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Does race belong in the hypertension guidelines?

Journal of Human Hypertension volume 35, pages 940–941 (2021)Cite this article

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Angela Saini’s book “Superior: the Rise of Race Science” has shone light on the dogmatic inclusion of ethnicity in the British NICE hypertension guidelines [1]. It is not the first-time ethnicity has been used in treatment of medical conditions: a combination of hydralazine and isosorbide dinitrate (BiDil) used to treat heart failure was marketed as a drug for Black people [2]. Many have criticised this but it has paved the way for the inclusion of more representative population samples in clinical trials [3].

The NICE guidelines recommend that angiotensin converting enzyme (ACE) inhibitors are not recommended for Afro-Caribbean people as they show “inadequate response to ACE inhibitors”. The justification is that Black people are phenotypically and genetically different to the other members of the human race. Phenotypically, Black people have been thought to be low-renin responders [4, 5]. Despite this renin activity varies independently of blood pressure so basing treatment decisions based on renin activity alone seems myopic [4]. A meta-analysis by Kaufman and Cooper found a minimal 4 mmHg difference in systolic blood pressure response to ACE inhibitors between White and Black populations [6]. Lastly, a recent review article examined several guidelines and monotherapy hypertension trials suggested there is conflicting evidence indicating worse cardiovascular and cerebrovascular morbidity and mortality from use of ACE inhibitors and angiotensin receptor blockers (ARBs) in Black patients with hypertension compared to White patients [7]. It is important to acknowledge that the location of many of these studies were in the UK and USA contributing to significant geographic bias and lack of applicability to Black people in other countries.

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Authors and Affiliations

  1. Institute of Population Health Sciences, Barts and The London School of Medicine and Dentistry, Yvonne Carter Building, 58 Turner Street, London, E1 2AB, UK

    Dipesh P. Gopal

  2. The Essex Cardiothoracic Centre, Basildon, SS16 5NL, UK

    Rohin Francis

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Correspondence to Dipesh P. Gopal.

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No honoraria paid to promote Angela Saini’s book “Superior: the rise of race science”. No further competing interests.

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Gopal, D.P., Francis, R. Does race belong in the hypertension guidelines?. J Hum Hypertens 35, 940–941 (2021). https://doi.org/10.1038/s41371-020-00414-2

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