Q J Med 1999; 92: 481
© 1999 Association of Physicians
Correspondence |
Hypertensive disease in Black patients
George Washington University Medical Centre, Washington DC
Sir,
I enjoyed reading the excellent review article on the management of Black hypertensive patients by Gibbs et al.1 Having practiced for nearly three decades in Washington, DC where nearly 3/4 of the population is Afro-American, I wish to confirm that beta-blockers and angiotensin-converting-enzyme (ACE) inhibitors are less effective at lowering high blood pressure in Black patients, due mainly to the low renin state in these patients. I also wish to make two additional comments regarding the side-effects of these two classes of antihypertensive drugs.
The beta-blockers are notorious for inducing sexual impotence, and the effect is dose-related. Therefore Black male patients tend to be non-compliant with taking the beta-blockers, although often they feel too embarrassed to report this side-effect to their physicians. Taking a sexual history from an Afro-American patient is very important, especially if he is on antihypertensive therapy.
The ACE inhibitors also have another unpleasant side-effect—cough—that is not dose-dependent.2 For the same reason that ACE-inhibitor-induced angioneurotic oedema is more common in Black patients as a result of hypersensitivity to bradykinin,3 cough is also more frequent in Black patients, especially women, taking ACE inhibitors. The increased sensitivity to bradykinin is more prominent in patients with hypertension than in normotensive subjects.3 Kinins such as bradykinin are normally degraded in part by ACE, accumulate in the lungs as a result of inhibition of ACE, and thus promote bronchospasm and cough in susceptible individuals.4 Because uncontrollable cough constitutes an embarrassment, especially in public places such as theatres and concert halls, Black patients may refuse ACE inhibitors once this effect appears.
References
1.
Gibbs CR, Beevers DG, Lip GYH. The management of hypertensive disease in Black patients.Q J Med 1999; 92:187–92.
2. Coulter DM, Edwards IR. Cough associated with captopril and enalapril. Br Med J 1987; 294:1521–3.
3. Gainer JV, Nadeau JH, Ryder D, Brown NJ. Increased sensitivity to bradykinin among African Americans. J Allergy Clin Immunol 1996; 98:283–7.[Web of Science][Medline]
4. Israili ZH, Hall WD. Cough and angioneurotic edema associated with angiotensin-converting enzyme inhibitor therapy. A review of the literature and pathophysiology. Ann Intern Med 1992; 117:234–42.
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