Although a randomized controlled trial5 and a review of multiple studies6 demonstrated that African Americans may be less responsive to monotherapy with ACE inhibitors, the AASK trial confirmed that ACE inhibitors can provide significant clinical benefits for African Americans with hypertensive renal disease. AASK, a double-blind RCT of 1094 African American patients with renal insufficiency, compared the effects of an ACE inhibitor (ramipril [Altace]), a dihydropyridine calcium channel blocker (amlodipine), or a beta blocker (metoprolol [Lopressor]) on the progression of hypertensive renal disease.
The study showed a 44% relative risk reduction (95% CI, 13%–65%; number needed to treat [NNT]=25) in progression to end-stage renal disease, and a significant decrease in the combined endpoints of glomerular filtration rate events (decrease >50%), end-stage renal disease, and death (decreased by 38%) in the ramipril group compared with the amlodipine group (95% CI, 13%–56%; NNT=56 per patient-year).5,7 Metoprolol appeared to have intermediate outcomes.8
Recommendations from others
Both the International Society on Hypertension in Blacks (ISHIB) guidelines1 and the JNC 79 recommend therapeutic lifestyle modification that includes DASH diet, dietary sodium restriction, and weight reduction. Both guidelines recognize the importance of thiazide diuretics and recommend its use as first-line therapy or as a part of combination therapy for hypertension among African Americans. They also recommend initiating therapy with 2 agents for blood pressure significantly above target level (20/10 mm Hg above target per JNC 7, 15/10 mm Hg above target per ISHIB).
The ISHIB report emphasizes the need for not overlooking renal protection with an ACE inhibitor for African Americans with renal disease. The American Diabetes Association recommends that all patients with diabetes and hypertension be treated with a regimen that includes either an ACE inhibitor or an ARB.10