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CLINICAL RESEARCH: HYPERTENSION

Cardiovascular risk reduction in hypertensive black patients with left ventricular hypertrophy

The life study

Stevo Julius, MD^*,*, Michael H. Alderman, MD, Gareth Beevers, MD, Björn Dahlöf, MD, Richard B. Devereux, MD, FACC^||, Janice G. Douglas, MD^¶, Jonathan M. Edelman, MD^#, Katherine E. Harris, DrPH^#, Sverre E. Kjeldsen, MD^**, Shawna Nesbitt, MD, Otelio S. Randall, MD and Jackson T. Wright, Jr, MD, PhD^¶

^* Department of Internal Medicine, Division of Hypertension, University of Michigan, Ann Arbor, Michigan, USA
Albert Einstein College of Medicine, Bronx, New York, USA
City Hospital, Birmingham, England, UK
Department of Medicine, Sahlgrenska University Hospital, Östra, Göteborg, Sweden
^|| Division of Cardiology, Cornell Medical Center, New York, New York, USA
^¶ Case Western Reserve University, Division of Hypertension, Cleveland, Ohio, USA
^# Merck & Co., Inc., West Point, Pennsylvania, USA
^** Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, and Department of Cardiology, Ullevaal University Hospital, Oslo, Norway, USA
Department of Internal Medicine, Division of Hypertension, University of Texas Southwestern, Dallas, Texas, USA
Howard University Hospital, General Clinical Research Center, Washington, DC, USA

Manuscript received June 6, 2003; revised manuscript received October 10, 2003, accepted November 3, 2003.

^* Reprint requests and correspondence: Dr. Stevo Julius, Department of Internal Medicine, Division of Hypertension, University of Michigan Medical Center, 3918 Taubman Center, Ann Arbor, Michigan 48109-0356, USA.
sjulius{at}umich.edu

OBJECTIVES: We report on a subanalysis of the effects of losartan and atenolol on cardiovascular events in black patients in the Losartan Intervention For Endpoint reduction in hypertension (LIFE) study.

BACKGROUND: The LIFE study compared losartan-based to atenolol-based therapy in 9,193 hypertensive patients with left ventricular hypertrophy (LVH). Overall, the risk of the primary composite end point (cardiovascular death, stroke, myocardial infarction) was reduced by 13% (p = 0.021) with losartan, with similar blood pressure (BP) reduction in both treatment groups. There was a suggestion of interaction between ethnic background and treatment (p = 0.057).

METHODS: Exploratory analyses were performed that placed LIFE study patients into black (n = 533) and non-black (n = 8,660) categories, overall, and in the U.S. (African American [n = 523]; non-black [n = 1,184]).

RESULTS: A significant interaction existed between the dichotomized groups (black/non-black) and treatment (p = 0.005); a test for qualitative interaction was also significant (p = 0.016). The hazard ratio (losartan relative to atenolol) for the primary end point favored atenolol in black patients (1.666 [95% confidence interval (CI) 1.043 to 2.661]; p = 0.033) and favored losartan in non-blacks (0.829 [95% CI 0.733 to 0.938]; p = 0.003). In black patients, BP reduction was similar in both groups, and regression of electrocardiographic-LVH was greater with losartan.

CONCLUSIONS: Results of the subanalysis are sufficient to generate the hypothesis that black patients with hypertension and LVH might not respond as favorably to losartan-based treatment as non-black patients with respect to cardiovascular outcomes, and do not support a recommendation for losartan as a first-line treatment for this purpose. The subanalysis is limited by the relatively small number of events.

Abbreviations and Acronyms   ACE = angiotensin-converting enzyme   ALLHAT = Antihypertensive therapy and Lipid Lowering Heart Attack prevention Trial   BP = blood pressure   CHD = coronary heart disease   CI = confidence interval   ECG = electrocardiogram/electrocardiographic   ISH = isolated systolic hypertension   LIFE = Losartan Intervention For Endpoint reduction in hypertension study   LVH = left ventricular hypertrophy   MI = myocardial infarction   SOLVD = Studies Of Left Ventricular Dysfunction   VA = Veterans Administration

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