Using angiotensin converting enzyme inhibitors in African-American hypertensives: A new approach to treating hypertension and preventing target-organdamage

Angiotensin converting enzyme (ACE) inhibitors have been avoided as an init ial therapeutic option in the treatment of hypertension in African-American s. A major reason for this has been the widespread perception of clinicians that these agents have poor blood pressure (BP) lowering efficacy in this population. Remarkably uniform and pervasive interpretations of clinical tr ial data have formed the basis of this clinical perception and can be summa rised as follows: (1) there has been a lesser BP lowering effect of ACE inh ibitors in African-Americans compared to whites, particularly at low doses; and (2) short-acting ACE inhibitors like captopril prescribed at the midpo int of its maximal total daily nose lower BP less effectively, than higher doses of calcium antagonists in African-Americans. A reinterpretation of pu blished data from these same clinical trials suggests that: (1) the majorit y of African-Americans have meaningful BP responses to ACE inhibitors, albe it at a higher average dose than in whites; and (2) high levels of dietary sodium intake appear to explain a significant portion of the racial differe nces in BP response at the lower doses of ACE inhibitors. Thus, ACE inhibit ors can effectively lower BP in African-Americans. These data suggest that the clinician should not avoid these agents in African-Americans because of a presumed lack of BP lowering efficacy. Rather, we should recognise the i mportance of adequate drug dosing and modest reductions in dietary sodium i ntake in augmenting the BP lowering effect of ACE inhibitors in hypertensiv e African-Americans.