New recommendations for treating hypertension in black patients: evidence and/or consensus?

Hypertension is the major cause of morbidity, mortality, and disability in black populations in the United States and increasingly worldwide. Its greater severity, resistance to treatment, and more frequent financial challenges to achieve control in this population make it critical that population-specific recommendations for hypertension management be based on the very best evidence. In 2003, the International Society of Hypertension in Blacks (ISHIB) published its first consensus statement.1 The 2003 Statement has been widely promoted as the authoritative guideline for managing hypertension in black patients. The consensus statement2 in this issue of Hypertension updates the 2003 statement, and, although the authors are careful not to call it a guideline, it may become viewed similarly. Thus, it could dramatically impact the management of hypertension in this population. The ISHIB statement has a number of commendable features. Written by a very impressive group of experts, it is a well-organized, comprehensive document providing an excellent update on the epidemiology, significance, and pathophysiology of hypertension in the black population, as well as substantial practical advice on its management. A particularly worthwhile feature is the discussion of psychosocial factors influencing blood pressure (BP) control in this population, including those related to patient-provider interaction. However, it makes several sweeping recommendations that are both unsupported by randomized clinical trial evidence and, moreover, are inconsistent with the most recent results of large randomized clinical outcome trials in black hypertensive patients. While acknowledging that less than one third of black hypertensive patients are controlled to <140/90 mm Hg, the ISHIB statement recommends substantially lower BP goals in patients already <140/90 mm Hg. In uncomplicated hypertensive patients without target organ damage, preclinical cardiovascular disease (CVD), or history of CVD, it recommends lowering the target BP from <140/90 to <135/85 mm Hg. The selection of this new BP target …