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Hypertension is a common health condition that affects 1 in 3 adults (32.6%) in the US.1  However, hypertension is not evenly distributed in the US population; the incidence of hypertension is disproportionately higher among Black Americans than White Americans, affecting 42% of Black men and 44% of Black women.2

The prevalence of hypertension and of cardiovascular disease among Black women are particularly high.3 Compared with White women, Black women are 60% more likely to have high blood pressure.4 Black women also are more likely to be diagnosed with hypertension at a younger age, have higher blood pressure readings, and die earlier from complications related to hypertension compared with White women.5,6 In 2017, Black men and women were 20% more likely to die from heart disease than non-Hispanic White patients.4

Despite the availability of effective medications and tailored therapies for Black patients, disease management is less effective among Black patients than White patients, yielding higher mortality rates.1-7 In a study by Jamerson et al, Black women were less likely than White women to achieve blood pressure control. After 5 years, 59% of Black women and 65% of White women had blood pressure less than 140/90 mm Hg .7  

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Risk Factors for Hypertension in Black Women

The high rate of hypertension among Black women stems from biological, genetic, environmental, and social factors. Biological factors associated with higher risk of hypertension include aortic stiffness, vascular remodeling, and endothelial dysfunction.8 One biological factor of note involves response to stress. Hypertension in Black women arises, in part, from augmented adrenergic vascular reactivity and reduced vasodilator responses to stress. The body activates its hypertensive stress response more often and keeps the vessels constricted for longer periods of time in Black women than in non-Black women.8

Patients may have a genetic predisposition to this biological response. Several genes implicated in activation of the renin-angiotensin-aldosterone system (RAAS) have been studied in Black populations and have revealed a surprising number of novel variants and pathways possibly implicated in the pathogenesis of hypertension. Among them, a variant of the armadillo repeat containing 5 (ARMC5) gene appears to be a rare inherited cause of primary aldosteronism and, consequently, low-renin hypertension in Black individuals.9

Environmental factors that contribute to hypertension include limited physical activity, smoking, alcohol use, and institutional racism.4 Other causes of hypertension among Black men and women include diet, specifically a Southern diet, defined in the REGARDS study as a high intake of fried foods, organ meats, processed meats, egg and egg dishes, added fats, high-fat dairy foods, sugar-sweetened beverages, and bread.10,11

The Southern diet has been associated with an increased risk of incident stroke, coronary heart disease, end-stage renal disease, chronic kidney disease, sepsis, fatal cancer, and cognitive decline.12-16  The Southern diet as well as a high dietary ratio of sodium to potassium have been shown to be mediating factors for the difference in stroke risk between Black and White individuals. Less adherence to the Dietary Approaches to Stop Hypertension (DASH) diet (vegetables, fruits, and low-fat dairy products) was a significant mediating factor among Black and White women.11

In 2018, Howard et al found that Black women have a higher mean BMI and larger waist circumference than White women, and both waist circumference and BMI are significantly associated with incident hypertension.10 Among Black women, BMI was the second-largest mediating factor for hypertension and larger waist circumference was the third-largest mediating factor. The prevalence of obesity in Black women has doubled over the last 2 decades.17

The higher incidence of hypertension among Black women has been linked to social factors such as low income (≤ $35,000) and education level (high school degree or less).10 A lower socioeconomic status may be associated with living in a high-stress or segregated environment with higher crime rates and more marital divisions, which has been linked to increased blood pressure among Black individuals.8,18 Still et al found that Black women often take on the role of caregiver for older family members and children, as well as take care of the home, which increases their susceptibility to psychological stressors.18

A number of studies have focused on the societal factor of minority stress and its association with health outcomes. Racial discrimination and stressors related to minority status have been associated with hypertension and increased cardiometabolic health risks in Black women.19-22