Renin-angiotensin system blockade beneficial for Black and non-Black patients with HFrEF
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Key takeaways:
- RAS blockers had similar mortality benefit by race in patients with HFrEF.
- RAS blockers improved HF hospitalization to a lesser degree for Black patients than for others, but the absolute benefit was similar.
Renin-angiotensin system blockade conferred similar mortality benefits for Black vs. non-Black patients with HF, and despite less benefit for hospitalization for Black patients, absolute benefit was comparable, researchers reported.
The comparable absolute benefit of renin-angiotensin system (RAS) blockade on first HF hospitalizations among Black compared with non-Black patients with HF with reduced ejection fraction despite less effect is “difficult to explain,” the researchers wrote in a meta-analysis published in JAMA.
“Although ACE inhibitors are a cornerstone of evidence-based therapy in patients with HF, it has been suggested that Black patients may have less response to these drugs than do white patients. This hypothesis originated from post hoc analyses of the second Vasodilator Heart Failure Trial (V-HeFT II) and the Studies of Left Ventricular Dysfunction (SOLVD) and similar concerns have been voiced about antihypertensive efficacy,” Li Shen, MBChB, PhD, of the School of Clinical Medicine at Hangzhou Normal University in Hangzhou, China, and the British Heart Foundation Cardiovascular Research Centre at the University of Glasgow, and colleagues wrote. “Therefore, we have reexamined the question of whether Black patients with HFrEF respond differently to RAS blockade by conducting a meta-analysis of individual patient data from the prospective placebo-controlled trials investigating a RAS blocker and reporting mortality and hospitalization, including analysis of total (first and recurrent) hospitalizations for HF.”
For this meta-analysis, Shen and colleagues analyzed data from the SOLVD-Prevention, SOLVD-Treatment and CHARM-Alternative trials, in which patients were not receiving background RAS inhibitor treatment, to evaluate whether there were any differences in CV outcomes from RAS blockers among Black compared with non-Black patients with HFrEF.
Individual patient data were attained for 8,825 patients (9.9% Black). The primary outcome was first HF hospitalization or CV death during a median follow-up of 34 months.
The HR for the primary outcome among patients who received RAS blockade compared with placebo was 0.84 for Black patients (95% CI, 0.69-1.03) and 0.73 for non-Black patients (95% CI, 0.67-0.79; P for interaction = .14), according to the study.
The HR for CV death alone was 0.83 for Black patients (95% CI, 0.65-1.07) and 0.84 for non-Black patients (95% CI, 0.77-0.93; P for interaction = .99), according to the study.
The HR for first HF hospitalization alone was 0.89 for Black patients (95% CI, 0.7-1.13) and 0.62 for non-Black patients (95% CI, 0.56-0.69; P for interaction = .006). Despite the lower effect observed for Black patients, the absolute reduction in HF hospitalizations was 4.5 per 100 patient-years for Black patients compared with 5.4 per 100 patient-years for non-Black patients.
The researchers subsequently conduced supportive analyses including the CHARM-Added and Val-HeFT trial, in which patients had an angiotensin receptor blocker added to background ACE inhibition. The findings of the supportive analyses were consistent with the primary meta-analysis.
“This apparent difference between effects on mortality and hospitalization is puzzling and difficult to explain, given that these two outcomes are related and usually reduced in tandem by efficacious therapies,” the researchers wrote. “The substantial absolute reduction in the total HF hospitalizations with RAS blockade in Black patients, coupled with an equivalent reduction in mortality in Black patients and non-Black patients, emphasizes the value of this cornerstone treatment in HFrEF in both patient groups. There has been concern that the uncertainty about the benefit of RAS blockers has contributed to the undertreatment of Black patients with these drugs, and it is hoped that this meta-analysis will allay such concerns.”
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