Current Heart Failure Reports

, Volume 2, Issue 2, pp 72–77

The impact of race on response to RAAS inhibition

  • Thomas W. Wallace
  • Mark H. Drazner
Article

Abstract

Retrospective analyses of the Studies of Left Ventricular Dysfunction (SOLVD) and Vasodilator Heart Failure Trials (V-HeFT) have addressed the question of whether angiotensin-converting enzyme (ACE) inhibitors are equally efficacious in black patients and white patients with heart failure. In SOLVD, there was no ethnic difference in the efficacy of enalapril for reducing mortality and preventing the development of heart failure, but enalapril was more effective in whites in reducing hospitalizations. In V-HeFT II, enalapril was more efficacious than the combination of isosorbide dinitrate and hydralazine in whites in reducing mortality, but not in blacks. However, the combination of isosorbide dinitrate and hydralazine may be particularly advantageous in black patients as suggested by V-HeFT I and the recent African American Heart Failure Trial. In aggregate, the available data suggest that ACE inhibitors should remain a cornerstone of therapy for heart failure with a reduced ejection fraction in white patients and black patients.

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References and Recommended Reading

  1. 1.
    Kaplan JB, Bennett T: Use of race and ethnicity in biomedical publication. JAMA 2003, 289:2709–2716.PubMedCrossRefGoogle Scholar
  2. 2.
    Cooper RS, Kaufman JS, Ward R: Race and genomics. N Engl J Med 2003, 348:1166–1170.PubMedCrossRefGoogle Scholar
  3. 3.
    Burchard EG, Ziv E, Coyle N, et al.: The importance of race and ethnic background in biomedical research and clinical practice. N Engl J Med 2003, 348:1170–1175.PubMedCrossRefGoogle Scholar
  4. 4.
    Carson P, Ziesche S, Johnson G, Cohn JN: Racial differences in response to therapy for heart failure: analysis of the vasodilator-heart failure trials. Vasodilator-Heart Failure Trial Study Group. J Card Fail 1999, 5:178–187. This retrospective analysis of V-HeFT contrasts the relative efficacy of isosorbide dinitrate/hydralazine and enalapril in black patients versus white patients.PubMedCrossRefGoogle Scholar
  5. 5.
    Dries DL, Strong MH, Cooper RS, Drazner MH: Efficacy of angiotensin-converting enzyme inhibition in reducing progression from asymptomatic left ventricular dysfunction to symptomatic heart failure in black and white patients. J Am Coll Cardiol 2002, 40:311–317. This retrospective analysis demonstrated that enalapril was equally efficacious in black patients and white patients in delaying the progression from ALVD to symptomatic heart failure. This analysis was conducted in follow-up to the study by Exner et al. [6] to see whether there was an ethnic disparity in the efficacy of enalapril for other outcomes. This study also confirmed the increased risk of adverse outcomes in black patients versus white patients first identified by Dries et al. [10] and here defined by the progression from ALVD to symptomatic heart failure.PubMedCrossRefGoogle Scholar
  6. 6.
    Exner DV, Dries DL, Domanski MJ, Cohn JN: Lesser response to angiotensin-converting-enzyme inhibitor therapy in black as compared with white patients with left ventricular dysfunction. N Engl J Med 2001, 344:1351–1357. This matched-cohort study suggested that enalapril was less efficacious in black patients than in white patients in preventing heart failure hospitalization.PubMedCrossRefGoogle Scholar
  7. 7.
    Yancy CW, Fowler MB, Colucci WS, et al.: Race and the response to adrenergic blockade with carvedilol in patients with chronic heart failure. N Engl J Med 2001, 344:1358–1365.PubMedCrossRefGoogle Scholar
  8. 8.
    Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. The SOLVD Investigators.N Engl J Med 1991, 325:293–302.Google Scholar
  9. 9.
    Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions. The SOLVD Investigators.N Engl J Med 1992, 327:685–691.Google Scholar
  10. 10.
    Dries DL, Exner DV, Gersh BJ, et al.: Racial differences in the outcome of left ventricular dysfunction. N Engl J Med 1999, 340:609–616. This important study first suggested that black patients with heart failure had a worse outcome than did white patients. Additionally, the authors reported that there was no evidence of interaction between race and enalapril efficacy, suggesting that the disparity in outcome between ethnic groups was unlikely to be secondary to differences in response to ACE inhibitors.PubMedCrossRefGoogle Scholar
  11. 11.
    Cohn JN, Archibald DG, Ziesche S, et al.: Effect of vasodilator therapy on mortality in chronic congestive heart failure. Results of a Veterans Administration Cooperative Study. N Engl J Med 1986, 314:1547–1552.PubMedCrossRefGoogle Scholar
  12. 12.
    Effects of enalapril on mortality in severe congestive heart failure. Results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS). The CONSENSUS Trial Study Group.N Engl J Med 1987, 316:1429–1435.Google Scholar
  13. 13.
    Cohn JN, Johnson G, Ziesche S, et al.: A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure. N Engl J Med 1991, 325:303–310.PubMedCrossRefGoogle Scholar
  14. 14.
    Taylor AL, Ziesche S, Yancy C, et al.: Combination of isosorbide dinitrate and hydralazine in blacks with heart failure. N Engl J Med 2004, 351:2049–2057. This is a recent important study demonstrating the efficacy of the combination of isosorbide dinitrate and hydralazine in black patients with heart failure and a reduced left ventricular ejection fraction. Because no white patients were enrolled in this study, it is uncertain whether this combination of agents will prove equally efficacious in white patients.PubMedCrossRefGoogle Scholar
  15. 15.
    Materson BJ, Reda DJ, Cushman WC, et al.: Single-drug therapy for hypertension in men. A comparison of six antihypertensive agents with placebo. The Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents. N Engl J Med 1993, 328:914–921.PubMedCrossRefGoogle Scholar
  16. 16.
    Flack JM, Yunis C, Preisser J, et al.: The rapidity of drug dose escalation influences blood pressure response and adverse effects burden in patients with hypertension: the Quinapril Titration Interval Management Evaluation (ATIME) Study. ATIME Research Group. Arch Intern Med 2000, 160:1842–1847.PubMedCrossRefGoogle Scholar
  17. 17.
    Mokwe E, Ohmit SE, Nasser SA, et al.: Determinants of blood pressure response to quinapril in black and white hypertensive patients: the Quinapril Titration Interval Management Evaluation Trial. Hypertension 2004, 43:1202–1207.PubMedCrossRefGoogle Scholar
  18. 18.
    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, 288:2981–2997.Google Scholar
  19. 19.
    Davis BR, Furberg CD, Wright JT Jr, et al.: ALLHAT: setting the record straight. Ann Intern Med 2004, 141:39–46.PubMedGoogle Scholar
  20. 20.
    Cohn JN, Julius S, Neutel J, et al.: Clinical experience with perindopril in African-American hypertensive patients: a large United States community trial. Am J Hypertens 2004, 17:134–138.PubMedCrossRefGoogle Scholar
  21. 21.
    Julius S, Alderman MH, Beevers G, et al.: Cardiovascular risk reduction in hypertensive black patients with left ventricular hypertrophy: the LIFE study. J Am Coll Cardiol 2004, 43:1047–1055.PubMedCrossRefGoogle Scholar
  22. 22.
    Wright JT Jr, Bakris G, Greene T, et al.: Effect of blood pressure lowering and antihypertensive drug class on progression of hypertensive kidney disease: results from the AASK trial. JAMA 2002, 288:2421–2431.PubMedCrossRefGoogle Scholar
  23. 23.
    Brewster LM, van Montfrans GA, Kleijnen J: Systematic review: antihypertensive drug therapy in black patients. Ann Intern Med 2004, 141:614–627.PubMedGoogle Scholar

Copyright information

© Current Science Inc. 2005

Authors and Affiliations

  • Thomas W. Wallace
  • Mark H. Drazner
    • 1
  1. 1.University of Texas Southwestern Medical CenterDallasUSA

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