Clinical research study
Outcomes with Angiotensin-converting Enzyme Inhibitors vs Other Antihypertensive Agents in Hypertensive Blacks

https://doi.org/10.1016/j.amjmed.2015.04.034Get rights and content

Abstract

Background

Angiotensin-converting enzyme inhibitors are used widely in the treatment of patients with hypertension. However, their efficacy in hypertensive blacks when compared with other antihypertensive agents is not well established.

Methods

We performed a cohort study of patients using data from a clinical data warehouse of 434,646 patients from New York City's Health and Hospitals Corporation from January 2004 to December 2009. Patients were divided into the following comparison groups: angiotensin-converting enzyme inhibitors vs calcium channel blockers, angiotensin-converting enzyme inhibitors vs thiazide diuretics, and angiotensin-converting enzyme inhibitors vs β-blockers. The primary outcome was a composite of death, myocardial infarction, and stroke. Secondary outcomes included the individual components and heart failure.

Results

In the propensity score-matched angiotensin-converting enzyme inhibitors vs calcium channel blocker comparison cohort (4506 blacks in each group), angiotensin-converting enzyme inhibitors were associated with a higher risk of primary outcome (hazard ratio [HR], 1.45; 95% confidence interval [CI], 1.19-1.77; P = .0003), myocardial infarction (HR, 3.40; 95% CI, 1.25-9.22; P = .02), stroke (HR, 1.82; 95% CI, 1.29-2.57; P = .001), and heart failure (HR, 1.77; 95% CI, 1.30-2.42; P = .0003) when compared with calcium channel blockers. For the angiotensin-converting enzyme inhibitors vs thiazide diuretics comparison (5337 blacks in each group), angiotensin-converting enzyme inhibitors were associated with a higher risk of primary outcome (HR, 1.65; 95% CI, 1.33-2.05; P < .0001), death (HR, 1.35; 95% CI, 1.03-1.76; P = .03), myocardial infarction (HR, 4.00; 95% CI, 1.34-11.96; P = .01), stroke (HR, 1.97; 95% CI, 1.34-2.92; P = .001), and heart failure (HR, 3.00; 95% CI, 1.99-4.54; P < .0001). For the angiotensin-converting enzyme inhibitors vs β-blocker comparison, the outcomes between the groups were not significantly different.

Conclusions

In a real-world cohort of hypertensive blacks, angiotensin-converting enzyme inhibitors were associated with a higher risk of cardiovascular events when compared with calcium channel blockers or thiazide diuretics.

Section snippets

Patient Population

Data from the New York City Health and Hospital Corporation's clinical data warehouse encompassing more than 1.8 million patients from its inception on January 2004 to December 2009 were chosen. The Health and Hospital Corporation consists of 11 acute care hospitals, 6 diagnostic and treatment centers, 4 long-term care facilities, a certified home health care agency, and more than 80 community health clinics, which provide care for approximately one fifth of all general hospital discharges and

Angiotensin-Converting Enzyme Inhibitors vs Calcium Channel Blockers

Of the 434,646 patients with hypertension, 11,144 black patients taking angiotensin-converting enzyme inhibitors and 6044 black patients taking calcium channel blockers satisfied our inclusion criteria. The baseline characteristics of patients taking angiotensin-converting enzyme inhibitors vs calcium channel blockers are outlined in Table 1. Propensity score matching matched 9012 black patients (4506 in each group) with a similar propensity score. Post-matching, the absolute standardized

Discussion

The results of the study with data derived from a real-world clinical practice cohort of hypertensive blacks showed that angiotensin-converting enzyme inhibitors were associated with worse cardiovascular outcomes when compared with calcium channel blockers or thiazide diuretics. However, the outcomes with angiotensin-converting enzyme inhibitors were largely similar to that of β-blockers (except worse outcomes for heart failure noted with angiotensin-converting enzyme inhibitors).

Conclusions

In this largest cohort of hypertensive blacks, the use of angiotensin-converting enzyme inhibitors was associated with worse cardiovascular outcomes when compared with the use of calcium channel blockers or thiazide diuretics. The data support the antihypertensive choice recommended by major national and international guideline committees for hypertensive blacks. These relationships should be considered when treating hypertensive blacks and should be tested in well-powered future randomized

References (33)

  • S.T. Normand et al.

    Validating recommendations for coronary angiography following acute myocardial infarction in the elderly: a matched analysis using propensity scores

    J Clin Epidemiol

    (2001)
  • S.J. Middlemost et al.

    Effectiveness of enalapril in combination with low-dose hydrochlorothiazide versus enalapril alone for mild to moderate systemic hypertension in black patients

    Am J Cardiol

    (1994)
  • National Institute for Health and Care Excellence

    Hypertension: Clinical management of primary hypertension in adults. NICE guidelines [CG127]

    (2011)
  • P.A. James et al.

    2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8)

    JAMA

    (2014)
  • G. Mancia et al.

    2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC)

    J Hypertens

    (2013)
  • S. Yusuf et al.

    Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators

    N Engl J Med

    (2000)
  • S.D. Solomon et al.

    Effect of candesartan on cause-specific mortality in heart failure patients: the Candesartan in Heart failure Assessment of Reduction in Mortality and morbidity (CHARM) program

    Circulation

    (2004)
  • W. Zidek et al.

    First-line antihypertensive treatment in patients with pre-diabetes: rationale, design and baseline results of the ADaPT investigation

    Cardiovasc Diabetol

    (2008)
  • A.L. Taylor et al.

    Should ethnicity serve as the basis for clinical trial design? Importance of race/ethnicity in clinical trials: lessons from the African-American Heart Failure Trial (A-HeFT), the African-American Study of Kidney Disease and Hypertension (AASK), and the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT)

    Circulation

    (2005)
  • J.T. Wright et al.

    Outcomes in hypertensive black and nonblack patients treated with chlorthalidone, amlodipine, and lisinopril

    JAMA

    (2005)
  • ALLHAT Officers

    Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT)

    JAMA

    (2002)
  • T. Morimoto et al.

    An evaluation of risk factors for adverse drug events associated with angiotensin-converting enzyme inhibitors

    J Eval Clin Pract

    (2004)
  • J.T. Wright et al.

    Effect of blood pressure lowering and antihypertensive drug class on progression of hypertensive kidney disease: results from the AASK trial

    JAMA

    (2002)
  • L.C. Reardon et al.

    Hyperkalemia in outpatients using angiotensin-converting enzyme inhibitors. How much should we worry?

    Arch Intern Med

    (1998)
  • N.A. Dreyer

    Good ReseArch for Comparative Effectiveness (GRACE) Principles

  • W.A. Ray

    Evaluating medication effects outside of clinical trials: new-user designs

    Am J Epidemiol

    (2003)

    • Cited by (19)

    • Hypertension in African Americans

      2023, Hypertension: A Companion to Braunwald's Heart Disease

    • Hypertensive Disorders of Pregnancy

      2020, Clinics in Perinatology
      Citation Excerpt :

      In addition to taking into consideration recognized side effects for each of the antihypertensive medications, it is important to note that patients may respond differently to one medication and not another. The non-pregnant medical literature has demonstrated that calcium channel blockers (CCBs) to be more effective in African American patients.49 Consequently, the National Institute for Health and Clinical Excellence clinical practice guidelines for hypertension recommend CCBs as the initial therapy.50

    • Cardiovascular Health Disparities in Underserved Populations

      2019, Physician Assistant Clinics
      Citation Excerpt :

      Effective combinations include beta adrenoceptor antagonist/diuretic, ACEI/diuretic, ACEI/calcium channel antagonist, and angiotensin receptor antagonist/diuretic. Despite these data on the effectiveness of ACEIs, other studies suggest that ACEIs were associated with a greater risk of cardiovascular events when compared with CCBs or thiazide diuretics.117 ACEI-based therapy was superior to either a BB- or CCB-based regimen and a CCB-based regimen combined with strict BP control may be the next best choice to an ACEI-based regimen in this population.118

    • Hypertension in black patients

      2018, JMV-Journal de Medecine Vasculaire

    • Hypertension in African Americans

      2018, Hypertension: A Companion to Braunwald's Heart Disease

    • An enhanced appreciation of cultural competency: Get off your island!

      2017, Journal of the American Pharmacists Association
      Citation Excerpt :

      For example, Ashkenazi Jews are genetic carriers of rare diseases such as Tay-Sachs and Gaucher diseases.2 Studies have shown less mean blood pressure response and worse cardiovascular outcomes with angiotensin-converting enzyme inhibitor (ACEI) monotherapy versus monotherapy with calcium channel blockers or thiazide diuretics in African Americans.3-5 Patients of Asian ancestry who possess the HLA-B*1502 allele have an increased incidence of carbamazepine-induced cutaneous reactions.6

    View all citing articles on Scopus

    Funding: This project was supported by a grant (R01HS018589) from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of Agency for Healthcare Research and Quality. GO's effort was also supported by a K24 grant from the National Institutes of Health (K24HL111315).

    Conflict of Interest: None.

    Authorship: All authors had access to the data and played a role in writing this manuscript.

    View full text
    Copyright © 2015 Elsevier Inc. All rights reserved.