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Future perspectives and implications
1John Radcliffe Hospital, Oxford, UK.
Insights
Ramipril significantly reduced stroke, heart attack, and cardiovascular death in high-risk patients over 55. This ACE inhibitor offers broad cardiovascular event prevention beyond current indications.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Trials
Background:
- High-risk patients often have multiple cardiovascular risk factors.
- Previous studies indicated potential benefits of ramipril in specific populations.
Purpose of the Study:
- To evaluate the efficacy of ramipril in reducing major adverse cardiovascular events (MACE).
- To assess ramipril's benefit in a broad population of elderly, high-risk individuals.
Main Methods:
- Analysis of data from the HOPE, MICRO-HOPE, and SECURE trials.
- Inclusion of patients over 55 with prior vascular events or diabetes plus one risk factor.
- Ramipril treatment compared against placebo over 4.5 years.
Main Results:
- Stroke incidence reduced by 32%.
- Myocardial infarction incidence reduced by 20%.
- Cardiovascular death incidence reduced by 25%.
Conclusions:
- Ramipril provides substantial cardiovascular risk reduction in high-risk patients over 55.
- Benefits are observed regardless of baseline hypertension status and are independent of other treatments.
- High-dose ACE inhibition with ramipril is suitable for a wider patient group at risk of cardiovascular events.
Abstract:
Over a 4.5 year follow-up period, the HOPE (Heart Outcomes Prevention Evaluation) trial, and the MICRO-HOPE (Microalbuminuria, Cardiovascular, and Renal Outcomes) and SECURE (Study to Evaluate Carotid Ultrasound changes in patients treated with Ramipril and vitamin E) substudies have all demonstrated a large benefit of ramipril versus placebo in patients over 55 years at high risk (by reason of a prior vascular event), or by being diabetic subjects with one additional risk factor. The baseline blood pressure on average was normal, at 139/79 mmHg, and was modestly reduced by 3.3/1.4 mmHg. Patients with known left ventricular dysfunction were excluded, as were those with uncontrolled hypertension. The incidence of stroke was reduced by 32%, myocardial infarction by 20% and cardiovascular death by 25%. The benefits conferred were in addition to, and largely independent of, other conventional treatments such as aspirin, lipid-lowering agents, beta-blockers, diuretics and calcium channel blockers. The relative risk reduction was very similar whether or not the patient was a known hypertensive at baseline. High dose ACE inhibition with ramipril is applicable to a far wider population of patients at high risk of cardiovascular events than the current indications of hypertension and left ventricular dysfunction.