ACE Inhibitors May Not Be as Effective in Black Patients

Hypertensive Blood Pressure
Hypertensive Blood Pressure
Black patients may be less response to antihypertensive treatment with angiotensin-converting enzyme inhibitors than white patients.

Angiotensin-converting enzyme (ACE) inhibitor-based treatment regimens may not work as well at improving cardiovascular outcomes in black patients with hypertension compared with white patients, according to study findings published in the Journal of the American College of Cardiology.

Although ACE inhibitors are commonly prescribed to lower blood pressure in patients with hypertension, previous findings from randomized controlled clinical trials suggested that ACE inhibitor-based treatment regimens may not yield the same benefits in black patients. This is the first study to compare the treatments’ performance in the two populations in a real-world setting.

“Our findings demonstrate that hypertensive blacks on an ACE inhibitor-based regimen had higher rates of [cardiovascular] events and were at higher risk of the composite outcome of all-cause mortality, nonfatal AMI, or nonfatal stroke than whites on an ACE inhibitor-based regimen,” wrote study author Gbenga Ogedegbe, MD, MPH, of New York University Langone Medical Center, and colleagues.

They examined data from nearly 60,000 patients with high blood pressure who received care within New York City’s Health and Hospital Corporation from January 2004 to December 2009. In addition to a hypertension diagnosis, all participants had been prescribed an ACE inhibitor, beta blocker, thiazide-type diuretic, or calcium-channel blocker for at least six months.

Individuals were divided into two groups based on self-reported race, and then subdivided based on whether or not they received treatment with ACE inhibitors. The researchers compared the risk of composite outcome across races and treatment groups using weighted Cox proportional hazard models.

They followed the participants for up to 2,000 days, and examined laboratory tests, clinical diagnoses, or diagnosis-derived events that occurred at least 28 days after the patient began antihypertensive medication to determine rates of all-cause mortality, stroke, and acute myocardial infarction (MI).

Participants who had a prior diagnosis of nonfatal acute MI, nonfatal stroke, congestive heart failure (CHF), or kidney failure before taking antihypertensive medication were excluded from the study.

A final analysis of 59,319 new users of ACE inhibitors, 47% of whom were black, showed that black patients who were treated with an ACE inhibitor had higher rates of acute MI (0.46% vs 0.26%), stroke (2.4% vs 1.9%), and CHF (3.75% vs 2.25%) than black patients who were not treated with an ACE inhibitor.

ACE inhibitor use in black patients had a statistically significant rate of poor cardiovascular outcomes (8.7% vs 7.7%), but this did not occur in white patients (6.4% vs 6.7%). Black patients who received ACE inhibitor treatment were no more likely to develop adverse effects than white patients.

“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,” Dr. Ogedegbe said during a press release.

The researchers recommended initiating other antihypertensive therapies to preclude the use of ACE inhibitors, as well as conducting additional research to understand the mechanisms that create disparate effectiveness of ACE-inhibitor medication in black patients and white patients.

Disclosures: Dr. Ogedegbe had grant-funded support from the National Heart, Lung, and Blood Institute.


  1. Ogedegbe G, Shah NR,  Phillips C, Goldfeld K et al.  Comparative Effectiveness of Angiotensin-Converting Enzyme Inhibitor-Based Treatment on Cardiovascular Outcomes in Hypertensive Blacks Versus Whites. J Am Coll Cardiol. 2015; 66:1224-33.