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Race and association of angiotensin converting enzyme/angiotensin receptor blocker exposure with outcome in heart failure

El-Refai, Mostafa; Hrobowski, Tara; Peterson, Edward L.; Wells, Karen; Spertus, John A.; Williams, L. Keoki; Lanfear, David E.

Journal of Cardiovascular Medicine: September 2015 - Volume 16 - Issue 9 - p 591–596
doi: 10.2459/JCM.0000000000000091
Original articles: Heart failure

Purpose Angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) have been established as a mainstay of heart failure treatment. Current data are limited and conflicting regarding the consistency of ACE/ARB benefit across race groups in heart failure. This study aims to clarify this point.

Methods This was a retrospective study of insured patients with a documented ejection fraction of less than 50%, hospitalized for heart failure between January 2000 and June 2008. Pharmacy claims data were used to estimate ACE/ARB exposure over 6-month rolling windows. The association between ACE/ARB exposure and all-cause hospitalization or death was assessed by proportional hazards regression, with adjustment for baseline covariates and β-blocker exposure. Further analyses were stratified by race, and included an ACE/ARB × Race interaction term.

Results A total of 1095 patients met inclusion criteria (619 African-American individuals). Median follow-up was 2.1 years. In adjusted models, ACE/ARB exposure was associated with lower risk of death or hospitalization in both groups (African-Americans hazard ratio 0.47, P < 0.001; whites hazard ratio 0.55, P < 0.001). A formal test for interaction was consistent with similar effects in each group (P = 0.861, β = 0.04).

Conclusion ACE/ARB exposure was equally associated with a protective effect in preventing death or rehospitalization among heart failure patients with systolic dysfunction in both African-American patients and whites.

aDepartment of Internal Medicine

bHeart and Vascular Institute

cDepartment of Public Health Sciences, Henry Ford Hospital, Detroit, Michigan

dMid America Heart Institute, Kansas City, Missouri

eCenter for Health Services Research, Henry Ford Hospital, Detroit, Michigan, USA

Correspondence to David E. Lanfear, Henry Ford Hospital, 2799 W. Grand Blvd., K14, Detroit, MI 48202, USA Tel: +1 313 916 6375; fax: +1 313 916 8799; e-mail:

Received 14 October, 2013

Revised 26 February, 2014

Accepted 26 February, 2014

© 2015 Italian Federation of Cardiology. All rights reserved.