title: Comparative Effectiveness of Angiotensin-Converting Enzyme Inhibitor-Based Treatment on Cardiovascular Outcomes in Hypertensive Blacks Versus Whites.
abstract: BACKGROUND
  Clinical trial evidence suggests poorer outcomes in blacks compared with whites when treated with an angiotensin-converting enzyme (ACE) inhibitor-based regimen, but this has not been evaluated in clinical practice.
  
  
  OBJECTIVE
  This study evaluated the comparative effectiveness of an ACE inhibitor-based regimen on a composite outcome of all-cause mortality, stroke, and acute myocardial infarction (AMI) in hypertensive blacks compared with whites.
  
  
  METHODS
  We conducted a retrospective cohort study of 434,646 patients in a municipal health care system. Four exposure groups (Black-ACE, Black-NoACE, White-ACE, White-NoACE) were created based on race and treatment exposure (ACE or NoACE). Risk of the composite outcome and its components was compared across treatment groups and race using weighted Cox proportional hazard models.
  
  
  RESULTS
  Our analysis included 59,316 new users of ACE inhibitors, 47% of whom were black. Baseline characteristics were comparable for all groups after inverse probability weighting adjustment. For the composite outcome, the race treatment interaction was significant (p = 0.04); ACE use in blacks was associated with poorer cardiovascular outcomes (ACE vs. NoACE: 8.69% vs. 7.74%; p = 0.05) but not in whites (6.40% vs. 6.74%; p = 0.37). Similarly, the Black-ACE group had higher rates of AMI (0.46% vs. 0.26%; p = 0.04), stroke (2.43% vs. 1.93%; p = 0.05), and congestive heart failure (3.75% vs. 2.25%; p < 0.0001) than the Black-NoACE group. However, the Black-ACE group was no more likely to develop adverse effects than the White-ACE group.
  
  
  CONCLUSIONS
  ACE inhibitor-based therapy was associated with poorer cardiovascular outcomes in hypertensive blacks but not in whites. These findings confirm clinical trial evidence that hypertensive blacks have poorer outcomes than whites when treated with an ACE inhibitor-based regimen.
authors.affiliation: Department of Population Health, Center for Healthful Behavior Change, New York University School of Medicine, New York, New York. Electronic address: Olugbenga.ogedegbe@nyumc.org.
authors.forename: Gbenga
authors.initials: G
authors.lastname: Ogedegbe
authors.affiliation: Kaiser Permanente Southern California, Pasadena, California.
authors.forename: Nirav R
authors.initials: NR
authors.lastname: Shah
authors.affiliation: Morehouse School of Medicine, Atlanta, Georgia.
authors.forename: Christopher
authors.initials: C
authors.lastname: Phillips
authors.affiliation: Department of Population Health, Center for Healthful Behavior Change, New York University School of Medicine, New York, New York.
authors.forename: Keith
authors.initials: K
authors.lastname: Goldfeld
authors.affiliation: Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Jason
authors.initials: J
authors.lastname: Roy
authors.affiliation: The Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, New York.
authors.forename: Yu
authors.initials: Y
authors.lastname: Guo
authors.affiliation: Department of Population Health, Center for Healthful Behavior Change, New York University School of Medicine, New York, New York.
authors.forename: Joyce
authors.initials: J
authors.lastname: Gyamfi
authors.affiliation: Department of Population Health, Center for Healthful Behavior Change, New York University School of Medicine, New York, New York.
authors.forename: Christopher
authors.initials: C
authors.lastname: Torgersen
authors.affiliation: New York City Health and Hospitals Corporation, New York, New York; Division of General Internal Medicine, New York University School of Medicine, New York, New York.
authors.forename: Louis
authors.initials: L
authors.lastname: Capponi
authors.affiliation: The Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, New York.
authors.forename: Sripal
authors.initials: S
authors.lastname: Bangalore
mesh_terms: D000328:Adult; D000368:Aged; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use*; D000959:Antihypertensive Agents / Q000627:therapeutic use*; D044383:Black People / Q000208:ethnology*; D002318:Cardiovascular Diseases / Q000175:diagnosis / Q000188:drug therapy / Q000208:ethnology; D015331:Cohort Studies; D005260:Female; D006801:Humans; D006973:Hypertension / Q000175:diagnosis / Q000188:drug therapy* / Q000208:ethnology*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D016896:Treatment Outcome; D044465:White People / Q000208:ethnology*
chemical_list: D000806:Angiotensin-Converting Enzyme Inhibitors; D000959:Antihypertensive Agents
keywords: antihypertensive medications; cardiovascular disease; electronic health record; race