Difference in blood pressure response to ACE-Inhibitor monotherapy between black and white adults with arterial hypertension: a meta-analysis of 13 clinical trials

Abstract

BackgroundAmong African-Americans adults, arterial hypertension is both more prevalent and associated with more complications than among white adults. Hypertension is also epidemic among black adults in sub-Saharan Africa. The treatment of hypertension among black adults may be complicated by lesser response to certain classes of anti-hypertensive agents.MethodsWe systematically searched literature for clinical trials of ACE-inhibitors among hypertensive adults comparing blood pressure response between whites and blacks. Meta-analysis was performed to determine the difference in systolic and diastolic blood pressure response. Further analysis including meta-regressions, funnel plots, and one-study-removed analyses were performed to investigate possible sources of heterogeneity or bias.ResultsIn a meta-analysis of 13 trials providing 17 different patient groups for evaluation, black race was associated with a lesser reduction in systolic (mean difference: 4.6 mmHg (95% CI 3.5-5.7)) and diastolic (mean difference: 2.8 mmHg (95% CI 2.2-3.5)) blood pressure response to ACE-inhibitors, with little heterogeneity. Meta-regression revealed only ACE-inhibitor dosage as a significant source of heterogeneity. There was little evidence of publication bias.ConclusionsBlack race is consistently associated with a clinically significant lesser reduction in both systolic and diastolic blood pressure to ACE-inhibitor therapy in clinical trials in the USA and Europe. In black adults requiring monotherapy for uncomplicated hypertension, drugs other than ACE-inhibitors may be preferred, though the proven benefits of ACE-inhibitors in some sub-groups and the large overlap of response between blacks and whites must be remembered. These data are particularly important for interpretation of clinical drug trials for hypertensive black adults in sub-Saharan Africa and for the development of treatment recommendations in this population.

Advances in understanding the renin-angiotensin-aldosterone system (RAAS) in blood pressure control and recent pivotal trials of RAAS blockade in heart failure and diabetic nephropathy

“…ACEIs were associated with a higher risk of primary outcome (myocardial infarction, stroke, and heart failure) compared with CCB (4,506 matched pairs; HR 1.45, 95% CI 1.19–1.77; P = 0.0003), and a higher risk for primary outcome was observed when ACEIs were compared with thiazide diuretics in AAs (5,337 matched pairs; HR 1.65, 95% CI 1.33–2.05; P < 0.0001) 90 . A meta-analysis of 13 different trials in the USA and Europe showed that SBP and diastolic BP reduction with ACEI monotherapy was consistently lower among AAs than among whites 91 . Therefore, as recommended by the members appointed to the Eighth Joint National Committee (JNC 8), initial anti-hypertensive therapy for the AA population should include a thiazide or CCB.…”

Renin‐Angiotensin System Inhibitors vs Other Antihypertensives in Hypertensive Blacks: A Meta‐Analysis

“…18 These FIGURE 3. Random-effect meta-analysis of the effects of renin-angiotensin system (RAS) inhibitors vs b-blockers on all-cause mortality, myocardial infarction, stroke, heart failure, and composite outcome.…”

Cardiovascular disease and diabetes in patients with African or Asian background

“…A meta-analysis on the efficacy of antihypertensive monotherapy in diabetes patients of African ancestry (20) shows that: beta blockers provide minimal reduction in systolic blood pressure, and difference from placebo is uncertain calcium channel blockers and thiazides both effectively lower blood pressure ACE inhibitors have little effect on diastolic blood pressure, but appear to reduce the risk of renal injury ACE inhibitors reduced blood pressure to a lesser extent in persons of African ancestry than in Caucasians -the average difference was 4.6 mm Hg in systolic and 2.8 mm Hg in diastolic pressure (21). ACE inhibitors should therefore not be the first-line drugs in cases of uncomplicated, mild or moderate hypertension in this group (21,24).…”

“…ACE inhibitors should therefore not be the first-line drugs in cases of uncomplicated, mild or moderate hypertension in this group (21,24).…”