality Weekly focused on coronary artery disease (CAD) and stroke mortality.2 CAD remains the nation's leading cause of death and has been since 1921, while stroke has been the third leading cause since 1938. However, the numbers show striking racial disparities. Overall, CAD is more likely as a cause of death among men than women, but both black men and black women are much more likely to die of heart disease and stroke than white men and women.

Data are similar for premature deaths, which is defined as those that occur prior to age 75 years: CAD deaths are nearly twice as high for black women than white women 45-74 years of age, and about 50 percent higher for black men than white men in the same age range. Hispanics have lower rates of CAD death than non-Hispanics. For stroke, the situation is similar: blacks have higher mortality rates than whites, but Hispanics have lower rates than non-Hispanics. CAD and stroke account for the largest proportion of inequality in life expectancy between whites and blacks, despite the existence of low-cost, highly effective preventive treatment.

There also are wide variations in risk factors based on race and ethnicity. For example, hypertension prevalence in blacks in the United States is high and rising: in 1988-1994 and 1999-2002, hypertension increased from 35.8 to 41.4 percent among black adults (with a high of 44 percent for black women); prevalence rates among whites increased, too, but at a lower rate for the same period: 24.3 to 28.1 percent.3 As Ronald G. Victor, MD, points out, there are areas of the world where blacks have much lower rates of hypertension, suggesting the issue is less genetic than environmental.

While not often emphasized, Dr. Victor adds that in terms of hypertension awareness, treatment and control, rates for all three are much lower for black men than black women. At 86 percent, the awareness rate among black women stands as one of the highest awareness rates for hypertension in the country, perhaps suggesting a benchmark of achievable awareness. Conversely, awareness is 71 percent among black men with a control rate of 35 percent; essentially the same as a decade ago for the general population. So, we have a long way to go to get the black male population aware, treated (currently 60 percent), and in control of their high blood pressure (BP).

In the U.S., blacks develop hypertension earlier in life than whites, and their average BP readings are much higher. As a result, compared with whites, blacks have a 1.3-times greater rate of nonfatal stroke, a 1.8-times greater rate of fatal stroke, a 1.5-times greater rate of death attributable to heart disease, and a 4.2-times greater rate of end-stage kidney disease.3

The high cardiovascular disease morbidity and mortality rates in U.S. blacks is due, at least in part, to the high prevalence of CAD risk factors, combined with suboptimal monitoring and control.

Hypertension and the Barbershop

Compared with black women, black men see physicians much less frequently for preventive care—and thus, the aforementioned lower rates of hypertension awareness, treatment and control. When asked, these men say they feel healthy and have no reason to seek medical care.

This led Dr. Victor and others to target health messaging to a nonmedical setting: the community barbershop.

They developed a continuous hypertension-monitoring and referral program conducted by barbers among black male patrons of 17 black-owned barbershops in Dallas County, Texas. Participants in BARBER-1 underwent 10-week baseline BP screening, and then study sites were randomized to a comparison group that received standard BP pamphlets (eight shops, 77 hypertensive patrons per shop) or an intervention group in which barbers continually offered BP checks with haircuts and promoted physician follow-up with sex-specific, peer-based health messaging (nine shops, 75 hypertensive patrons per shop).4

After 10 months, those frequenting intervention barbershops demonstrated better hypertension control than those at comparison barbershops (absolute group difference, 8.8 percent; p = 0.04); the intervention effect persisted after adjusting for covariates (p = 0.03).

In an editorial accompanying the BARBER-1 results, Clyde Yancy, MD, wrote, "The black barbershop experience is a remarkable social barometer that provides gut-check social commentary, defines a 'captive audience,' and represents a commensurate 'teachable moment;' but is this an appropriate venue to convey meaningful health messages and/or conduct health screening? The investigators of the BARBER-1 study suggest that it might be."5


  1. Yancy CW, et al. J Am Coll Cardiol. 2011;57(3):245-52. 
  2. Freiden TR, et al. MMWR Morb Mortal Wkly Rep. 2011;60:1-2.
  3. Roger VL, et al. Circulation. 2012;125:e12-e230.
  4. Victor RG, et al. Arch Intern Med. 2011;171:342-50.
  5. Yancy CW. Arch Intern Med. 2011;171:350-2.

To listen to an interview with Ronald G. Victor, MD, about hypertension in minorities, visit . The interview was conducted by Eric L. Michelson, MD.

Keywords: Prevalence, Cause of Death, Coronary Artery Disease, Stroke, Life Expectancy, Hypertension, Awareness

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