Role of race in the pharmacotherapy of heart failure

Equal Treatment, Unequal Outcomes? Debunking the Racial Disparity in Renin Angiotensin Aldosterone System Inhibitor Associated Reduction in Heart Failure Hospitalizations

BACKGROUND

Renin angiotensin aldosterone system inhibitors (RAASi) are a mainstay treatment in patients with heart failure with reduced ejection fraction (HFrEF) in part to prevent hospitalizations. However, whether RAAS inhibitors reduce the risk of hospitalization in Black patients is not entirely clear because enrollment of Black patients in previous clinical trials was low, and a previous meta-analysis showed a significant racial disparity: reduction in hospitalizations with an RAAS inhibitor in White patients but not Black patients. Previous studies relied on the use of self-identified race instead of genomic ancestry. Therefore, this study aimed to investigate the role of self-identified race and genomic ancestry in the racial disparity in RAAS inhibitor associated reductions in HFrEF hospitalizations.

METHODS

The primary outcome was time to first heart failure hospitalization. A (de-identified) heart failure patient registry and data from the GUIDE-IT multi-center randomized control trial were analyzed with Cox proportional hazards models un/adjusted for clinical risk factors, death as a competing risk, and time-varying RAAS inhibitor exposure. The proportion of Yoruba African ancestry was quantified.. Analysis of self - identified race were performed in both the registry and GUIDE-IT. Analysis of genomic ancestry was only performed in the registry since this information was not available in GUIDE-IT. A fixed effect meta-analysis combined results of both the registry and GUIDE-IT for race.

RESULTS

The registry had 1010 total HFrEF patients (Black = 509 and White = 501) with 852 having ancestry quantification (>80% Yoruba African Ancestry = 381 and <5% Yoruba African Ancestry = 471). GUIDE-IT had 810 HFrEF patients (Black = 322 and White = 488). There was no significant difference in the association of RAAS inhibitor exposure with heart failure hospitalization by race (meta-analysis p-value for race*RAAS inhibitor exposure interaction = 0.49; Black patients HR [95% CI] for RAAS inhibitor exposure = 0.89 [0.64-1.23)] P = 0.47; White patients = 1.20 (0.83-1.75) P = 0.34). Results were similar when analyzed by ancestry (p-value for ancestry*RAAS inhibitor exposure interaction = 0.57; >80% Yoruba African Ancestry = 0.93 [0.51-1.69] P = 0.80; <5% Yoruba African Ancestry = 1.29 [0.57-2.92] P = 0.54).

CONCLUSIONS

In contrast to a previous meta-analysis, this more contemporary analysis of 2 HFrEF patient datasets demonstrates the absence of a racial disparity in RAAS inhibitor associated reductions in heart failure hospitalizations. The difference in this racial disparity over time may be due to improvements in background heart failure therapies, racial differences in healthcare usage, and the use of more advanced statistical approaches.

The Effects of β-Adrenergic Blockers in African Americans with Chronic Heart Failure

Objective:

To review the available literature regarding the use of β-adrenergic blockers in African Americans with heart failure.

Data Sources:

Primary literature was located via MEDLINE (1966–January 2004). Key search terms were β-adrenergic blockers; heart failure, congestive; carvedilol; metoprolol; bisoprolol; and bucindolol.

Data Synthesis:

In African Americans, the prevalence of chronic heart failure (CHF) is nearly twice that of white people. African Americans exhibit symptoms of CHF at an earlier age, develop more marked functional decline after hospitalization for CHF, and have almost a twofold higher mortality rate compared with white patients. Sympathetic nervous system activation is a key pathophysiologic response in CHF; by attenuating this system, β-blockers have been shown to decrease mortality. Unfortunately, minority populations have been underrepresented in many of the trials evaluating β-blockers. Of the 4 β-blockers assessed in CHF, bucindolol has shown detrimental effects when used in African Americans. Metoprolol and bisoprolol have not been sufficiently evaluated to determine if response varies by race. Carvedilol has the best documented benefit in this population.

Conclusions:

Response to β-adrenergic blockers in CHF varies by race. Bucindolol has shown detrimental effects when used in African Americans. Further investigation is warranted to determine if metoprolol and bisoprolol are equally efficacious to carvedilol in African American patients with CHF.

Beta-blockade in chronic heart failure: does it work in everyone?

Chronic heart failure continues to exact a heavy burden on society due to high morbidity and mortality, in spite of advances in management. Beta-adrenergic blockade, by the suppression of sympathetic activity, attenuates the adverse ventricular remodeling seen in heart failure, and decreases mortality and hospitalization rates. Recently reported trials, meta-analyses, and sub-analyses extend the benefit of beta-blockade to severe heart failure, women, elderly patients, and African Americans. In addition, recent data also indicate the cost-effectiveness of beta-blockade in combating this deadly disease. These data indicate the strength of evidence for the use of beta-blockade for most patients with chronic heart failure.