Are angiotensin-converting enzyme (ACE) inhibitors effective for black people?

Manufacturers advise that angiotensin-converting enzyme (ACE) inhibitors as monotherapy have an effect on blood pressure that is less in black patients than in non-black patients. In addition, ACE inhibitors for which adequate data are available cause a higher rate of angioedema in black than in non-black patients.^1-14

A 2016 systematic review of antihypertensive drug therapy in black patients found that on average ACE inhibitors and beta-adrenergic blockers are the least effective at lowering systolic blood pressure and diastolic blood pressure respectively, while calcium channel blockers (CCBs) and diuretics have a greater effect. ACE inhibitor monotherapy as an initial treatment for hypertension in blacks was not only less effective, but also associated with higher rates of adverse cardiovascular outcomes.¹⁵

Some black patients are significantly less sensitive to drugs that block the renin-angiotensin system such as ACE inhibitors, angiotensin II receptor blockers (ARBs), and beta blockers. The cause of these differences in drug responses is largely unknown. Pharmacokinetics, plasma renin, and genetic polymorphisms does not predict the response of black patients to antihypertensive drugs. An emerging view that low nitric oxide and high creatine kinase may explain individual responses to antihypertensive drugs unites previous observations, but currently clinical data are very limited.¹⁶

The International Society on Hypertension in Blacks recommends monotherapy with a diuretic or CCB if blood pressure is 10 mm Hg above target levels. When blood pressure is >15/10 mm Hg above target, 2-drug therapy is recommended, with either a CCB plus a renin-angiotensin system blocker (ACE inhibitor, ARB, beta blocker) or alternatively, in edematous and/or volume-overload states, with a thiazide diuretic plus a renin-angiotensin system blocker.¹⁷

However, ACE inhibitors and ARBs have been found to be the most effective antihypertensive drug classes at reversing vascular hypertrophy and lowering the risk and progression of cardiovascular and renal disease in all populations, including in black people.^18-23

The International Society on Hypertension in Blacks recommends the following medications for treating hypertension based on comorbidities:¹⁷

Table 1: Preferences for antihypertensive drugs by comorbidity

✓ - Recommended, • - Likely benefit or safety proven, Ø – Contraindicated

References

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13. Altace [package insert]. New York, NY: Pfizer Laboratories; 2022.
14. Mavik [package insert]. Whippany, NJ: Halo Pharmaceutical Inc.; 2017.
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17. Flack JM, Sica DA, Bakris G, et al. Management of high blood pressure in Blacks: an update of the International Society on Hypertension in Blacks consensus statement. Hypertension 2010; 56 (5): 780-800.
18. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int Suppl (2011) 2013; 3 (1): i-150.
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