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Comparative effects of ramipril on ambulatory and office blood pressures: a HOPE Substudy
P Svensson1, U de Faire, P Sleight
1Department of Medicine Karolinska Hospital, Stockholm, Sweden. persv@divmed.ks.se
Insights
Ramipril significantly reduced cardiovascular events. While office blood pressure changes were modest, 24-hour ambulatory blood pressure monitoring revealed greater reductions, especially at night, explaining ramipril's benefits.
Area of Science:
- Cardiology
- Pharmacology
- Hypertension Research
Background:
- The HOPE trial demonstrated ramipril's efficacy in reducing cardiovascular events in high-risk patients.
- The observed benefits were only partially explained by modest reductions in office blood pressure (OBP).
- Ramipril administration at bedtime and daytime OBP measurements may underestimate its full blood pressure-lowering effect.
Purpose of the Study:
- To investigate the 24-hour ambulatory blood pressure (ABP) changes with ramipril in patients with peripheral arterial disease.
- To determine if ABP monitoring better reflects ramipril's blood pressure-lowering effects compared to OBP.
Main Methods:
- Thirty-eight HOPE study participants with peripheral arterial disease underwent 24-hour ABP monitoring before and after 1 year of ramipril treatment.
- Office blood pressure (OBP) was measured before ABP device fitting.
- Ramipril was administered once daily at bedtime.
Main Results:
- Ramipril did not significantly reduce OBP or daytime ABP.
- A significant reduction in 24-hour ABP was observed (10/4 mm Hg, P=0.03).
- Nighttime ABP showed a more pronounced reduction (17/8 mm Hg, P<0.001), lowering the night/day ratio.
Conclusions:
- Ambulatory blood pressure monitoring reveals greater blood pressure reductions with ramipril, particularly during nighttime, compared to OBP.
- The cardiovascular benefits of ramipril in the HOPE study may be more strongly linked to its 24-hour blood pressure-lowering patterns than previously recognized.
Abstract:
In the HOPE-trial, the ACE inhibitor ramipril significantly reduced cardiovascular morbidity and mortality in patients at high risk for cardiovascular events. The benefit could only partly be attributed to the modest mean reduction of office blood pressure (OBP) during the study period (3/2 mm Hg). However, because according to the HOPE protocol ramipril was given once daily at bedtime and blood pressure was measured during the day, the 24-hour reduction of blood pressure may be underestimated based on OBP. Thirty-eight patients with peripheral arterial disease enrolled in the HOPE study underwent 24-hour ambulatory blood pressure (ABP) measurement before randomization and after 1 year. OBP was measured in the sitting position immediately before fitting the ABP measuring equipment to the patients. Ramipril did not significantly reduce OBP (8/2 mm Hg, P=NS) or day ABP (6/2 mm Hg, P=NS) after 1 year. Twenty-four-hour ABP was significantly reduced (10/4 mm Hg, P=0.03), mainly because of a more pronounced blood pressure lowering effect during nighttime (17/8 mm Hg, P<0.001). The night/day ratio was also significantly lowered in the ramipril group. ABP shows greater falls, especially at night, than OBP during treatment with ramipril given once daily at bedtime. Although, OBP is the correct comparator when comparing with previous large intervention trials and epidemiological studies, the effects on cardiovascular morbidity and mortality seen with ramipril in the HOPE study may, to a larger extent than previously ascribed, relate to effects on blood pressure patterns over the 24-hour period.