Cardiovascular protection with ace inhibitors--more HOPE for EUROPA?

Treatment with angiotensin converting enzyme (ACE) inhibitors reduces mortality and morbidity among patients with heart failure, left-ventricular dysfunction after myocardial infarction and with hypertension. In addition, they have been shown to slow the progression of chronic kidney disease and reduce the recurrence of stroke and vascular events.

There has been an enormous interest in the potential cardioprotective effects of ACE inhibitors. This principle has been assessed in two landmark double blind placebo controlled clinical trials, HOPE and EUROPA. This article seeks to review and compare the important findings of these two clinical studies.

In the HOPE study, ramipril once daily produced a 22% reduction in the primary composite endpoint of myocardial infarction, stroke, or cardiovascular death (P < 0.001) among an older cohort (>55 years) of patients at high risk of future cardiovascular complications. The EUROPA study assessed the effects of the ACE inhibitor perindopril in a larger group of lower risk patients with established stable cardiovascular disease. In EUROPA, once daily treatment with perindopril lead to a significant 20% relative risk reduction in the combined primary endpoint (cardiovascular mortality, non-fatal myocardial infarction, and resuscitated cardiac arrest; p = 0.0003).

HOPE and EUROPA provide compelling evidence to suggest that all patients with evidence of stable cardiovascular disease or diabetes (plus one additional risk factor) should be treated with an ACE inhibitor.