March 28, 2023

CSWN talks with Sripal Bangalore, MD, Associate Professor, New York University School of Medicine, about the comparative effectiveness of ACE inhibitor-based treatment on CV outcomes in hypertensive black and white patients. This interview was conducted at ESC 2015 in London.

Just a few months ago we did an interview with clyde yancy and at the time we were talking about you know the original 1/2 study and i was saying that it was a little controversial and his response was yet think we were talking about one of the early publications of a heft and then a very recent publication in jack heart failure and the whole concept that breakthrough

Science is really still coming out of that paper so i was trying to be a little diplomatic now yes it is a controversial area we agree now with dr. shriveled bangalore who is an md and director of research the cardiac catheterization laboratory and an associate professor of medicine at the new york university school of medicine and this is a paper that is coming

Out in jack it’s a detailed look at the comparative effectiveness of ace inhibitors in blacks versus white this really was controversial years ago is it really still yeah sure i would say that if you look at major hypertension guidelines ace inhibitors is up top right and so what has happened is people just use ace inhibitors as first-line agents for everybody

Regardless of race yeah that’s what it says and that’s what and people don’t read the fine print but there is this lingering doubt about the efficacy of ace i mean started with all had 15,000 patients and black patients were included there and there was this question maybe they’re not as effective and of course there’s all other data so but we really wanted to

See these are all subgroup analyses from large randomized routes so this parts were very small so we wanted to see what is the real-world efficacy of using an ace inhibitor and in blacks when you compare it to whites so how large was the study what did you do where who were these people yeah so you know this is a database from the health and hospital corporation

So it’s a network of many different hospitals in new york cities so being a inner-city population we do have pretty enriched group of black patients so what we did was we wanted to look at new users of ace inhibitors we define that as if somebody has not used a’s in the last six months but started ace and they should be either self declared black or white and we

Have 50,000 patients so that’s a large lot of patients and then we categorize them as whether they were using ace versus not using ace and looked at looked at their outcomes what did you find so we found something interesting so what we found was in among blacks if they were on ace there was actually an increase in the risk of composite outcomes our composite

Outcomes was death mir stroke we also found that there was increase in the risk of mi there was increase in the risk of stroke and also increase in the risk of heart failure and what we also found was there was race ace interaction in the sense that for the poor whites if you are an ace there was no harm but if you are on if you’re a black and on ace there was

Increased risk in composite outcomes and again for the white patients if they were if you are on ace there was actually a reduction in mortality with using ace now the only good news was the black ace group was no more likely to develop adverse effects than the white ace right i guess you’d that’s the that’s marginally good news i mean it obviously is mostly

A bad news situation but you did find that which was almost surprising yeah i said i think it depends on what you call adverse events all right i mean koff everything else is adverse events but for me having an mi and stroke is much more adverse event yeah now you know editorial comment by richard jay kovacs in the same issue he says the opportunity to improve

Outcomes is staggering once you look at this so just not use ace inhibitors um i wouldn’t say that i think we have to be very careful and we see this data and that the data is also supported by subgroup analysis of randomized trials in other words i’ve used ace and blanks the blood pressure control map will not be as optimal so in other words if you are using ace

For whatever reason please be reminded of this data maybe you should get add something else and so and maybe it should not be the first line that have been fought yeah because that’s what dr. kovacs was saying he said that blood pressure should be controlled with one to two alternative anti hypertensive agents after simple education of the frontline providers

Absolutely completely okay i mean that’s really what needs to be done right now it’s the the doctors themselves who need to get the data and understand that there is an issue here and that you know why we want to treat patients equally in this case dr. yancey first pointed out and got holy hell for it if you’ll pardon the expression they just respond differently

To ace inhibitor yeah absolutely that’s critical because sometimes the message gets lost you know the message usually is ace is one of the frontline agents for treatment of hypertension and sometimes we don’t think about this difference based on race so i think that’s the key message to think and you have a patient in front of you and if it is if it is a black

Patient you need to consider alternatives in fact as a follow-up to this paper we published in american journal medicine where we showed that compared to ace thiazide diuretics and ccb’s do better or for blacks and i think this is a critical message and it’s actually very consistent with the guidelines yeah it’s consistent with what dr. yancey was presented years

Ago that there are options out there that do seem to be quite effective please check jack for this particular paper and for cardial source world news i’m executive editor rick mcguire you

Transcribed from video
The Comparative Effectiveness of ACE Inhibitors in Blacks vs. Whites By CSWNews