We thank Drs. Kaufman and Flack for their careful reading of our paper and for their response. They raise an important issue regarding separate consideration of hypertensive black persons when discussing treatment (1). Although there is overlap in response with other population groups, there are differences as well, and there is clearly no consensus on this matter. As a result, different national and international guidelines offer the clinician different advice on treatment of black patients.

The comments by Drs. Kaufman and Flack allow us to reemphasize the purpose of our systematic review, which was to establish, for the first time, the efficacy of different antihypertensive drugs in hypertensive black persons through methodologically rigorous review of the existing data. The review was focused on black persons, not on comparisons with other population groups. We carefully chose this design to answer the clinical question of how best to initiate treatment in black patients, a group with greater hypertension prevalence and higher hypertension-related mortality rates (2, 3).

Authors often have very strong opinions about treatment of hypertension in black persons. Therefore, it was mandatory for us to strictly adhere to our protocol and methodologic principles, regardless of the findings. We prespecified that results would be pooled by drug type (4). Response with different baseline blood pressures was a prespecified subgroup, and sensitivity analyses included trials with per protocol versus intent-to-treat analyses. Our conclusions about the efficacy of ACE inhibitors in reaching goal blood pressure were indeed based on 3 available trials, which constituted the existing evidence. In contrast to other drugs, the effect of ACE inhibitors was not significantly different from placebo for this outcome, and this is what we highlighted. Trials that used per protocol analyses also included patients with higher blood pressures, and in these trials ACE inhibitors were particularly ineffective.

Undoubtedly, more studies are needed. As we recommended, future trials should assess the blood pressure–lowering efficacy of drugs in patients with different baseline blood pressures. Future research should also determine whether initial treatment with ACE inhibitors (as well as -blockers and angiotensin-receptor blockers) is indeed less effective than other treatment strategies in reducing cardiovascular events, such as stroke, in black patients. Until further evidence emerges, the existing evidence we presented could guide clinicians in choosing drugs that will ensure tight blood pressure control in black hypertensive patients.