September 30, 2015
ACE Inhibitors Associated With Worse Cardiovascular Outcomes in African-Americans

New York—Pharmacists might raise some questions when an African-American customer presents a prescription for an angiotensin-converting-enzyme (ACE) inhibitor.

A study published recently in Journal of the American College of Cardiology points out that those drugs are associated with significantly worse cardiovascular outcomes in hypertensive African Americans compared to whites. The new comparative effectiveness research study was led by researchers in the Department of Population Health at NYU Langone Medical Center.

Study authors note that their study is unique in that it evaluates, outside of a clinical trial, racial differences in cardiovascular outcomes and mortality between hypertensive black and white patients whose treatment was initiated with ACE inhibitors.

Background information in the article states that evidence from randomized controlled trials has previously indicated that ACE inhibitors do provide the same benefits in blacks compared to whites. Part of the problem in evaluating the information, according to study authors, has been that blacks often are underrepresented in the studies, even though they have disproportionately higher rates of hypertension-related morbidity and mortality than other racial and ethnic groups.

“We know what works in clinical trials. But when you go into the real world clinical practice setting, physicians don't often translate that evidence into practice,” lead author Gbenga Ogedegbe, MD, MPH, said in an NYU press release. “This is the first study that looks at this issue in a real- world, clinical practice setting.”

For the study, the researchers used data from electronic health records of nearly 60,000 patients who have high blood pressure and received care between 2004 and 2009 within New York City’s Health and Hospital Corporation (HHC). About 35% of patients seen in the HHC system, which operates all public hospitals and clinics in New York City, are African American.

Rates of all-cause mortality, heart attack, stroke, and congestive heart failure were compared between African American and white patients who were prescribed one of four classes of antihypertensive drugs to treat high blood pressure: ACE inhibitors, beta blockers, calcium-channel blockers, or thiazide-type diuretics.

Among the black patients, ACE inhibitor use was associated with a statistically significant rate of worse cardiovascular outcomes than not using the drugs (8.7% compared to 7.7%) but not in whites (6.4% compared to 6.74%). Overall, African Americans had higher rates of acute myocardial infarction, stroke, and congestive heart failure than the similar group not on ACE inhibitors.

“ACE inhibitor–based therapy was associated with poorer cardiovascular outcomes in hypertensive blacks but not in whites,” the study authors write. “These findings confirm clinical trial evidence that hypertensive blacks have poorer outcomes than whites when treated with an ACE inhibitor–based regimen.”

“The results of this study add to a growing consensus among physicians that treatment of hypertension in blacks should not be initiated with ACE inhibitors,” Ogedegbe notes.

In January, the Joint National Committee recommended initiating other treatments besides ACE inhibitors in patients of African descent, she added, pointing out that this study could provide information for other guidelines in process.

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