What is hypertensive cardiomyopathy and why is it more common in Black men?

Hypertensive cardiomyopathy is a pattern of cardiac remodeling driven by sustained pressure overload: chronic elevated blood pressure causes progressive left ventricular hypertrophy (the heart muscle thickens in response to working harder against elevated resistance), then diastolic dysfunction (the thickened ventricle becomes stiffer and fills less efficiently), and eventually systolic dysfunction and heart failure. This is the predominant heart failure phenotype in Black Americans, not the ischemic cardiomyopathy from coronary artery disease that dominates in white Americans.

The incidence numbers quantify what "more common" means: heart failure incidence of 9.1 per 1,000 person-years in Black Americans versus 2.4 per 1,000 person-years in white Americans. Heart failure before age 50 is twenty times more frequent in Black Americans than in white Americans. These numbers emerge from decades of higher hypertension prevalence (57% of Black men have hypertension), higher rates of uncontrolled hypertension, salt-sensitive physiology that makes control harder, and a medication prescribing gap where ACE inhibitors, less effective in Black patients, were prescribed as first-line treatment before the ALLHAT trial data changed guidelines. The heart failure begins as a blood pressure problem and becomes a structural problem. The prevention window is the blood pressure stage. (Yancy, JAMA, 2024)

Cardiologist's calibrated position, Solid (1) for the mechanistic pathway and the epidemiology of hypertensive cardiomyopathy in Black Americans.

What to do: Know your blood pressure. Not your annual physical office reading, your home average over two weeks. A blood pressure of 142/90 that appears "borderline" in the office is progressive left ventricular hypertrophy if it has been running at that level for several years. The heart is remodeling in silence.

For the full picture, read The Cardiac Inheritance.