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Meta-Analysis
. 2013 Sep 26:14:201.
doi: 10.1186/1471-2369-14-201.

Difference in blood pressure response to ACE-Inhibitor monotherapy between black and white adults with arterial hypertension: a meta-analysis of 13 clinical trials

Robert N Peck  1 , Luke R Smart, Rita Beier, Anthony C Liwa, Heiner Grosskurth, Daniel W Fitzgerald, Bernhard M W Schmidt
Affiliations
Meta-Analysis

Difference in blood pressure response to ACE-Inhibitor monotherapy between black and white adults with arterial hypertension: a meta-analysis of 13 clinical trials

Robert N Peck et al. BMC Nephrol. .

Abstract

Background: Among African-Americans adults, arterial hypertension is both more prevalent and associated with more complications than among white adults. Hypertension is also epidemic among black adults in sub-Saharan Africa. The treatment of hypertension among black adults may be complicated by lesser response to certain classes of anti-hypertensive agents.

Methods: We systematically searched literature for clinical trials of ACE-inhibitors among hypertensive adults comparing blood pressure response between whites and blacks. Meta-analysis was performed to determine the difference in systolic and diastolic blood pressure response. Further analysis including meta-regressions, funnel plots, and one-study-removed analyses were performed to investigate possible sources of heterogeneity or bias.

Results: In a meta-analysis of 13 trials providing 17 different patient groups for evaluation, black race was associated with a lesser reduction in systolic (mean difference: 4.6 mmHg (95% CI 3.5-5.7)) and diastolic (mean difference: 2.8 mmHg (95% CI 2.2-3.5)) blood pressure response to ACE-inhibitors, with little heterogeneity. Meta-regression revealed only ACE-inhibitor dosage as a significant source of heterogeneity. There was little evidence of publication bias.

Conclusions: Black race is consistently associated with a clinically significant lesser reduction in both systolic and diastolic blood pressure to ACE-inhibitor therapy in clinical trials in the USA and Europe. In black adults requiring monotherapy for uncomplicated hypertension, drugs other than ACE-inhibitors may be preferred, though the proven benefits of ACE-inhibitors in some sub-groups and the large overlap of response between blacks and whites must be remembered. These data are particularly important for interpretation of clinical drug trials for hypertensive black adults in sub-Saharan Africa and for the development of treatment recommendations in this population.

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Figures

Figure 1
Figure 1
Flow diagram for identification, screening, and inclusion of papers for this meta-analysis.
Figure 2
Figure 2
Forest Plot for difference in mean reduction of systolic blood pressure (SBP). Forest Plot for difference in mean reduction of systolic blood pressure (SBP) between whites and blacks. White race was associated with a greater reduction in SBP (mean difference: 4.64 (95% CI 3.53-5.75)).
Figure 3
Figure 3
Forest Plot for difference in mean reduction of systolic blood pressure (SBP). Forest Plot for difference in mean reduction of diastolic blood pressure (DBP) between whites and blacks. White race was associated with a greater reduction in DBP (mean difference: 2.82 (95%CI 2.17-3.47)).
Figure 4
Figure 4
Funnel Plots for standard error of changes in systolic (A) and diastolic (B) blood pressure. Funnel Plots for standard error of difference in mean change in systolic (A) and diastolic (B) blood pressures. These Funnel Plots do not show any evidence of publication bias.
Figure 5
Figure 5
Meta-regression analyses for systolic (A) and diastolic (B) blood pressure. (A) Meta-regression analyses for systolic blood pressure (SBP). The difference in SBP reduction between whites and blacks was significantly blunted by increasing doses of ACE inhibitors (p = 0.048). None of the other associations were statistically significant. Meta-regression analyses for diastolic blood pressure (DBP). (B) Meta-regression analyses for diastolic blood pressure (DBP). None of the associations were statistically significant but there was a trend toward lesser difference in DBP reduction between whites and blacks when greater doses of ACE-inhibitors were used.
Figure 6
Figure 6
One-study-removed analysis for difference in mean reduction of systolic and diastolic blood pressures. One-study-removed analysis for difference in mean reduction of systolic (SBP, above) and diastolic (DBP, below) blood pressure between whites and blacks. Removal of each single study did not change the result of the meta-analysis.
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