Importance of the Hispanic heritage regarding diagnosis and management of hypertension

Abstract

Hypertension (HTN) is a very prevalent and growing clinical problem that is not always promptly diagnosed and ∼6% of US adults remain undiagnosed. Though numerous risk factors have been linked to the development of HTN, ethnicity has traditionally been simply considered as a significant risk among non-Hispanic Blacks. However, emerging data seems to suggest that Hispanics, the largest and fastest-growing minority in the USA, might have rates of uncontrolled HTN that significantly exceeds the rates observed for non-Hispanic whites. Unfortunately, paucity of a significant Hispanic representation in major clinical trials has raised significant healthcare concerns regarding our true understanding of the meaning of HTN and associated cardiovascular consequences among this ethnic group. Consequently, there is urgency not only in having a better understanding of HTN among Hispanics, but also to examine the potential factors that may play a role in regulating the expression of HTN and its associated cardiovascular manifestations in this ethnic group.

Keywords:

• Diabetes
• evidence-based medicine
• hypertension
• Hispanics
• latinos
• obesity
• population studies
• renal dysfunction.

Hypertension (HTN) is a very prevalent clinical problem not only being currently diagnosed in one out of every three US adults; but also undiagnosed HTN continues to plague ∼6% of all US adults that are silently at risk for developing adverse cardiovascular (CVD) events [1-3].

Though numerous risk factors have been linked to the development of HTN [2,4], ethnicity has traditionally being simply considered a significant risk among non-Hispanic Blacks [5-8]. However, emerging data seems to suggest that Hispanics, the largest and fastest-growing minority in the USA, might have rates of uncontrolled HTN that significantly exceeds the rates observed for non-Hispanic whites [9,10]. Specifically, although based on limited epidemiological data, HTN-related death rates among Hispanics are mostly seen among Puerto Rican Americans [11]. Paucity of a significant Hispanic representation in major clinical trials has raised significant healthcare concerns regarding our true understanding of the meaning of HTN and associated CVD consequences among this ethnic group. The latter is clinically relevant not only because the known diverse cultural and racial heterogeneity of Hispanics that include individuals of Mexican origin, Puerto Ricans, individuals from Cuban, Dominican Republic, the rest of the Caribbean, as well as all of Central and South America add to the cultural and genetic pool diversity of the Hispanic ethnic group [12,13], but also because the current aggregate minority is projected to become the majority by 2042 [14,15]. Aside from the impact caused by HTN to the US economy in 2010 estimated around $76.6 billion [16], the full human impact HTN and its associated CVD consequences might have is beyond our comprehension. Therefore, it is critically important that efforts are not only directed to enhance our understanding of HTN among Hispanics; but also to better comprehend how the diverse heritage of this ethnic group affects HTN. Unfortunately, aside from one of the concluding statements made by the previous Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) that “sufficient numbers of Mexican Americans, other Hispanic Americans…have not been included in most of the major clinical trials to allow reaching strong conclusions about their responses to individual antihypertensive therapies [17]”. The recently published JNC 8 failed to offer any specific guideline or recommendation regarding HTN on Hispanics [18].

It is therefore urgent that as health professionals, not only we become more sensitive to this ever-growing clinical burden of HTN; but also aware for the need of hardcore data that would ultimately address how this unique amalgamation of diverse Hispanic heritages, customs, traditions and beliefs have in modifying both clinical expression of HTN and its associated CVD manifestations. Consequently, this should serve as a call to action to get clinical researchers of different medical specialties and disciplines not only involved in recruiting Hispanic individuals, but also to study the particular devastating effects HTN might exert in this ethnic group. Furthermore, we should all feel compelled to find answers to many unresolved issues such as what is the potential effect that ancestral origin might have had on salt-sensitivity or how both diurnal and nocturnal variation varies among Hispanics, particularly in Caribbean Hispanics that have a greater Afro-American influence [19]. Similarly, the association between diabetes and HTN that appears to be more prevalent among Puerto Rican Hispanics offers the unique opportunity to study the combined impact of these two conditions [20-22].

This is a very timely and important topic that requires our immediate attention and effective intervention. The time is now to examine the potential effect that genetic drift might have in both the expression of HTN and its associated CVD manifestations.

Declaration of interest

The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.