Heart failure is a major health concern in the US and is particularly problematic in the African-American community where the disease has an earlier onset and exhibits increased mortality, even with hospitalisation. Early onset is manifested primarily in middle-aged patients, where the rates of heart failure are higher than that with a higher mortality than in whites. Between the ages of 45 and 64, African-American males have a 70% higher risk for heart failure than Caucasian males. African-American females between the ages of 45 and 54 have a 50% greater risk to develop heart failure than Caucasian females. It is estimated that there are approximately 700,000 African-Americans with heart failure in the US, and this number is expected to grow to 900,000 by 2010.
These differences between the races is possibly related to hypertension as an underlying etiology, which leads to left ventricular (LV) dysfunction in blacks more commonly than in whites. Several clinical trials have identified and investigated this phenomenon, and interesting conclusions have been found.
Lessons Learned from Clinical Trials
Based on clinical trial data, the treatment for heart failure should be essentially the same for all populations. Unfortunately, the evidence for traditional medications such as angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs) and beta-blockers is not robust in the African-American population. Primarily due to small sample sizes in some of the large randomized trials, it may also be due to some differences in terms of etiology in many African-Americans, including the predominance of hypertension as an under-lying cause, increased obesity, and perhaps salt sensitivity.
Although the ACE inhibitor trials, such as Studies of Left Ventricular Dysfunction (SOLVD) show that in African-Americans, these inhibitors have less of an effect (specifically for hospitalization), this does not necessarily mean that ACE inhibitors should not be used in black patients. However, with the administration of ACE inhibitors, there may potentially be the need to also administer diuretics or higher doses to help control blood pressure and restrict sodium to ensure that the benefits of ACE inhibition are not blunted.