What are the considerations for an African American patient taking an Angiotensin-Converting Enzyme (ACE) inhibitor?

From the Guidelines

African Americans taking ACE inhibitors should be switched to an ARB or a single pill combination including a thiazide-like diuretic plus CCB or CCB plus ARB due to the increased risk of angioedema and potentially lower efficacy in this population. According to the 2020 international society of hypertension global hypertension practice guidelines 1, black populations have a higher risk of kidney disease, stroke, heart failure, and mortality due to physiological differences, including a suppressed RAAS. The guidelines recommend first-line pharmacological therapy as a single pill combination including a thiazide-like diuretic plus CCB or CCB plus ARB, and among RAS-inhibitors, ARBs may be preferred as angioedema is about 3 times more likely to occur with ACE inhibitors among black patients 1.

Some key points to consider in the management of hypertension in African Americans include:

• Annual screening for hypertension is advised for adults 18 years and older 1
• Lifestyle modification should place additional focus on salt restriction, increased intake of vegetables and fruits (potassium intake), weight management, and reducing alcohol intake 1
• The increased cardiovascular risk in African Americans may be due to physiological differences, including a suppressed RAAS, altered renal sodium handling, increased cardiovascular reactivity, and early vascular aging (large artery stiffness) 1

It is essential to monitor blood pressure regularly to determine the effectiveness of the medication and adjust the treatment plan as needed. Patients should never discontinue their ACE inhibitor without consulting their healthcare provider. The goal is to prioritize morbidity, mortality, and quality of life, and switching to a more effective medication or combination may be necessary to achieve optimal blood pressure control in African American patients.

From the FDA Drug Label

Although lisinopril was antihypertensive in all races studied, Black hypertensive patients (usually a low-renin hypertensive population) had a smaller average response to monotherapy than non-Black patients ACE inhibitors, including lisinopril, have an effect on blood pressure that is less in black patients than in non-blacks.

Key Points:

• Lisinopril is effective in all races, but Black patients may have a smaller average response to monotherapy.
• ACE inhibitors, including lisinopril, have a less pronounced effect on blood pressure in Black patients compared to non-Black patients.
• Concomitant administration of lisinopril and hydrochlorothiazide may reduce blood pressure in Black and non-Black patients, and any racial differences in blood pressure response may no longer be evident 2.

From the Research

ACE Inhibitors in African American Hypertensives

• ACE inhibitors have been avoided as an initial therapeutic option in the treatment of hypertension in African-Americans due to the perception of poor blood pressure lowering efficacy in this population 3.
• However, a reinterpretation of published data suggests that the majority of African-Americans have meaningful blood pressure responses to ACE inhibitors, albeit at a higher average dose than in whites 3.
• High levels of dietary sodium intake appear to explain a significant portion of the racial differences in blood pressure response at the lower doses of ACE inhibitors 3.

Treatment Recommendations

• The Eighth Joint National Committee (JNC-8) published hypertension guidelines that varied depending on patient race, with different treatment recommendations for Black and non-Black patients 4.
• For Black patients, the recommendation removed ACE inhibitors and ARBs from the algorithm, suggesting alternative treatments such as thiazide diuretics or calcium channel blockers 4, 5.
• However, some studies suggest that ACE inhibitors can be effective in African American patients, particularly when used in combination with other medications or with modest reductions in dietary sodium intake 3, 6, 7.

Efficacy and Safety of ACE Inhibitors in Black Patients

• Numerous monotherapy trials indicate that Black patients may have a reduced blood pressure response with ACE inhibitors or ARBs compared with white patients 7.
• Conversely, additional studies propose that race may not be the primary predictor of blood pressure response 7.
• Reduced efficacy is not observed in trials involving combination therapy, suggesting that ACE inhibitors or ARBs can be effective in Black patients when used in combination with other medications 7.
• Some studies suggest increased cardiovascular and cerebrovascular morbidity and mortality with ACE inhibitor or ARB monotherapy in Black patients, but data are conflicting 7.

Prescribing Patterns and Hypertension Outcomes

• National guidelines recommend different pharmacologic management of hypertension for Black/African Americans compared with non-Black patients, which may have influenced prescription patterns 6.
• Among Black/African American patients, 46.4% had uncontrolled hypertension compared with 39.0% of non-Black patients, suggesting that hypertension control remains worse in Black patients despite following race-based guidelines 6.
• An individualized approach to hypertension therapy for all patients may be more important than race-based guidelines 6.