Reviews and Notes: Cardiology: Pathophysiology of Hypertension in Blacks

Pathophysiology of Hypertension in Blacks

John C. S. Fray and Janice G. Douglas; eds. 299 pages. New York: Oxford University Press; 1993. $85.00.

Hypertension is more prevalent, severe, complicated, and difficult to manage in black patients than in white. Although considerable evidence suggests that genetic, environmental, sociocultural, and psychosocial factors contribute to the pathogenesis of hypertension in blacks, and many anatomic, physiologic, and pharmacologic differences between hypertension in blacks and whites have been defined, our understanding of this disorder remains limited and the effectiveness of our therapeutic approaches suboptimal. Perhaps, as the editors of this text suggest, key reasons for the limited therapeutic success are a failure to appreciate fully the effects of socioeconomic and psychosocial factors in the pathogenesis of hypertension in blacks, a lack of adequate knowledge of the physiology of the disease, and a lack of adequate conceptual paradigms to guide research.

Fray and Douglas have attempted to address these issues by compiling a comprehensive, authoritative description of the physiologic basis of hypertension in blacks and effective therapeutic strategies, taking into consideration the effects of biologic, psychosocial, behavioral, environmental, and sociocultural influences. The book is organized into four sections. The first offers possible origins of hypertension in blacks. Grim and Wilson discuss their intriguing—although controversial—hypothesis that hypertension in blacks is a consequence of the slave trade, particularly the “middle passage,” and that the observed increased salt sensitivity is an evolutionary result of the need for enhanced sodium conservation mechanisms. In another chapter, Falkner argues for a genetic defect, but one that resides in the insulin-stimulated glucose uptake system and gives rise to hyperinsulinemia and insulin resistance.

The second section of the book provides detailed discussions of several conceptual models that bring together sociocultural and psychosocial factors and their effect on the physiologic mechanisms that raise blood pressure. Several chapters explore the ways in which psychosocial, cultural, and economic stresses may induce physiologic changes that lead to chronic elevation of blood pressure in blacks.

The third section features chapters on the physiologic consequences of salt sensitivity, nutritional factors, intracellular ionic changes, and renin in blacks. The final section includes a chapter on Fray's equilibrium model, which seeks a unifying perspective, and a chapter on rational therapeutic strategies for evaluating and treating hypertension in blacks.

This comprehensive text is intended primarily for researchers and educators. However, others interested in the subject should find it a useful reference as well. Most readers should find the introductory chapter to be especially useful. It provides an overview, summary, and synthesis of the material to follow. Two illustrations in this chapter effectively summarize the role of psychosocial stressors in the pathogenesis of hypertension in blacks, bring together the main features of the evidence presented in subsequent chapters, and lead to the conclusion that because psychosocial stressors are the primary initiating factors of hypertension in blacks the term “essential hypertension” might more appropriately be referred to as “psychosocial stressor-induced hypertension”.

• Copyright ©2004 by the American College of Physicians