Are Angiotensin-Converting Enzyme Inhibitors Effective in the Treatment of Hypertension in Black Patients?

Hypertension is prevalent, and it is a leading worldwide cause of death and disability. Hypertension control rates globally are low. Limited access to care, affordability and availability of medications, the commonly asymptomatic nature of hypertension, and therapeutic inertia are contributors to the low control rates. Angiotensin-converting enzyme inhibitors (ACEis) are an important class of anti-hypertensive medications. Historical trials have shown a blunted blood pressure response in patients identifying as Black with ACEis, compared to diuretics or calcium-channel blockers. This finding has not been consistent among trials. Yet, guidelines have recommended that ACEis not be used as initial therapy for hypertension in those patients identifying as Black. We reviewed the evidence for this recommendation and the current guidelines that maintain it. High-quality evidence for avoiding ACEi use in patients identifying as Black was limited. Evidence has been found for the effectiveness of ACEis in blood pressure reduction in all populations, particularly when used in combination. How race was identified in most of the studies reviewed was not described. We conclude that factors other than the social construct of race should be used to guide antihypertensive therapy.