# Presentation: 045148

## Prevention and Control of CVD RF Policy Level, Health Systems and Community:  Main  Issues and Perspectives-Hypertension 

**Keith C. Ferdinand, M.D., F.A.C.C**
**Medical Director, Heartbeats Life Center**
**Professor of Clinical Pharmacology, **
**Xavier University College of Pharmacy**

**Notes:**
Title Slide, no note

## Cardiovascular Disease Facts in African Americans

- Flack et al. *J Clin Hypertens*. 2003;5(suppl 1):5-11.

- Hypertension highly prevalent, frequently undetected, often uncontrolled
- 25% of all African Americans have high-risk lipid profiles
- Sudden death from CVD up to 3 times higher among African American men than white men

**Notes:**
Hypertension is prevalent in African Americans, but rates of detection and control are poorer than in whites.
Most population-based studies show lower serum total-cholesterol and a lower prevalence of hypercholesterolemia in African Americans than in whites. Nevertheless, dyslipidemia is common among African Americans.
Poor lipid control in African Americans has been linked to inadequate treatment regimens, incorrect drug regimens, and patient noncompliance.
Rates of sudden death from cardiovascular disease may be as much as 3 times higher in African American men than in white men.

## Cardiovascular Risk Factors for Hispanics

- Obesity
- HTN
- Dyslipidemia
- Type 2 diabetes mellitus
- Lifestyle
- Lack of physical activity
- Smoking
- Excessive drinking

- Laffer et al. *Hypertension* 1995;26:1079-84.  Stern and Haffner. *Diabetes/Metabolism Reviews*. 1990;6:29-45. Crespo et al. *Public Health Rep*. 1996;3(suppl 2):7-10.

**Notes:**
The most common cardiovascular risk factors in Hispanics are:
Obesity
Hypertension
Dyslipidemia
Type 2 diabetes mellitus
Lifestyle:
Lack of physical activity
Smoking
Excessive drinking

## Heart Disease Is the Leading Cause of Death Among Hispanics

**White non-Hispanics**
- Heart disease
- Cancer
- Unintentional injuries
- Stroke
- COPD
- Pneumonia & influenza
- Diabetes
- Suicide
- Liver disease & cirrhosis
- Homicide and legal intervention

**Hispanics**
- Heart disease
- Cancer
- Unintentional injuries
- Stroke
- Diabetes
- Liver disease & cirrhosis
- Homicide & legal intervention
- Pneumonia & influenza
- COPD
- HIV
- Suicide

- National Centers for Health Statistics.  Health United States. 2000.

**Notes:**
In 2000, the leading causes of death in non-Hispanic whites were:
Heart disease
Cancer
Unintentional injuries
Stroke
COPD
Pneumonia & influenza
Diabetes
Suicide
Liver disease & cirrhosis
Homicide & legal intervention

The leading causes of death in Hispanics were:
Heart disease
Cancer
Unintentional injuries
Stroke
Diabetes
Liver disease & cirrhosis
Homicide & legal intervention
Pneumonia & influenza
COPD
Human Immunodeficiency Virus
Suicide

## Cardiovascular Disease Facts in Hispanic Americans

- Laffer and Elijovich. *Hypertension*. 1995;26:1079-1084; Crespo et al. *Public Health Rep*.
- 1996;3(suppl 2):7-10; American Heart Association. *Heart Disease and Stroke Statistics* — *2003 Update*.

- Less improvement in cardiovascular mortality compared with whites and African Americans
- Overall, Hispanic American women have higher hypertension awareness, treatment, control than Hispanic American men
- Prevalence of dyslipidemia in Mexican Americans:
- TC 240 mg/dL: 18% of males; 17% of females
- TC 200 mg/dL (borderline): 53% of males; 48% of females

**Notes:**
Hispanic Americans as a group have shown less improvement in cardiovascular mortality compared with non-Hispanic whites.
Overall, Hispanic American women have higher rates of hypertension awareness, treatment, and control than Hispanic American men.
Prevalence of dyslipidemia in Hispanic Americans:
Total cholesterol 240 mg/dL: 18% of males; 17% of females
Total cholesterol 200 mg/dL (borderline): 53% of males; 48% of females

## Hypertension Is More Prevalent in Black Men Than in White Men

**Men**

**Age (years)**

**0**

**20**

**40**

**60**

**80**

**100**

**18-39**

**40-59**

**≥****60**

- Error bars indicate 95% confidence intervals.  Data are weighted to the US population.
- Hajjar and Kotchen. *JAMA.* 2003;290:199-206.

**Notes:**
Hypertension is more prevalent among black men than among white men of comparable age.
Prevalence increases with age in black men.
Black men aged 60 years show the highest prevalence of hypertension.

## Hypertension Is More Prevalent in Black Women Than in White Women

- Error bars indicate 95% confidence intervals.  Data are weighted to the US population.
- Hajjar and Kotchen. *JAMA.* 2003;290:199-206.

**Hypertension Prevalence (%)**

**Women**

**Age (years)**

**18-39**

**40-59**

**≥****60**

**0**

**20**

**40**

**60**

**80**

**100**

**Notes:**
As is true for their male counterparts, black women have a higher prevalence of hypertension than white women of comparable age.
Hypertension becomes more prevalent with age in black women.
Black women aged 60 years show the highest prevalence of hypertension.

## Hypertension Is as Prevalent in Hispanic Men as in White Men

**Men**

**Age (years)**

**0**

**20**

**40**

**60**

**80**

**100**

- Error bars indicate 95% confidence intervals.  Data are weighted to the US population.
- Hajjar and Kotchen. *JAMA.* 2003;290:199-206.

**18-39**

**40-59**

**≥****60**

**Notes:**
Rates of hypertension are similar in Hispanic and white men.
Hispanic men exhibit an age-related increase in the incidence of hypertension.

## Hypertension Is as Prevalent in Hispanic Women as in White Women

**Non-Hispanic white**

**Hispanic  (Mexican American)**

**Hypertension Prevalence (%)**

**Women**

**Age (years)**

**18-39**

**40-59**

**≥****60**

**0**

**20**

**40**

**60**

**80**

**100**

- Error bars indicate 95% confidence intervals.  Data are weighted to the US population.
- Hajjar and Kotchen. *JAMA.* 2003;290:199-206.

**Notes:**
Among Hispanic women, hypertension rates are similar to those observed in white women.
Hispanic women also show an age-related increase in the prevalence of hypertension.

## Hypertension Is Largely Uncontrolled Across Ethnic Groups

- Flack et al. *J Clin Hypertens*. 2003;5(suppl 1):5-11.

**Non-Hispanic**** whites **
**(n=32.8 million)**

**Non-Hispanic****African Americans**
**(n=5.7 million)**

**Mexican****Americans****(n=1.3 million)**

**0**

**20**

**40**

**60**

**80**

**100**

- Percent

**24**

**24**

**15**

**29**

**25**

**17**

**17**

**19**

**31**

**27**

**41**

**32**

**Notes:**
Data on hypertension from NHANES III participants were used to determine prevalence, management, and treatment outcome:
Awareness of hypertension among non-Hispanic African Americans is relatively high, although treatment and control are suboptimal, as they are for the white population.  Only 56% of African American and 53% of white patients with hypertension receive treatment; respective figures for hypertension control(<140/90 mm Hg) are only 25% and 24%.
A failure to recognize hypertension compounded by undertreatment lowers positive outcomes among Mexican Americans; 41% of those with hypertension are unaware of their condition; only 40% are treated; and 15% achieve target BP levels.

## Overview of Cardiac Morbidity and Mortality Among Hispanics

- Puerto Ricans have worse CV health status than Mexican- or Cuban-Americans
- Less improvement in CV morbidity compared with whites and African Americans
- Hispanic American women have higher HTN awareness, treatment, control than Hispanic-American men
- High prevalence of dyslipidemia

**Notes:**
Puerto Ricans have a worse cardiovascular status than Mexican or Cuban Americans.
Hispanic Americans, as a group, have shown less improvement in CV morbidity compared with non-Hispanic whites.
Overall, Hispanic American women have higher rates of hypertension awareness, treatment, and control than Hispanic American men.
Dyslipidemia is highly prevalent in Hispanic Americans.

## JNC 7 Blood Pressure (BP) Classification

- *Classification for ages 18 years and older.
- JNC 7. *JAMA*.  2003;289:2560-2572.

- Normal	<120	 and	<80	Encourage
- Prehypertension	120-139	or	80-89	Yes
- Stage 1hypertension	140-159	or	90-99	Yes
- Stage 2hypertension 	≥160	or	≥100	Yes

**Systolic BP,**
** ****mm Hg***

**BP**
**Classification**

**Lifestyle****Modification**

**Diastolic BP, ****mm Hg**

**Notes:**
The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) provides new guidelines for prevention and management of this highly prevalent disease. 
JNC 7 classifies blood pressure (BP) as follows: systolic BP (SBP) of 120-139 mm Hg or a diastolic BP (DBP) of 80-89 mm Hg is considered prehypertension; SBP/DBP 140-159 or 90-99 mm Hg indicates stage 1 hypertension; SBP 160 mm Hg or DBP 100 mm Hg denotes stage 2 hypertension, which requires health-promoting lifestyle modifications to prevent CVD.

## JNC 7 Recommends Lower BP Goals for Patients at Higher Risk for CVD

| Patient type | Goal |
| --- | --- |
| Patients with diabetes | <130/80 mm Hg |
| Patients with chronic kidney disease | <130/80 mm Hg |

- For the general population, BP goal remains unchanged (<140/90 mm Hg)

**Notes:**
JNC 7 provides new guidelines for prevention and management of hypertension.
The BP goal for individuals without substantial comorbidity is <140/90 mm Hg.
Patients with diabetes or chronic renal failure should aim for a BP <130/80 mm Hg.

## JNC 7: Considerations for Special Populations

- Treatment generally similar for all demographic groups
- Socioeconomic factors and lifestyle important barriers to BP control
- Prevalence, severity of hypertension increased in blacks

- JNC 7. *JAMA*. 2003;289:2560-2672.

**Notes:**
The treatment of hypertension is generally similar across all demographic groups.
Socioeconomic factors and lifestyle are important barriers to BP control in minority populations.
The prevalence, severity, and impact of hypertension are increased in blacks, who also demonstrate a reduced BP response to certain types of antihypertensive monotherapy.

## JNC 7: Considerations for Special Populations (cont’d)

- JNC 7. *JAMA*. 2003;289:2560-2672.

- JNC 7: Considerations for Special Populations (cont’d)

- Reduced BP responses to monotherapy with beta-blockers, ACE inhibitors, or ARBs, versus diuretics or CCBs, in blacks
- Adding adequate doses of a diuretic usually eliminates these differences

**Notes:**
The reduced BP response to monotherapy among blacks involves major drug classes: beta-blockers, angiotensin-converting enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs), compared with diuretics and calcium-channel blockers (CCBs).
These differential responses are largely eliminated by drug combinations that include adequate doses of a diuretic.

## JNC 7: Compelling Indications for Individual Drug Classes

**x**

- Recurrent stroke prevention

- MI = myocardial infarction; CAD=coronary artery disease; Aldo Ant = aldosterone antagonist.
- *Based on benefits from outcome studies or existing guidelines, the compelling indication is managed in parallel with the BP.
- JNC 7. *JAMA*. 2003;289:2560-2672.

**x**

**x**

- Chronic kidney disease

- Aldo Ant

- CCB

- ARB

- ACE Inhibitor

- Beta-Blocker

- Diuretic

**Recommended Drugs**

**High-Risk Condition****With Compelling Indication***

**Notes:**
JNC 7 recommends thiazide diuretics, either alone or in combination with beta-blockers, ACE inhibitors, ARBs, or CCBs, as initial therapy for most patients.
ACE inhibitors and ARBs are recommended for patients with chronic renal disease.
Patients with recurrent stroke are best managed with a combination of thiazide diuretics and ACE inhibitors.
Patients with acute coronary syndromes should be treated initially with beta-blockers and ACE inhibitors.
CCBs are recommended in hypertensive patients with diabetes or with a high risk for coronary artery disease (CAD).

## Multiple Antihypertensive Agents Are Needed to Achieve Target BP

- Bakris et al. *Am J Kidney Dis.* 2000;36:646-661; Lewis et al. *N Engl J Med.* 2001;345:851-860;
- ALLHAT Officers.  *JAMA.*  2002:288;2981-2997.

**Notes:**
Clinical trials have confirmed the importance of achieving a target BP of <130/85 mm Hg to preserve renal function and reduce cardiovascular events. Hypertension and diabetes are particularly prevalent in African Americans. 
Recent data suggest even lower BP targets (eg, DBP <80 mm Hg) for optimal preservation of renal function and reduction in cardiovascular risk in patients with diabetic nephropathy.
Clinical trials that randomized patients with diabetes or renal disease demonstrate their need for at least 2 antihypertensive medications to achieve lower BP target levels.

## JNC 7: Treatment Recommendations for Minority Populations 

- JNC 7: Treatment Recommendations for Minority Populations

- Blacks: diuretics, calcium antagonists
- Hispanic Americans: follow guidelines for obesity and diabetes

**Notes:**
The JNC 7 report notes that blacks with hypertension respond better to diuretics and CCBs than to other antihypertensive classes.  
Angioedema occurs more frequently (2 to 4 times more than other groups) in black patients treated with ACE inhibitors.
JNC 7 makes no reference to Hispanic Americans other than mentioning that BP control rates are lowest in Mexican Americans and Native Americans.
JNC VI suggested that clinicians treating Hispanic patients can follow recommendations for hypertension with concomitant obesity and type 2 diabetes.  These conditions are highly prevalent among Hispanics.

## Minorities Have Less Health Insurance Coverage

- Mills. Health Insurance Coverage: 2000. US Census Bureau:  Washington, DC; 2001.
- Harris. *Diabetes Care*. 2001;24:454-459; Camarota.  *Immigration from Mexico. *Center for Immigration Studies:  Washington, DC; 2001.

**African American**

**Non-Hispanic White**

**All Hispanic**

**Mexican American**

**Foreign-born****Mexican American**

**0**

**20**

**40**

**60**

**80**

**100**

**Percentage with health insurance coverage**

**Notes:**
According to the 2000 US Census, 68% of Hispanics had health insurance, compared with 90.3% of non-Hispanic whites and 81.5% of blacks. 
Only 47.4% of foreign-born Mexican Americans living in the United States had health insurance. 
NHANES III studied samples of non-Hispanic whites, African Americans, and Mexican Americans to assess medical history and treatment of diabetes, healthcare access and use, and health status and outcomes.  Insurance coverage differed across groups: among non-Hispanic white patients <65 years of age, 91% had insurance, compared with 89% of African Americans and 66% of Mexican Americans.

## Hispanics Have Less Access to Care

- Hispanics Have Less Access to Care

- In the elderly population, Mexican Americans less likely than other Hispanics to have seen a physician
- Non–English-speaking Hispanics less likely than English-speaking Hispanics to have had a physician visit
- Hispanics less likely than African Americans or whites to use antihypertensive medication

**Notes:**
Among Hispanics, health-resource utilization by Mexican Americans is relatively low.  According to the 1988 National Survey of Hispanic Elderly People, in a representative sample of 2299 interviews, Cuban Americans (N = 714) were 2.3 times and Puerto Ricans (N = 368) 2.6 times more likely than Mexican Americans (N = 773) to have seen a physician (P<.001).
English fluency largely explains disparities in healthcare use among Hispanics.  Spanish-speaking patients interviewed in the Community Tracking Study Household Survey (1996-1997) revealed significantly lower rates of physician visits (relative risk, 0.77; 95% CI, 0.72-0.83) than non-Hispanic white patients when adjustments for predisposing need and enabling factors were made.  Use patterns did not differ significantly, however, in English-speaking Hispanic and non-Hispanic white patients.
A cross-sectional analysis of the 1992 Health and Retirement Study showed that 63.6% of 2450 non-Hispanic white, 72.6% of 939 non-Hispanic African American, and 52.5% of 345 Hispanic adults with a history of hypertension reported current medication use to control it (P<.001 across all groups).  The lower rate of use by Hispanic adults was consistent regardless of gender, insurance coverage, or health status.

## Effective Cultural-Based Programs Should Consider a Number of Variables

- Adherence to therapy depends on
- Social, economic, and personal circumstances
- Empathetic and nonjudgmental assistance from providers
- Financial concerns and employment
- Drug addiction

**Notes:**
From a larger study of 309 inner-city African American men with high BP, 19 African American men aged 33 to 49 years who had success with adherence and treatment were selected to undergo a structured interview that was later analyzed for social, personal, and cultural factors linked to adherence and treatment success. 
Three major conflicts provided insights into what influenced patients’ behaviors and decisions:
Personal – how the patient defined health (absence of symptoms and control of add-on drugs), conceptualized high BP, and interpreted treatment recommendations, along with attitudes about seeking help from professionals, concerns for their male image, and privacy.
Social – living as a black person in an inner city:  limited resources that force choices of resource allocation (eg, missing work to go to the doctor), lifestyle issues, health-related experiences of family or peers.
Cultural – the patient-provider relationship:  a caring attitude by the provider and the matching of treatment goals and procedures to the patient’s life are key to successful management of hypertension.

## Salud Para Su Corazon (Health for Your Heart) A Latino Focused Initiative

- Latino CVD Profile:
- CVD leading cause of death among Latinos
- Youthful:  Opportunity for early intervention
- Acculturation to unhealthy lifestyles
- Public Health  Dilemma:
-  English only CVH materials not reaching Spanish speaking communities
- Literal Spanish translation inefficient -cultural translation needed

**Notes:**
As I mentioned earlier, the Latino project was one of the earlier minority outreach initiatives implemented at OPEC. The Latino CVD profile includes:
-CVD is the leading cause of death
-the Latino population is a youthful population and therefore an excellent opportunity for early intervention and practice of the heart healthy lifestyle.
-Also many lifestyles that do not promote CVH are being adopted, such as increase consumption of high fat and high calorie fast foods in the the Latino diet that are more affordable and accessible in the U.S as compared to the country of origin.
-NHLBI, prior to developing the Latino project, had implemented general public national education campaigns for cardiovascular health, but as the public health messages were in English many persons in the Latino community were not reached because of language barriers.
-Also a literal Spanish translation of public health messages originally developed for English speakers was inefficient. For example, Latino diet food preferences were not included in general public documents aimed a reaching a broad audience. These nuances were important in promoting heart healthy practices.

## Who is Behind Salud Para su Corazón?

**Promotores (lay health workers)**
**Leaders and movers**
**Trusted and respected**
**Role models**
**Champions**
**A Passion for improving the health of their community**
**Willingness to be trained as outreach workers**

**Notes:**
So, who is the power behind salud?

The core of the program consists of promotores de salud—lay health workers.  LHW are key members in the health team.  Promotores are members of the communities that they serve.  Because of the established trust promotores influence their members values and behaviors.  They are effective in overcoming communication barriers because they share the language, cultural beliefs, and social and ethnic characteristics of the members of the community.  Promotores are the early adopters of the program’s lessons and, thus, are key role models in the communities. 
The promotora model is based on a naturally ocurring networks, and family and friendship linkages that exist within the latino community.

For example during the training, the promotores create the vision for their graduating group to promote Salud in their community.  This is the first step as a unified voice which marks the direction for community action!

. 

## Conclusions

- Hypertension is underdiagnosed and undertreated in African Americans and Hispanics
- CVD is the leading cause of death in both populations

**Notes:**
Hypertension is underdiagnosed and undertreated in African Americans and Hispanics.
CVD is the leading cause of death in both populations.

## Conclusions (cont’d)

- New guidelines recommend pharmacotherapy to lower BP in both populations
- Multiple medications are usually required
- More aggressive screening and comprehensive, culturally sensitive risk management may increase BP control and decrease cardiovascular morbidity and mortality in African Americans and Hispanics

**Notes:**
New guidelines recommend pharmacotherapy to lower BP in both African Americans and Hispanics.
In most multicultural patients, multiple medications are required to achieve goal BP.
More-aggressive screening and comprehensive, culturally sensitive risk management may increase BP control and decrease cardiovascular morbidity and mortality in African Americans and Hispanics.