Underutilization of Angiotensin‐Converting Enzyme Inhibitors in High‐Risk Blacks: A Case of Missed Opportunities
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Key result
African American men with coronary artery disease treated with ACE inhibitors had significantly lower mortality from CAD compared to those not taking ACE inhibitors.
Why the study?
Do ACE inhibitors reduce cardiovascular morbidity and mortality in high-risk African American patients?
Population
High-risk African American patients with cardiovascular disease, hypertension, or heart failure
Comparison
Angiotensin-converting-enzyme (ACE) inhibitors vs Avoidance or underuse of ACE inhibitors
Design
Editorial
Authors
Discussion
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Implication
ACE inhibitors should not be withheld from high-risk African American patients based on race alone, as they provide significant cardiovascular benefits, especially when used in combination therapy.
Key Points
- To evaluate the efficacy and persistent clinical underutilization of angiotensin-converting enzyme (ACE) inhibitors in high-risk Black patients with cardiovascular disease.
- Reviewed findings from a retrospective cohort of 810 African American men undergoing diagnostic coronary angiography evaluating ACE inhibitor therapy and mortality.
- Synthesized historical and contemporary clinical trial evidence (including SOLVD, ALLHAT, AASK, and ACCOMPLISH) regarding renin-angiotensin system blockade, combination therapy, and blood pressure responses across racial groups.
- In 810 African American men with coronary artery disease, ACE inhibitor treatment produced significantly lower coronary artery disease mortality compared to non-treatment (P=.006), with similar stroke mortality rates between groups.
- In the ACCOMPLISH trial, combination therapy containing the ACE inhibitor benazepril lowered systolic blood pressure from 145.1 mm Hg to 133.6 mm Hg in 1361 African American patients (P<.05).
- Prior reports of diminished response in SOLVD (death rates 12.2 vs 9.7 per 100 person-years; heart failure hospitalization 13.2 vs 7.7 per 100 person-years) were confounded by baseline socioeconomic disparities, higher diabetes rates, and lower concomitant cardioprotective medication use.
Structured PICO
Do ACE inhibitors reduce cardiovascular morbidity and mortality in high-risk African American patients?
P
Population
810 African American men who underwent diagnostic coronary angiography, evaluated retrospectively for the effect of ACE inhibitors on mortality.
E
Exposure
Angiotensin-converting-enzyme (ACE) inhibitors
C
Comparator
Avoidance or underuse of ACE inhibitors
O
Outcome
Cardiovascular morbidity and mortality
Main Result
p-value: p=.006
ACE inhibitors should not be withheld from high-risk African American patients based on race alone, as they provide significant cardiovascular benefits, especially when used in combination therapy.
Limitations
- Retrospective analysis design
Cite This Study
Keith C. Ferdinand (2009) conducted an editorial in Coronary artery disease (n=810). Angiotensin-converting-enzyme (ACE) inhibitors vs. Not taking ACE inhibitors was evaluated on Mortality from coronary artery disease (CAD) (p=.006). African American men with coronary artery disease treated with ACE inhibitors had significantly lower mortality from CAD compared to those not taking ACE inhibitors.
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