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Charles Curry, MD, says he worries about misconceptions that could be perpetuated in the care of black patients with heart failure.
"For treating hypertension, it’s well-known that black people don’t respond as well to ACE inhibitors," he says, citing a Veterans Affairs study that found a beta-blocker or ACE inhibitor alone was good enough to control high blood pressure in 70% of the study’s white patients, but only half to 60% of the black patients could be controlled with just one of the drugs.
When these drugs are used with diuretics and digitalis, however, the doctor is using a universally accepted therapy that’s right for everyone with heart failure, says Curry, who is chief of the division of cardiovascular disease at Howard University in Washington, DC.
A doctor may conclude incorrectly that just because a drug used by itself is not as effective for treating hypertensive black people as for white patients, the same drug will not be effective for treating black patients with heart failure.
"The problem is, they are two different diseases," Curry says.
Other physicians say to avoid falling into the myth trap, it’s important to remember that patients will be getting more than one drug to bring their conditions into better control.
"Very rarely do you have to treat patients with single drugs," says George A. Mensah, MD, chief of cardiology and the head of cardiovascular care at the Veterans Affairs Medical Center in Augusta, GA.
And when black patients have both heart failure and hypertension, it may take more than one drug to bring blood pressure under control.
"I think that is an important point," says Daniel L. Dries, MD, MPH, a cardiology and clinical trials research fellow at the National Heart, Lung, and Blood Institute in Bethesda, MD. "Black patients with heart failure who are on ACE inhibitors still tend to run hypertensive," he says.
The ACE inhibitor dosage should be maximized first, then titrate the beta-blocker up from a low dose. At this point, a black patient could have a blood pressure of 160/90 with an ejection fraction of 15%, he says.
To lower blood pressure further, Dries says he uses clonidine because its use in this situation has been proven. Felodipine or Amlodipine also can be used to control blood pressure. They do not improve patient survival but can help get a handle on blood pressure.
Mensah adds that following the multidrug routine for heart failure helps doctors avoid another racially based myth:
Because African-Americans tend to have lower concentrations of renin, they don’t need ACE inhibitor therapy. (That’s why traditional CHF treatment for black patients was digitalis and a diuretic.) In actuality, if a patient has heart failure, he or she will benefit from ACE inhibitors. "I’m amazed how many patients, regardless of race, are not on ACE inhibitors," Dries says. "And that’s proven medication."
Other problem areas that affect patients across the racial spectrum include:
1. Adding the beta-blocker to heart failure therapy before the patient is titrated up on ACE inhibitors.
Dries says he often sees patients come into the hospital with bad heart failure symptoms. They are not on a maximized dose of ACE inhibitors and they are given a beta-blocker.
"That’s a mistake," he says.
2. Patients are not on an appropriate level of diuretics.
"The most common mistake I see is not knowing how much extra fluid a person is retaining," Dries says. Physicians need to check a patient’s throat for a bulge, which indicates extra fluid. "Sometimes you diurese and the patient feels 100% better."