In a well-written review, Aambø et al. (1) discussed cardiovascular disease in patients of African or Asian ancestry, highlighting therapeutic implications. The authors pointed out that angiotensin converting enzyme (ACE) inhibitors are less effective antihypertensives in patients of African ancestry, and reported on statin-induced myalgia in this group.

We further on the clinical implications in African ancestry patients with a recent systematic review (2) showing that ACE inhibitor-based treatment yielded better clinical outcomes in kidney disease than other drug classes, but this benefit did not translate in reduction of cardiovascular events. Moreover, the use of lisinopril-initiated treatment vs. chlorthalidone was associated with a greater risk of combined coronary heart disease (1.15[1.02–1.30]), combined cardiovascular disease (1.19[1.09–1.30]), stroke 1.40[1.17–1.68], and angina 1.24[1.07–1.44]. In addition, losartan-initiated treatment was associated with a nearly significant increase in stroke events compared with atenolol (unadjusted hazard ratio, 1.99[1.00–3.98]), and a 97% higher risk for sudden death, with a trend towards increased risk with losartan. These data indicate that compared to other antihypertensive drugs, therapy initiated with blockers of the renin-angiotensin-system is associated with greater cardiovascular event risk in African ancestry patients.

Regarding cholesterol lowering, baseline resting plasma creatine kinase activity is known to be higher in healthy persons of African ancestry, particularly in men, and this does not necessarily preclude the use of statins (3). However, there was no difference in all-cause mortality between pravastatin and usual care in hypertensive African Americans (RR 1.01[0.85–1.19]). Although the relative risk for atherosclerotic coronary heart disease with pravastatin was lower (RR 0.73[0.58–0.92] vs 1.02[0.81–1.28] in others; p=0.03), the stroke risk was significantly higher (RR 1.12 vs 0.74 in others, p=0.03). As a result, there was no significant effect of pravastatin on combined cardiovascular outcomes in hypertensive African ancestry patients (2).

As Norway is home to migrants from more than 160 different countries, clinical guidelines and medical practice need to accommodate a growing diversity of patients. African-Norwegians are mainly of Somalian or Eritrean ancestry (4), and it should be noted that most of the presented data apply to persons of West and South African ancestry (2,3). The paper by Aambø et al. is an excellent initiative that will hopefully stimulate research and clinical interest in the cardiovascular health of different ancestry subgroups.

References
1. Aambø A, Klemsdal TO. Cardiovascular disease and diabetes in patients with African or Asian background. Tidsskr Nor Laegeforen. 2017;137(22)
2. Brewster LM1, van Montfrans GA, Oehlers GP et al. Systematic review: antihypertensive drug therapy in patients of African and South Asian ethnicity. Intern Emerg Med. 2016;11(3):355-74.
3. Brewster LM, Mairuhu G, Sturk et al. Distribution of creatine kinase in the general population: implications for statin therapy. Am Heart J. 2007;154(4):655-61.
4. Statistics Norway. https://www.ssb.no/en/befolkning/