Using Angiotensin Converting Enzyme Inhibitors in African-American Hypertensives: A New Approach to Treating Hypertension and Preventing Target-Organ Damage

Abstract

Angiotensin converting enzyme (ACE) inhibitors have been avoided as an initial therapeutic option in the treatment of hypertension in African-Americans. A major reason for this has been the widespread perception of clinicians that these agents have poor blood pressure (BP) lowering efficacy in this population. Remarkably uniform and pervasive interpretations of clinical trial data have formed the basis of this clinical perception and can be summarised as follows: (1) there has been a lesser BP lowering effect of ACE inhibitors in African-Americans compared to whites, particularly at low doses; and (2) short-acting ACE inhibitors like captopril prescribed at the midpoint of its maximal total daily dose lower BP less effectively than higher doses of calcium antagonists in African-Americans. A reinterpretation of published data from these same clinical trials suggests that: (1) the majority of African-Americans have meaningful BP responses to ACE inhibitors, albeit at a higher average dose than in whites; and (2) high levels of dietary sodium intake appear to explain a significant portion of the racial differences in BP response at the lower doses of ACE inhibitors. Thus, ACE inhibitors can effectively lower BP in African-Americans. These data suggest that the clinician should not avoid these agents in African-Americans because of a presumed lack of BP lowering efficacy. Rather, we should recognise the importance of adequate drug dosing and modest reductions in dietary sodium intake in augmenting the BP lowering effect of ACE inhibitors in hypertensive African-Americans.

Effect of the Dietary Approaches to Stop Hypertension Diet and Reduced Sodium Intake on Blood Pressure Control

“…18 In addition, reduced sodium intake, which stimulates the renin-angiotensin system, improves the efficacy of angiotensin converting enzyme inhibitors and angiotensin receptor blockers. 19 These findings suggest that BP control rates will improve with the addition of DASH diet and reduced sodium intake in patients treated with at least some types of antihypertensive medication. This hypothesis remains to be tested further in clinical trials.…”

A Noninferiority Comparison of Valsartan/Hydrochlorothiazide Combination Versus Amlodipine in Black Hypertensives

“…1,2 However, blacks with hypertension do respond to appropriate (higher) doses of ACE inhibitors and ARBs. 6 The augmented BPlowering effect of drugs that target the RAS by the addition of a diuretic is accepted as another method to eliminate any …”

“…This supposed lack of effect has been attributed to the misperception that all of these patients have low-renin, salt-sensitive, volume-dependent hypertension. 5,6 In fact, blacks represent a heterogeneous population with respect to renin levels, 7 which may not accurately predict response to treatment. 8,9 Any difference in effect from other classes of antihypertensive agents is eliminated when angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) are used in higher doses or in combination with a diuretic.…”

Determinants of Blood Pressure Response to Quinapril in Black and White Hypertensive Patients

“…[1][2][3][4] More specifically, blacks with hypertension have been reported to be less responsive to monotherapy with angiotensin-converting enzyme (ACE) inhibitors, 5 ␤-blockers, 6 -8 and angiotensin receptor blockers 9 than to diuretics and calcium antagonists. Many of these same studies have reported that white hypertensive patients respond better to these antihypertensive agents than do blacks.…”