Systematic review: antihypertensive drug therapy in patients of African and South Asian ethnicity

The socio-colonial history of Surinamese surnames applied to a validated surname list to identify ancestry in health research

Around half of the population of Suriname, who are mainly of African and South Asian descent, migrated to the Netherlands at the end of the previous century, where they face higher perinatal and maternal mortality and up to 5 years lower life expectancy than European-Dutch. Analyses by ancestry are needed to address these inequalities, but the law prohibits registration by ancestry. Therefore, a list of Surinamese surnames was compiled and validated to identify the largest groups, African-Surinamese or South Asian-Surinamese ancestry in health research. A complete database of Surinamese surnames was provided by the National Population Registry of Suriname. Surname recognition by researchers of Surinamese ancestry was used. Disagreement was resolved using historical registers and through discussion. The list was further validated against contemporary lists of Surinamese surnames with self-defined ancestry, obtained during population and clinical studies in Suriname and the Netherlands. All 71,529 Surinamese surnames were encoded, as African-Surinamese (34%), South Asian-Surinamese (18%), Brazilian or other Iberian (17%), Indonesian-Surinamese (13%), Chinese-Surinamese (5%), First Nation (2%), and other (10%). Compared to self-defined ancestry, South Asian-Surinamese surname coding had 100% sensitivity, 99.8% specificity, and 99.9% accuracy. For African-Surinamese, who may have Dutch surnames, these values depended on geocoding. With a known Surinamese origin, sensitivity, specificity, and accuracy were, respectively, 97.3%, 100%, and 98.6%, but without this information, there was interference of African-Surinamese with European-Dutch surnames in the Dutch validation sample. In conclusion, the Surinamese Surname List has a high accuracy in identifying persons of Surinamese ancestry. This quick, inexpensive, and nonintrusive method, which is unaffected by response bias, might be a valuable tool in public health research to help address the profound health disparities by ancestry.

Management of Hypertension in the Asia-Pacific Region: A Structured Review

This article reviews available evidence regarding hypertension management in the Asia-Pacific region, focussing on five research questions that deal with specific aspects: blood pressure (BP) control, guideline recommendations, role of renin-angiotensin-aldosterone system (RAAS) inhibitors in clinical practice, pharmacological management and real-world adherence to guideline recommendations. A PubMed search identified 2537 articles, of which 94 were considered relevant. Compared with Europeans, Asians have higher systolic/diastolic/mean arterial BP, with a stronger association between BP and stroke. Calcium channel blockers are the most-commonly prescribed monotherapy in Asia, with significant variability between countries in the rates of angiotensin-converting enzyme inhibitors (ACEis)/angiotensin-receptor blockers (ARBs) and single-pill combination (SPC) use. In clinical practice, ARBs are used more commonly than ACEis, despite the absence of recommendation from guidelines and clinical evidence supporting the use of one class of drug over the other. Ideally, antihypertensive treatment should be tailored to the individual patient, but currently there are limited data on the characteristics of hypertension in Asia-Pacific individuals. Large outcome studies assessing RAAS inhibitor efficacy and safety in multi-national Asian populations are lacking. Among treated patients, BP control rates were ~ 35 to 40%; BP control in Asia-Pacific is suboptimal, and disproportionately so compared with Western nations. Strategies to improve the management of hypertension include wider access/availability of affordable treatments, particularly SPCs (which improve adherence), effective public health screening programs targeting patients to drive health-seeking behaviours, an increase in physician/patient awareness and early implementation of lifestyle changes. A unified Asia-Pacific guideline on hypertension management with pragmatic recommendations, particularly in resource-limited settings, is essential.

Antihypertensive effect of the stem bark aqueous extract of Garcinia lucida Vesque (Clusiaceae) in L-NAME-treated rats: Contribution of endothelium-dependent and -independent vasorelaxation

Garcinia lucida is used in Cameroonian folk medicine to handle a variety of ailments, including arterial hypertension. This study aimed at determining the phytochemical profile and the antihypertensive effect of the stem bark aqueous extract of G. lucida (AEGL). AEGL was subjected to LC-MS analysis, and its effect (75, 150, and 300 mg/kg/day; by gavage) was evaluated against Nω-nitro-L-arginine methyl ester (L-NAME; 40 mg/kg)-induced hypertension in adult male Wistar rats for four consecutive weeks. Blood pressure and heart rate were monitored weekly using tail-cuff plethysmography. The vasorelaxant effect of cumulative concentrations (3-10-30-100-300 μg/mL) of AEGL was examined on endothelium-intact and denuded thoracic aorta rings which were precontracted with KCl (90 mM) or norepinephrine (NE; 10-5 M), and in the absence or presence of L-NAME (10-4 M), indomethacin (10-5 M), methylene blue (10-6 M), tetraethylammonium (TEA, 5 × 10-6 M), glibenclamide (10 × 10-6 M) or propranolol (5 × 10-6 M). The influence of AEGL on the response to NE, KCl, and CaCl2 was also investigated. Six compounds, including Garcinia biflavonoids GB1 and GB2, were identified. AEGL prevented the development of hypertension (p < 0.01 and p < 0.001) without affecting the heart rate. AEGL induced a concentration-dependent relaxation of aortic rings precontracted with NE (EC50 = 7.915 μg/mL) that was significantly inhibited by the removal of the endothelium, L-NAME, or methylene blue (p < 0.05-0.001). Indomethacin, propranolol, TEA, and glibenclamide did not affect AEGL-evoked vasorelaxation. Preincubation of aortic rings with AEGL reduced the magnitude of contraction elicited by CaCl2 but did not alter that of KCl or NE. AEGL possesses an antihypertensive effect that is mediated by both endothelium-dependent and endothelium-independent mechanisms. The activation of the NO/sGC/cGMP pathway accounts for the endothelium-dependent vasorelaxation. These pharmacological effects of AEGL could be attributed to the presence of the Garcinia biflavonoids GB1 and GB2.

Comparison between the world health organization (WHO) and international society of hypertension (ISH) guidelines for hypertension

The global burden of hypertension remains an unsolved problem, especially in low- and middle-income countries (LMICs). For this reason, clinical practice guidelines containing the latest evidence-based recommendations are crucial in the management of hypertension. It is noteworthy that guidelines simply translated from those of high-income countries (HICs) are not the solution to the problem of hypertension in LMICs. Among the numerous guidelines available, those of the World Health Organisation and the International Society of Hypertension are the latest to be published as of the writing of this article. In this review, we conducted both general and specific comparisons between the recommendations supplied by both guidelines. Differences in aspects of hypertension management such as the timing of antihypertensive initiation, assessment of comorbidities and cardiovascular risk factors, pharmacological therapy selection, and blood pressure target and reassessment are explored. Lastly, the implications of the differences found between the two guidelines in both LMICs and HICs are discussed.Key messagesCurrently, with low treatment and control rates, hypertension remains a burden in low- and middle-income countries (LMICs).The lack of customised guidelines for LMICs cannot be solved simply by adopting guidelines from high-income countries.The World Health Organisation (WHO) recently published a clinical guideline for the pharmacological management of hypertension in LMICs. We compare select recommendations from the guidelines to those published by the International Society of Hypertension.

Initial combination therapy for hypertension in patients of African ancestry: a systematic review and meta-analysis

We systematically reviewed randomized controlled trials (RCTs) that consider the effect of initial dual antihypertensive combination treatment on blood pressure (BP), morbidity, or mortality in hypertensive African ancestry adults, using the methodology of the Cochrane Collaboration. Main outcomes were difference in means (continuous data) and risk ratio (dichotomous data).We retrieved 1728 reports yielding 13 RCTs of 4 weeks to 3 years duration (median 8 weeks) in 3843 patients. Systolic BP was significantly higher on β-adrenergic blocker vs. other combinations, 3.80 [0.82;6.78] mmHg, but comparable for other combinations. Hypokalemia and hyperglycemia occurred with calcium channel blocker (CCB) + diuretics > diuretics + angiotensin converting enzyme inhibitor (ACEI)/angiotensin-II-type-1-receptor antagonist (ARB) > CCB + ACEI/ARB. An RCT including high-risk patients reported combined morbidity/mortality for hydrochlorothiazide (mg) 25 + benazepril 40 vs. amlodipine 10 + benazepril 40 of respectively 8.9% vs. 6.6% (n = 1414, risk ratio 1.35 [0.94;1.94]; all patients, N = 11 506, 1.23 [1.11;1.37]).We conclude that limited evidence supports CCB + ACEI rather than HCT + ACEI as first-line initial combination therapy in African ancestry patients with hypertension.

PROSPERO

CRD42021238529.

The effect of empagliflozin on the total burden of cardiovascular and hospitalization events in the Asian and non-Asian populations of the EMPA-REG OUTCOME trial of patients with type 2 diabetes and cardiovascular disease

AIMS

The sodium-glucose co-transporter 2 inhibitor empagliflozin reduced the total burden of cardiovascular, mortality, and all-cause hospitalization events, including first and recurrent events, in EMPA-REG OUTCOME participants with type 2 diabetes (T2D) and established atherosclerotic cardiovascular disease (ASCVD). We investigated the effect of empagliflozin on the total burden of cardiovascular and hospitalization events in Asian participants.

MATERIALS AND METHODS

Participants were randomized to empagliflozin 10 mg, 25 mg or placebo plus standard of care. The primary and key secondary outcomes were the composite of cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke and the primary outcome plus hospitalization for unstable angina, respectively. The effect of pooled empagliflozin versus placebo on total (first plus recurrent) cardiovascular and hospitalization events was analysed using a negative binomial model that preserves randomization and accounts for within-patient correlation of multiple events. We analysed Asian versus non-Asian EMPA-REG OUTCOME population subgroups post hoc.

RESULTS

Among 1517 Asian participants, empagliflozin reduced the relative risk of total events of the primary outcome by 39% versus placebo [rate ratio (95% confidence interval): 0.61 (0.43, 0.89)], the key secondary outcome by 33% [0.67 (0.48, 0.93)], the composite of cardiovascular death (excluding fatal stroke) and hospitalization for heart failure by 43% [0.57 (0.33, 0.996)], and all-cause hospitalization by 21% [0.79 (0.65, 0.97)]. The effects of empagliflozin were consistent between Asian and non-Asian populations (treatment-by-subgroup interaction p > .05).

CONCLUSIONS

Empagliflozin reduced the total burden of cardiovascular and hospitalization events in Asian and non-Asian EMPA-REG OUTCOME participants with T2D and established ASCVD, consistent with the overall trial population.

Blood Pressure and Stroke: A Review of Sex- and Ethnic/Racial-Specific Attributes to the Epidemiology, Pathophysiology, and Management of Raised Blood Pressure

Raised blood pressure (BP) is the leading cause of death and disability worldwide, and its particular strong association with stroke is well established. Although systolic BP increases with age in both sexes, raised BP is more prevalent in males in early adulthood, overtaken by females at middle age, consistently across all ethnicities/races. However, there are clear regional differences on when females overtake males. Higher BP among males is observed until the seventh decade of life in high-income countries, compared with almost 3 decades earlier in low- and middle-income countries. Females and males tend to have different cardiovascular disease risk profiles, and many lifestyles also influence BP and cardiovascular disease in a sex-specific manner. Although no hypertension guidelines distinguish between sexes in BP thresholds to define or treat hypertension, observational evidence suggests that in terms of stroke risk, females would benefit from lower BP thresholds to the magnitude of 10 to 20 mm Hg. More randomized evidence is needed to determine if females have greater cardiovascular benefits from lowering BP and whether optimal BP is lower in females. Since 1990, the number of people with hypertension worldwide has doubled, with most of the increase occurring in low- and-middle-income countries where the greatest population growth was also seen. Sub-Saharan Africa, Oceania, and South Asia have the lowest detection, treatment, and control rates. High BP has a more significant effect on the burden of stroke among Black and Asian individuals than Whites, possibly attributable to differences in lifestyle, socioeconomic status, and health system resources. Although pharmacological therapy is recommended differently in local guidelines, recommendations on lifestyle modification are often very similar (salt restriction, increased potassium intake, reducing weight and alcohol, smoking cessation). This overall enhanced understanding of the sex- and ethnic/racial-specific attributes to BP motivates further scientific discovery to develop more effective prevention and treatment strategies to prevent stroke in high-risk populations.

Ethnicity-Specific Features of COVID-19 Among Arabs, Africans, South Asians, East Asians, and Caucasians in the United Arab Emirates

Background

Dubai (United Arab Emirates; UAE) has a multi-national population which makes it exceptionally interesting study sample because of its unique demographic factors.

Objective

To stratify the risk factors for the multinational society of the UAE.

Methods

A retrospective chart review of 560 patients sequentially admitted to inpatient care with laboratory confirmed COVID-19 was conducted. We studied patients’ demographics, clinical features, laboratory results, disease severity, and outcomes. The parameters were compared across different ethnic groups using tree-based estimators to rank the ethnicity-specific disease features. We trained ML classification algorithms to build a model of ethnic specificity of COVID-19 based on clinical presentation and laboratory findings on admission.

Results

Out of 560 patients, 43.6% were South Asians, 26.4% Middle Easterns, 16.8% East Asians, 10.7% Caucasians, and 2.5% are under others. UAE nationals represented half of the Middle Eastern patients, and 13% of the entire cohort. Hypertension was the most common comorbidity in COVID-19 patients. Subjective complaint of fever and cough were the chief presenting symptoms. Two-thirds of the patients had either a mild disease or were asymptomatic. Only 20% of the entire cohort needed oxygen therapy, and 12% needed ICU admission. Forty patients (~7%) needed invasive ventilation and fifteen patients died (2.7%). We observed differences in disease severity among different ethnic groups. Caucasian or East-Asian COVID-19 patients tended to have a more severe disease despite a lower risk profile. In contrast to this, Middle Eastern COVID-19 patients had a higher risk factor profile, but they did not differ markedly in disease severity from the other ethnic groups. There was no noticeable difference between the Middle Eastern subethnicities—Arabs and Africans—in disease severity (p = 0.81). However, there were disparities in the SOFA score, D-dimer (p = 0.015), fibrinogen (p = 0.007), and background diseases (hypertension, p = 0.003; diabetes and smoking, p = 0.045) between the subethnicities.

Conclusion

We observed variations in disease severity among different ethnic groups. The high accuracy (average AUC = 0.9586) of the ethnicity classification model based on the laboratory and clinical findings suggests the presence of ethnic-specific disease features. Larger studies are needed to explore the role of ethnicity in COVID-19 disease features.

Non-pharmacological interventions to achieve blood pressure control in African patients: a systematic review

OBJECTIVES

This systematic review aims to evaluate the evidence of non-pharmacological strategies to improve blood pressure (BP) control in patients with hypertension from African countries.

DESIGN

We performed a systematic review and searched Medline, Central, CINAHL and study registers until June 2020 for randomised studies on interventions to decrease BP of patients with hypertension in African countries. We assessed the study quality using the Cochrane risk of bias tool and narratively synthesised studies on non-pharmacological hypertension interventions.

SETTING

We included studies conducted in African countries.

PARTICIPANTS

Adult African patients with a hypertension diagnosis.

INTERVENTIONS

Studies on non-pharmacological interventions aiming to improve BP control and treatment adherence.

OUTCOMES

Main outcomes were BP and treatment adherence.

RESULTS

We identified 5564 references, included 23 with altogether 18 153 participants from six African countries. The studies investigated educational strategies to improve adherence (11 studies) and treatment by healthcare professionals (5 studies), individualised treatment strategies (2 studies), strategies on lifestyle including physical activity (4 studies) and modified nutrition (1 study). Nearly all studies on educational strategies stated improved adherence, but only three studies showed a clinically relevant improvement of BP control. All studies on individualised strategies and lifestyle changes resulted in clinically relevant effects on BP. Due to the type of interventions studied, risk of bias in domain blinding of staff/participants was frequent (83%). Though incomplete outcome data in 61% of the studies are critical, the general study quality was reasonable.

CONCLUSIONS

The identified studies offer diverse low-cost interventions including educative and task-shifting strategies, individualised treatment and lifestyle modifications to improve BP control. Especially trialled physical activity interventions show clinically relevant BP changes. All strategies were trialled in African countries and may be used for recommendations in evidence-based guidelines on hypertension in African settings.

PROSPERO REGISTRATION NUMBER

CRD42018075062.

Antihypertensive Medication Use and Its Effects on Blood Pressure and Haemodynamics in a Tri-ethnic Population Cohort: Southall and Brent Revisited (SABRE)

Objectives:

We characterised differences in BP control and use of antihypertensive medications in European (EA), South Asian (SA) and African-Caribbean (AC) people with hypertension and investigated the potential role of type 2 diabetes (T2DM), reduced arterial compliance (C_a), and antihypertensive medication use in any differences.

Methods:

Analysis was restricted to individuals with hypertension [age range 59–85 years; N = 852 (EA = 328, SA = 356, and AC =168)]. Questionnaires, anthropometry, BP measurements, echocardiography, and fasting blood assays were performed. BP control was classified according to UK guidelines operating at the time of the study. Data were analysed using generalised structural equation models, multivariable regression and treatment effect models.

Results:

SA and AC people were more likely to receive treatment for high BP and received a greater average number of antihypertensive agents, but despite this a smaller proportion of SA and AC achieved control of BP to target [age and sex adjusted odds ratio (95% confidence interval) = 0.52 (0.38, 0.72) and 0.64 (0.43, 0.96), respectively]. Differences in BP control were partially attenuated by controlling for the higher prevalence of T2DM and reduced C_a in SA and AC. There was little difference in choice of antihypertensive agent by ethnicity and no evidence that differences in efficacy of antihypertensive regimens contributed to ethnic differences in BP control.

Conclusions:

T2DM and more adverse arterial stiffness are important factors in the poorer BP control in SA and AC people. More effort is required to achieve better control of BP, particularly in UK ethnic minorities.

Hypertension in Women: A South-Asian Perspective

Introduction

Hypertension is an important contributor to cardiovascular disease related morbidity and mortality. Despite the magnitude of its negative impact on cardiovascular outcomes, treatment and control of hypertension remain suboptimal in both men and women.

Materials and Methods

Numerous databases, i.e., PubMed, ScienceDirect, etc., were searched using keywords to identify relevant studies to our narrative review. The findings from the most pertinent articles were summarized and integrated into our narrative review on hypertension in women.

Results

The pathophysiology of essential hypertension is still being delineated in both men and women; there are multiple sex specific factors in association with the development of hypertension in women, including age, combined oral contraceptives (COCs), polycystic ovarian syndrome (PCOS), preeclampsia, etc. There are several sex specific considerations in antihypertensives drug choices.

Discussion

Despite the magnitude of its negative impact on cardiovascular outcomes, treatment and control of hypertension remain suboptimal in women. Medical treatment and adherence is uniquely challenging for South Asian women due to a variety of socio-cultural-economic factors. Further research is warranted to identify optimal sex-specific treatment options that will improve the control of hypertension and decrease the risk of subsequent cardiovascular disease in both genders.

Improving the enrollment of women and racially/ethnically diverse populations in cardiovascular clinical trials: An ASPC practice statement

Cardiovascular disease (CVD) remains the leading cause of death for both women and men worldwide. In the United States (U.S.), there are significant disparities in cardiovascular risk factors and CVD outcomes among racial and ethnic minority populations, some of whom have the highest U.S. CVD incidence and mortality. Despite this, women and racial/ethnic minority populations remain underrepresented in cardiovascular clinical trials, relative to their disease burden and population percentage. The lack of diverse participants in trials is not only a moral and ethical issue, but a scientific concern, as it can limit application of future therapies. Providing comprehensive demographic data by sex and race/ethnicity and increasing representation of diverse participants into clinical trials are essential in assessing accurate drug response, safety and efficacy information. Additionally, diversifying investigators and clinical trial staff may assist with connecting to the language, customs, and beliefs of study populations and increase recruitment of participants from diverse backgrounds. In this review, a working group for the American Society for Preventive Cardiology (ASPC) reviewed the literature regarding the inclusion of women and individuals of diverse backgrounds into cardiovascular clinical trials, focusing on prevention, and provided recommendations of best practices for improving enrollment to be more representative of the U.S. society into trials.

Vasorelaxant-Mediated Antihypertensive Effect of the Leaf Aqueous Extract from Stephania abyssinica (Dillon & A. Rich) Walp (Menispermaceae) in Rat

Stephania abyssinica is a medicinal plant used in Cameroon alternative medicine to treat arterial hypertension (AHT). Previous in vitro studies demonstrated the endothelium nitric oxide-independent vasorelaxant property of the aqueous extract from Stephania abyssinica (AESA). But its effect on AHT is unknown. The present study was undertaken to explore other vasorelaxant mechanisms and to determine the antihypertensive effects of AESA in male Wistar rats. Phytochemical analysis of AESA was carried out using the liquid chromatography-mass spectrometry (LC-MS) method. The vasorelaxant effects of AESA (1-1000 μg/mL) were studied on rat isolated thoracic aorta rings, in the absence or presence of indomethacin (10 μM) or methylene blue (10 μM). The inhibitory effect of AESA on phenylephrine (PE, 10 μM) or KCl- (60 mM) induced contraction as well as the intracellular calcium release was also evaluated. The in vivo antihypertensive activity of AESA (43, 86, or 172 mg/kg/day) or captopril (20 mg/kg/day) administered orally was assessed in L-NAME- (40 mg/kg/day) treated rats. Blood pressure and heart rate (HR) were measured at the end of each week while serum or urinary nitric oxide (NO), creatinine, and glomerular filtration rate (GFR) were determined at the end of the 6 weeks of treatment, as well as histological analysis of the heart and the kidney. The LC-MS profiling of AESA identified 9 compounds including 7 alkaloids. AESA produced a concentration-dependent relaxation on contraction induced either by PE and KCl, which was significantly reduced in endothelium-denuded vessels, as well as in vessels pretreated with indomethacin and methylene blue. Moreover, AESA inhibited the intracellular Ca²⁺ release-induced contraction. In vivo, AESA reduced the AHT, heart rate (HR), and ventricular hypertrophy and increased serum NO, urine creatinine, and GFR. AESA also ameliorated heart and kidney lesions as compared to the L-NAME group. These findings supported the use of AESA as a potential antihypertensive drug.

Vitamin D and COVID-19: Role of ACE2, age, gender, and ethnicity

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus, disproportionally targets older people, particularly men, ethnic minorities, and individuals with underlying diseases such as compromised immune system, cardiovascular disease, and diabetes. The discrepancy in COVID-19 incidence and severity is multifaceted and likely involves biological, social, as well as nutritional status. Vitamin D deficiency, notably common in Black and Brown people and elderly, is associated with an increased susceptibility to many of the diseases comorbid with COVID-19. Vitamin D deficiency can cause over-activation of the pulmonary renin-angiotensin system (RAS) leading to the respiratory syndrome. RAS is regulated in part at least by angiotensin-converting enzyme 2 (ACE2), which also acts as a primary receptor for SARS-CoV-2 entry into the cells. Hence, vitamin D deficiency can exacerbate COVID-19, via its effects on ACE2. In this review we focus on influence of age, gender, and ethnicity on vitamin D-ACE2 interaction and susceptibility to COVID-19.

Managing cardiovascular disease risk in South Asian kidney transplant recipients

South Asians (SA) are at higher cardiovascular risk than other ethnic groups, and SA kidney transplant recipients (SA KTR) are no exception. SA KTR experience increased major adverse cardiovascular events both early and late post-transplantation. Cardiovascular risk management should therefore begin well before transplantation. SA candidates may require aggressive screening for pre-transplant cardiovascular disease (CVD) due to their ethnicity and comorbidities. Recording SA ethnicity during the pre-transplant evaluation may enable programs to better assess cardiovascular risk, thus allowing for earlier targeted peri- and post-transplant intervention to improve cardiovascular outcomes. Diabetes remains the most prominent post-transplant cardiovascular risk factor in SA KTR. Diabetes also clusters with other metabolic syndrome components including lower high-density lipoprotein cholesterol, higher triglycerides, hypertension, and central obesity in this population. Dyslipidemia, metabolic syndrome, and obesity are all significant CVD risk factors in SA KTR, and contribute to increased insulin resistance. Novel biomarkers such as adiponectin, apolipoprotein B, and lipoprotein (a) may be especially important to study in SA KTR. Focused interventions to improve health behaviors involving diet and exercise may especially benefit SA KTR. However, there are few interventional clinical trials specific to the SA population, and none are specific to SA KTR. In all cases, understanding the nuances of managing SA KTR as a distinct post-transplant group, while still screening for and managing each CVD risk factor individually in all patients may help improve the long-term success of all kidney transplant programs catering to multi-ethnic populations.

Evaluation of population-level pharmacogenetic actionability in Alabama

The evolution of evidence and availability of Clinical Pharmacogenetic Implementation Consortium (CPIC) guidelines have enabled assessment of pharmacogenetic (PGx) actionability and clinical implementation. However, population‐level actionability is not well‐characterized. We leveraged the Alabama Genomic Health Initiative (AGHI) to evaluate population‐level PGx actionability. Participants (>18 years), representing all 67 Alabama counties, were genotyped using the Illumina Global Screening array. Using CPIC guidelines, actionability was evaluated using (1) genotype data and genetic ancestry, (2) prescribing data, and (3) combined genotype and medication data. Of 6,331 participants, 4230 had genotype data and 3386 had genotype and prescription data (76% women; 76% White/18% Black [self‐reported]). Genetic ancestry was concordant with self‐reported race. For CPIC level A genes, 98.6% had an actionable genotype (99.4% Blacks/African; 98.5% White/European). With the exception of DPYD and CYP2C19, the prevalence of actionable genotypes by gene differed significantly by race. Based on prescribing, actionability was highest for CYP2D6 (70.9%), G6PD (54.1%), CYP2C19 (53.5%), and CYP2C9 (47.5%). Among participants prescribed atenolol, carvedilol, or metoprolol, ~ 50% had an actionable ADRB1 genotype, associated with decreased therapeutic response, with higher actionability among Blacks compared to Whites (62.5% vs. 47.4%; p < 0.0001). Based on both genotype and prescribing frequencies, no significant differences in actionability were observed between men and women. This statewide effort highlights PGx population‐level impact to help optimize pharmacotherapy. Almost all Alabamians harbor an actionable genotype, and a significant proportion are prescribed affected medications. Statewide efforts, such as AGHI, lay the foundation for translational research and evaluate “real‐world” outcomes of PGx.

Novel coronavirus disease 2019 (COVID-19) pandemic: From transmission to control with an interdisciplinary vision

There a lot of review papers addressing specific COVID-19 research sectors, then devoted to specialists. This review provides an in-depth summary of the available information about SARS-CoV-2 and the corresponding disease (also known as COVID-19), with a multi-disciplinary approach. After the paper introduction, the first section treats the virological characteristics of SARS-CoV-2, the medical implications of the infection, and the human susceptivity. Great attention is devoted to the factor affecting the infection routes, distinguishing among the possible human-to-human, environmental-to-human, and pollution-to-human transmission mechanisms. The second section is devoted to reporting the impact of SARS-CoV-2 not only on the healthcare systems but also on the economy and society. The third section is devoted to non-pharmaceutical behaviours against COVID-19. In this context, this review section presents an analysis of the European second wave allowing not only to focalize the importance of some restrictions, but also the relevance of social acceptance of some measures. The data reassumed in this work are very useful for interdisciplinary researchers that work in a team to find the basic available information about all the aspects connected with this pandemic (from virus diffusion mechanism to health information, from economic and social impacts to measures to reduce the pandemic spread), with great attention to social acceptance of restriction measures and of vaccines (that currently results to be insufficient to achieve community immunity). Then, this review paper highlights the fundamental role of the trans-multi-disciplinary research that is devoted not only to understand the basics of the pandemic to propose solutions but has also the commitment to find strategies to increase population resilience. For this aim, the authors strongly suggest the establishment of an international health-care trans-multi-disciplinary workforce devoted to investigate, mitigate, and control also future viral events.

Novel coronavirus disease 2019 (COVID-19) pandemic: From transmission to control with an interdisciplinary vision

There a lot of review papers addressing specific COVID-19 research sectors, then devoted to specialists. This review provides an in-depth summary of the available information about SARS-CoV-2 and the corresponding disease (also known as COVID-19), with a multi-disciplinary approach. After the paper introduction, the first section treats the virological characteristics of SARS-CoV-2, the medical implications of the infection, and the human susceptivity. Great attention is devoted to the factor affecting the infection routes, distinguishing among the possible human-to-human, environmental-to-human, and pollution-to-human transmission mechanisms. The second section is devoted to reporting the impact of SARS-CoV-2 not only on the healthcare systems but also on the economy and society. The third section is devoted to non-pharmaceutical behaviours against COVID-19. In this context, this review section presents an analysis of the European second wave allowing not only to focalize the importance of some restrictions, but also the relevance of social acceptance of some measures. The data reassumed in this work are very useful for interdisciplinary researchers that work in a team to find the basic available information about all the aspects connected with this pandemic (from virus diffusion mechanism to health information, from economic and social impacts to measures to reduce the pandemic spread), with great attention to social acceptance of restriction measures and of vaccines (that currently results to be insufficient to achieve community immunity). Then, this review paper highlights the fundamental role of the trans-multi-disciplinary research that is devoted not only to understand the basics of the pandemic to propose solutions but has also the commitment to find strategies to increase population resilience. For this aim, the authors strongly suggest the establishment of an international health-care trans-multi-disciplinary workforce devoted to investigate, mitigate, and control also future viral events.

The Connotation of Variances in the Risk Predictors, Medications, Homocysteine, and Homocysteine Pathway Gene Polymorphisms with CVA/Stroke

Cerebrovascular accidents (CVAs) are vascular multifactorial, multigenic ailments with intricate genetic, environmental risk influences. The present study aimed to establish affiliation of CVAs/stroke with blood parameters, differences in prescribed drugs consumption, and with differences in homocysteine pathway genes polymorphisms. The participants in study included controls n  = 251, transient ischemic attack (TIA) patients n  = 16, and stroke cases n  = 122, respectively, (total participants, n  = 389). The analyzed single nucleotide polymorphisms (SNPs) included C677T(rs1801133), A1298C(rs1801131) of methylene tetrahydrofolate reductase ( MTHFR ), A2756G(rs1805087) of methyl tetrahydrofolate homocysteine methyltransferase/methionine synthase ( MS ), and the A192G(rs662) of paraoxonase 1( PON1 ) genes, all validated by tetra-primer allele refractory mutation system polymerase chain reaction (T-ARMS-PCR). The insertion deletion (I/D; rs4646994) polymorphism in angiotensin converting enzyme ( ACE ) gene was analyzed using routine PCR. All studied traits were scrutinized through analysis of variance (ANOVA), and later through regression analysis. Through ANOVA and multiple comparison, there was association of CVA with serum homocysteine, cholesterol, and with diastolic blood pressure readings. When data was subjected to regression, serum homocysteine and diastolic blood pressure (significant through ANOVA), as well as two additional traits, high-density lipoproteins (HDL), and rs1801133 MTHFR SNP sustained statistical significance and noteworthy odds in relation to CVA and stroke. The ailments affecting cerebral vasculature are mutifactorial, whereby genes, proteins, and environmental cues all exert cumulative effects enhancing CVA risk. The current study emphasizes that SNPs and variation in circulating biomarkers can be used for screening purposes and for reviewing their effects in stroke/CVA-linked risk progression.

Racial disparities and cardiovascular disease: One size fits all approach?

BACKGROUND

Despite recent advancements in prevention, treatment, and management options, cardiovascular diseases contribute to one of the leading causes of morbidity and mortality. Several studies highlight the compelling evidence for the existence of healthcare inequities and disparities in the treatment and management control of cardiovascular diseases.

AIMS

To explore the role of racial disparities in the treatment of various cardiovascular diseases, highlighting the role of socioeconomic and cultural factors, and ultimately postulate solutions to eliminate the disparities.

METHODS

A comprehensive review of the literature was conducted using appropriate keywords on search engines of SCOPUS, Wiley, PubMed, and SAGE Journals.

CONCLUSION

By continued research to eliminate healthcare inequalities, there exists a potential to improve health-related outcomes in minority populations.

Interplay of COVID-19 and cardiovascular diseases in Africa: an observational snapshot

The COVID-19 pandemic, which started around December 2019 has, at present, resulted in over 450,000 deaths globally, and approximately 1% of these deaths have been reported in Africa. Despite the high prevalence of COVID-19 risk factors, namely: hypertension, diabetes, chronic pulmonary disease, cardiovascular diseases (CVDs) such as rheumatic heart disease, compromised immunity and obesity, low case fatality rates have been recorded in many parts of Africa so far. COVID-19 severity has previously been shown to be worse in patients with CVD and hypertension. We observed the severity of COVID-19 and mortality rates in Africa, and compared outcomes with prevalence of established risk factors (hypertension and CVD). We stratified data as per the United Nations’ 5 African subregions. North African countries show a positive association between the risk factors and the mortality rates from COVID-19. However, we observed discordant patterns in the relationship between COVID-19, and either CVD or hypertension, in sub-Saharan African countries. In this paper, we also review the pathogenesis of SARS-CoV-2 infection and how it worsens CVD and postulate that the differences in modulation of the renin–angiotensin–aldosterone system (RAAS) axis which controls angiotensin-converting enzyme (ACE)/ACE2 balance may be an important determinant of COVID-19 outcomes in Africa.

Clinical Experiences of Intravenous Hydralazine and Labetalol for Acute Treatment of Severe Hypertension in Pregnant Thai Women

Response to acute treatment of severe hypertension during pregnancy in Asian women was not known. Labor and delivery checklists of Thai women treated with intravenous hydralazine or labetalol for systolic blood pressure (SBP) ≥ 160 or diastolic blood pressure (DBP) ≥ 110 mm Hg from January 2011 to December 2013 were reviewed as parts of an audit. Primary outcome was prompt achievement of SBP 140-150 and DBP 90-100 mm Hg after the first bolus. Secondary outcomes were medication-related undesired effects. The mean ± standard deviation age and prevalence of chronic hypertension in hydralazine (n = 62) versus labetalol (n = 64) groups were 32.5 ± 6 versus 29.9 ± 6.8 years and 50% versus 21.9%, respectively (P < .05). Magnesium sulfate was promptly administered on admission to every woman to prevent seizure. Targeted blood pressure was timely achieved in 41.9% and 67.2% of the hydralazine and labetalol groups, respectively (P < .05). Nonreassuring fetal heart rate occurred in 51.6% and 32.8% of the hydralazine and labetalol groups, respectively (P = .05). The prevalence of cesarean section and Apgar score < 7 were not significantly different (P > .05). Real-life clinical experiences suggested significant advantages of intravenous labetalol over hydralazine in pregnant women with severe hypertension.

The impact of ethnicity on clinical outcomes in COVID-19: A systematic review

BACKGROUND

The relationship between ethnicity and COVID-19 is uncertain. We performed a systematic review to assess whether ethnicity has been reported in patients with COVID-19 and its relation to clinical outcomes.

METHODS

We searched EMBASE, MEDLINE, Cochrane Library and PROSPERO for English-language citations on ethnicity and COVID-19 (1st December 2019-15th May 2020). We also reviewed: COVID-19 articles in NEJM, Lancet, BMJ, JAMA, clinical trial protocols, grey literature, surveillance data and preprint articles on COVID-19 in MedRxiv to evaluate if the association between ethnicity and clinical outcomes were reported and what they showed. PROSPERO:180654.

FINDINGS

Of 207 articles in the database search, five reported ethnicity; two reported no association between ethnicity and mortality. Of 690 articles identified from medical journals, 12 reported ethnicity; three reported no association between ethnicity and mortality. Of 209 preprints, 34 reported ethnicity - 13 found Black, Asian and Minority Ethnic (BAME) individuals had an increased risk of infection with SARS-CoV-2 and 12 reported worse clinical outcomes, including ITU admission and mortality, in BAME patients compared to White patients. Of 12 grey literature reports, seven with original data reported poorer clinical outcomes in BAME groups compared to White groups.

INTERPRETATION

Data on ethnicity in patients with COVID-19 in the published medical literature remains limited. However, emerging data from the grey literature and preprint articles suggest BAME individuals are at an increased risk of acquiring SARS-CoV-2 infection compared to White individuals and also worse clinical outcomes from COVID-19. Further work on the role of ethnicity in the current pandemic is of urgent public health importance.

FUNDING

NIHR.

Pharmacotherapy for hypertension in Sub-Saharan Africa: a systematic review and network meta-analysis

BACKGROUND

The highest burden of hypertension is found in Sub-Saharan Africa (SSA) with a threefold greater mortality from stroke and other associated diseases. Ethnicity is known to influence the response to antihypertensives, especially in black populations living in North America and Europe. We sought to outline the impact of all commonly used pharmacological agents on both blood pressure reduction and cardiovascular morbidity and mortality in SSA.

METHODS

We used similar criteria to previous large meta-analyses of blood pressure agents but restricted results to populations in SSA. Quality of evidence was assessed using a risk of bias tool. Network meta-analysis with random effects was used to compare the effects across interventions and meta-regression to explore participant heterogeneity.

RESULTS

Thirty-two studies of 2860 participants were identified. Most were small studies from single, urban centres. Compared with placebo, any pharmacotherapy lowered SBP/DBP by 8.51/8.04 mmHg, and calcium channel blockers (CCBs) were the most efficacious first-line agent with 18.46/11.6 mmHg reduction. Fewer studies assessing combination therapy were available, but there was a trend towards superiority for CCBs plus ACE inhibitors or diuretics compared to other combinations. No studies examined the effect of antihypertensive therapy on morbidity or mortality outcomes.

CONCLUSION

Evidence broadly supports current guidelines and provides a clear rationale for promoting CCBs as first-line agents and early initiation of combination therapy. However, there is a clear requirement for more evidence to provide a nuanced understanding of stroke and other cardiovascular disease prevention amongst diverse populations on the continent.

TRIAL REGISTRATION

PROSPERO, CRD42019122490. This review was registered in January 2019.

The Burden of Atherosclerotic Cardiovascular Disease in South Asians Residing in Canada: A Reflection From the South Asian Heart Alliance

South Asians (SAs), originating from the Indian subcontinent (India, Pakistan, Sri Lanka, Bangladesh, Nepal, and Bhutan), represent one quarter of the global population and are the largest visible minority in Canada. SAs experience the highest rates of coronary artery disease in Canada. Although conventional cardiovascular risk factors remain predictive in SA, the excess risk is not fully explained by these risk factors alone. Abdominal obesity, metabolic syndrome, and insulin resistance likely contribute a greater risk in SAs than in other populations. The South Asian Heart Alliance has been recently formed to investigate and recommend the best strategies for the prevention of cardiometabolic disease in SAs in Canada. This topic review represents a comprehensive overview of the magnitude of cardiovascular disease in SAs in Canada, with a review of conventional and novel risk markers in the SA population. Both primary and secondary prevention strategies are suggested and when possible, adapted specifically for the SA population. The need for SAs and their healthcare professionals to be more aware of the problem and potential solutions, along with the need for population-specific research, is highlighted.

Hypertension: a new treatment for an old disease? Targeting the immune system

Arterial hypertension represents a serious public health problem, being a major cause of morbidity and mortality worldwide. The availability of many antihypertensive therapeutic strategies still fails to adequately treat around 20% of hypertensive patients, who are considered resistant to conventional treatment. In the pathogenesis of hypertension, immune system mechanisms are activated and both the innate and adaptive immune responses play a crucial role. However, what, when and how the immune system is triggered during hypertension development is still largely undefined. In this context, this review highlights scientific advances in the manipulation of the immune system in order to attenuate hypertension and end-organ damage. Here, we discuss the potential use of immunosuppressants and immunomodulators as pharmacological tools to control the activation of the immune system, by non-specific and specific mechanisms, to treat hypertension and improve end-organ damage. Nevertheless, more clinical trials should be performed with these drugs to establish their therapeutic efficacy, safety and risk-benefit ratio in hypertensive conditions. LINKED ARTICLES: This article is part of a themed section on Immune Targets in Hypertension. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v176.12/issuetoc.

Science-based Ethnic Bridging in Drug Development; Review of Recent Precedence and Suggested Steps Forward

BACKGROUND

Exposure, safety and/or efficacy of drugs are subject to potential differences between human races or ethnicities, as acknowledged by regulatory guidance and by label texts of various, but not all approved drugs.

OBJECTIVE

The objective of the present review was to assess recent regulatory precedence on drug use and race or ethnicity, with the goal of identifying opportunities for increasing the informative value of clinical ethnic or racial bridging in drug development.

METHODS

Recently, (January 2014-July 2018) FDA approved drug product label texts and approval packages were reviewed for claims, comments and underlying data on use of the product in specific ethnic or racial groups.

RESULTS

Among the 266 FDA-approved products, no product with unambiguous race- or ethnicity specific dosing instructions was retrieved. A small majority (55%) was approved with a claim or comment on race or ethnicity, and of these, a large majority (87%) was based on population pharmacokinetic data analysis. Statements were often related to incidence of a genotype for drug metabolizing enzyme or for other risk factors, or were related to body weight. Absence of clinically relevant exposure differences were often justified in terms of exposure ratios that notably exceeded the typical 0.80-1.25 no-effect boundary.

CONCLUSIONS

Recent precedence reflected a pragmatic, descriptive approach of racial or ethnic bridging, apparently meeting current regulatory expectations, whilst not resulting in strict guidance to prescribers. We recommend further work on defining the objectives of bridging studies, as well as criteria for their design and data analysis. Regarding the latter, we recommend investigating the value of prospectively defined tests for similarity with appropriate follow-up analysis in the case where the test has failed.

Underuse of hydralazine and isosorbide dinitrate for heart failure in patients of African ancestry: a cross-European survey

Aims

Population data indicate that one in 25 persons of African ancestry has heart failure, a condition with relatively high mortality of around 50% in 5 years. Combined hydralazine and isosorbide dinitrate added to conventional therapy in African ancestry patients with heart failure and reduced ejection fraction improves quality of life and reduces the rate of first hospitalization for heart failure by 33% and annual mortality by 43%. The objectives of this study were to quantify the use of this guideline‐recommended therapy in Europe and the potential effect of implementation gaps on mortality.

Methods and results

Prescription drug registration and utilization databases and population statistics were analysed in a cross‐European survey without language restriction. Main outcomes were the number of unique patients prescribed the fixed combination hydralazine–isosorbide dinitrate (primary) or both drugs (secondary) in Europe in 2015, and the excess mortality related to prescribing practices was estimated. The survey indicates that around 12 million persons of African ancestry live in Europe. It is estimated that 480 000 persons of this population group have heart failure, with 120 000 eligible for hydralazine and isosorbide dinitrate therapy. However, single‐pill hydralazine–isosorbide dinitrate is not authorized and therefore not dispensed in Europe in 2015. Out of the 25 European nations surveyed, the UK and the Netherlands are the only countries with major African ancestry populations where both hydralazine and isosorbide dinitrate are available for oral use, aside Norway, Sweden, and Finland. Hydralazine and isosorbide dinitrate are prescribed to <500 European patients in 2015. Thus, despite the recommendations of the European Society of Cardiology, the large majority of African‐European patients with heart failure do not receive this drug combination, potentially resulting in 4800 to 5800 excess deaths yearly.

Conclusions

The life‐saving, guideline‐recommended, adjunctive therapy for heart failure in African ancestry patients with hydralazine and isosorbide dinitrate is rarely used in Europe. This major evidence‐practice gap should urgently be overcome to reduce excess mortality in African‐European patients with heart failure.

Creatine kinase, energy reserve, and hypertension: from bench to bedside

We hypothesized that human variation in the activity of the ATP regenerating enzyme creatine kinase (CK) activity affects hypertension and cardiovascular disease risk. CK is tightly bound close to ATP-utilizing enzymes including Ca2+-ATPase, myosin ATPase, and Na+/K+-ATPase, where it rapidly regenerates ATP from ADP, H+, and phosphocreatine. Thus, relatively high CK was thought to enhance ATP-demanding processes including resistance artery contractility and sodium retention, and reduce ADP-dependent functions. In a series of studies of our group and others, CK was linked to hypertension and bleeding risk. Plasma CK after rest, used as a surrogate measure for tissue CK, was associated with high blood pressure and failure of antihypertensive therapy in case-control and population studies. Importantly, high tissue CK preceded hypertension in animal models and in humans, and human vascular tissue CK gene expression was strongly associated with clinical blood pressure. In line with this, CK inhibition substantially reduced the contractility of human resistance arteries ex vivo. We also presented evidence that plasma CK reduced ADP-dependent platelet aggregation. In subsequent intervention studies, the oral competitive CK inhibitor beta-guanidinopropionic acid (GPA) reduced blood pressure in spontaneously hypertensive rats (SHRs), and a 1-week trial of sub-therapeutic dose GPA in healthy men was uneventful. Thus, based on theoretical concepts, evidence was gathered in laboratory, case-control, and population studies that high CK is associated with hypertension and with bleeding risk, potentially leading to a new mode of cardiovascular risk reduction with CK inhibition.

Ethnic disparities in treatment rates for hypertension and dyslipidemia: an analysis by different treatment indications: the Healthy Life in an Urban Setting study

BACKGROUND

Studies have reported ethnic disparities in treatment rates for cardiovascular risk factors. These studies are generally based on treatment indications defined by individual cardiovascular risk factors (ICRF). However, according to most European guidelines, preventive treatment for these risk factors is recommended only among those with sufficient overall cardiovascular risk (OCR).

OBJECTIVE

To determine ethnic disparities in treatment rates for hypertension and dyslipidemia among those with an indication for treatment based on ICRF and OCR.

METHODS

Using data of the HELIUS study, we determined the occurrence of cardiovascular risk factors and treatment rates among 11 357 participants from six ethnic backgrounds living in Amsterdam. Via logistic regression analyses, we determined ethnic differences in blood pressure (BP)-lowering or lipid-lowering treatment rates among those needing treatment based on ICRF (BP >140 mmHg and LDL >2.5 mmol/l, respectively) and on OCR (estimated overall 10-year cardiovascular disease risk according to SCORE).

RESULTS

Relative to the Dutch, ethnic minority men showed higher treatment rates for hypertension and dyslipidemia, regardless of whether OCR of ICRF recommendations for treatment were used. Ethnic minority women showed similar treatment rates relative to the Dutch based on OCR, but higher treatment rates based on ICRF recommendations (e.g. odds ratios for antihypertensive treatment ranged from 0.93 to 1.75 and from 1.26 to 1.93, respectively).

CONCLUSION

Treatment rates for hypertension and dyslipidemia are not lower among ethnic minority groups relative to the Dutch. In some cases, they are even higher, but these differences may be overestimated whenever using ICRF as treatment indication.

Blood pressure response to metoprolol and chlorthalidone in European and African Americans with hypertension

Despite the availability of many antihypertensive drug classes, half of patients with hypertension have uncontrolled blood pressure (BP). The authors sought to assess the effect of age on BP response in European American and African American patients with hypertension. Clinic BP from the PEAR2 (Pharmacogenomics Evaluation of Antihypertensive Responses 2) study was used to estimate BP responses from baseline following sequential treatment with metoprolol 100 mg twice daily and chlorthalidone 25 mg daily for 8 to 9 weeks each, with a minimum 4-week washout between treatments. BP responses to both drugs were compared in 159 European Americans and 119 African Americans by age with adjustment for baseline BP and sex. European Americans younger than 50 years responded better to metoprolol than chlorthalidone (diastolic BP: -9.6 ± 8.0 vs -5.9 ± 6.8 mm Hg, adjusted P = .003), whereas patients 50 years and older responded better to chlorthalidone than metoprolol (systolic BP: -18.7 ± 13.8 vs -13.6 ± 14.8 mm Hg, adjusted P = .008). African Americans younger than 50 years responded similarly to both drugs, whereas those 50 years and older responded better to chlorthalidone than metoprolol (-17.0 ± 13.2/-9.6 ± 7.5 vs -7.0 ± 18.6/-6.7 ± 9.3 mm Hg, adjusted P<.0001/.008). Therefore, age should be considered when selecting antihypertensive therapy in European and African American populations with hypertension.

Is cardiovascular risk reduction therapy effective in South Asian, Chinese and other patients with diabetes? A population-based cohort study from Canada

OBJECTIVES

Guidelines recommend ACE inhibitors (ACEi), angiotensin receptor blockers (ARBs), calcium channel blockers (CCBs) and diuretics in all patients with diabetes mellitus. However, the effectiveness of these agents in South Asian and Chinese populations is unknown. We sought to determine whether ACEi, ARB, CCB and diuretics are associated with reduced mortality in South Asian, Chinese and other patients with diabetes.

DESIGN

Population-based cohort study using administrative health databases.

SETTING

Province of British Columbia, Canada (2006-2013).

PARTICIPANTS

Patients aged ≥35 years with incident diabetes.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome was all-cause mortality for each medication class compared with untreated patients within each ethnicity. Treatment effect was assessed using inverse probability of treatment weighted Cox proportional hazards models. Medication adherence effect on mortality was also evaluated.

RESULTS

208 870 patients (13 755 South Asian, 22 871 Chinese, 172 244 other Canadian) were included. ACEi reduced mortality in other patients (HR=0.88, 0.84-0.91), but power was insufficient to evaluate for benefit in Chinese and South Asian patients. ARB and diuretics reduced mortality in Chinese (ARB HR=0.64, 0.50-0.82; diuretics HR=0.77, 0.62-0.96) and other patients (ARB HR=0.69, 0.64-0.74; diuretics HR=0.66, 0.63-0.69) compared with untreated patients. No mortality benefit was observed among South Asians for any drug class or for CCB among all ethnicities. Higher medication adherence was associated with lower mortality for other patients only (HR=0.79, 0.72-0.86).

CONCLUSIONS

Effectiveness of cardiovascular risk reduction therapy on mortality varies considerably by ethnicity. Further study is needed to evaluate the mortality benefit of antihypertensive agents in South Asians. Inclusion of these ethnic groups in future clinical trials is essential to examine for differential responses.

Efficacy of Calcium Channel Blockers on Major Cardiovascular Outcomes for the Treatment of Hypertension in Asian Populations: A Meta-analysis

BACKGROUND

Whether calcium channel blockers exert a greater effect on cardiovascular risk reduction in Asian populations than other antihypertensive agents is unclear. We conducted a meta-analysis of hypertension trials of dihydropyridine calcium channel blockers in Asian populations to clarify this association.

METHODS

EMBASE, MEDLINE, and Cochrane databases were searched (from inception to August 2016) for randomized controlled trials on cardiovascular death, major adverse cardiovascular events, stroke, congestive heart failure, and coronary revascularization in Asian persons with hypertension. We identified 9 trials that reported data specific to Asian populations (N = 29,643). These trials included 1 placebo-controlled trial and 8 active comparator trials; of these, 5 had angiotensin receptor blockers as the active comparator.

RESULTS

One placebo-controlled trial (n = 9711) showed significantly reduced cardiovascular mortality, major adverse cardiovascular events, and stroke with calcium channel blockers. Among 8 active comparator trials (n = 19,932), there were no significant differences in mortality (relative risk [RR], 1.10; 95% confidence interval [CI], 0.72-1.67; I² = 0.0%), major adverse cardiovascular events (RR, 1.02; 95% CI, 0.90-1.15; I² = 0.0%), stroke (RR, 0.97; 95% CI, 0.80-1.17; I² = 0.0%), congestive heart failure (RR, 1.01; 95% CI, 0.51-2.00; I² = 53.7), or coronary revascularization rates (RR, 0.98; 95% CI, 0.76-1.25; I² = 0.0%) in the calcium channel blocker group compared with other antihypertensive agents. When restricting the meta-analysis to angiotensin receptor blocker comparators (n = 10,384), there were no significant differences in cardiovascular outcomes.

CONCLUSIONS

There is no evidence that dihydropyridine calcium channel blockers are superior to other antihypertensive agents in Asian populations for the treatment of hypertension.