A Review of ACE Inhibitors and ARBs in Black Patients With Hypertension

Ann Pharmacother. 2018 Nov;52(11):1143-1151. doi: 10.1177/1060028018779082. Epub 2018 May 29.


Objective: To review current guidelines and recent data evaluating the efficacy and safety of angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) in black hypertensive patients.

Data sources: Articles evaluating race-specific outcomes in hypertension were gathered using a MEDLINE search with keywords black, African American, ACE inhibitor, angiotensin receptor blocker, angiotensin system, and hypertension. Studies published from 2000 through April 2018 were reviewed.

Study selection and data extraction: Six guidelines, 8 monotherapy publications, and 5 combination therapy publications included race-specific results and were included in the review. The authors individually compared and contrasted the results from each publication.

Data synthesis: Numerous monotherapy trials indicate that black patients may have a reduced blood pressure (BP) response with ACE inhibitors or ARBs compared with white patients. Conversely, additional studies propose that race may not be the primary predictor of BP response. Reduced efficacy is not observed in trials involving combination therapy. Some studies suggest increased cardiovascular and cerebrovascular morbidity and mortality with ACE inhibitor or ARB monotherapy in black patients; however, data are conflicting. Relevance to Patient Care and Clinical Practice: This article clarifies vague guideline statements and informs clinicians on the appropriate use of ACE inhibitors or ARBs for hypertension treatment in black patients through an in-depth look into the evidence.

Conclusions: Potentially reduced efficacy and limited outcomes data indicate that ACE inhibitors or ARBs should not routinely be initiated as monotherapy in black hypertensive patients. Use in combination with a calcium channel blocker or thiazide diuretic is efficacious in black patients, and there are no data showing that this increases or decreases cardiovascular or cerebrovascular outcomes.

Keywords: ACE inhibitors; angiotensin II receptor antagonists; evidence-based practice; hypertension; literature evaluation.

Publication types

  • Review

MeSH terms

  • Angiotensin Receptor Antagonists / administration & dosage*
  • Angiotensin Receptor Antagonists / therapeutic use
  • Angiotensin-Converting Enzyme Inhibitors / administration & dosage*
  • Antihypertensive Agents / administration & dosage*
  • Black or African American*
  • Calcium Channel Blockers / administration & dosage
  • Drug Therapy, Combination
  • Humans
  • Hypertension / diagnosis
  • Hypertension / drug therapy*
  • Hypertension / epidemiology
  • Practice Guidelines as Topic / standards*
  • Sodium Chloride Symporter Inhibitors / administration & dosage


  • Angiotensin Receptor Antagonists
  • Angiotensin-Converting Enzyme Inhibitors
  • Antihypertensive Agents
  • Calcium Channel Blockers
  • Sodium Chloride Symporter Inhibitors