Jay S. Kaufman, PhD; John M. Flack, MD, MPH
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Kaufman J., Flack J.; Angiotensin-Converting Enzyme Inhibitors in Black Patients. Ann Intern Med. 2005;142:589. doi: 10.7326/0003-4819-142-7-200504050-00017
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Published: Ann Intern Med. 2005;142(7):589.
TO THE EDITOR:
We read with interest the review by Brewster and colleagues (1) summarizing the effects of single antihypertensive agents on blood pressure and blood pressure control, as reported in clinical studies that enrolled black patients in both the Americas and Africa. The authors highlighted the observation that for angiotensin-converting enzyme (ACE) inhibitors, the summary effect on diastolic control (as a binary outcome) did not differ significantly from placebo. However, they also found that for these agents, changes in both systolic (−7.43 mm Hg) and diastolic (−3.35 mm Hg) blood pressure were each significantly greater than for placebo. The finding that the effect of ACE inhibition was nonsignificant in relation to placebo was based on only 3 studies, 2 of which enrolled participants with baseline diastolic blood pressure greater than or equal to 110 mm Hg. Moreover, these 2 studies apparently used per protocol analysis (as opposed to intention-to-treat analysis); when only intention-to-treat analyses were considered, the effect of ACE inhibition on control of diastolic blood pressure was significantly greater than for placebo (relative risk, 1.74 [95% CI, 1.04 to 2.92]). An additional concern is that persons who were taking multiple antihypertensive medications but had poorly controlled blood pressure were allowed to participate in these trials and were subsequently treated with a single drug regimen, a scenario that probably attenuated the in-trial response.
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