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Effects of an Angiotensin-Converting-Enzyme Inhibitor,
Ramipril, on Death from Cardiovascular Causes, Myocardial Infarction, and
Stroke in High-Risk Patients
NEJM January 20,
2000;342:145 - HOPE Study Group.
We assessed the role of an angiotensin-converting-enzyme inhibitor, ramipril,
in patients who were at high risk for cardiovascular events but who did not
have left ventricular dysfunction or heart failure.
Methods: A total of 9297 high-risk patients (55 years of age or older)
who had evidence of vascular disease or diabetes plus one other cardiovascular
risk factor and who were not known to have a low ejection fraction or heart
failure were randomly assigned to receive ramipril
(10 mg per day orally) or matching placebo for a mean of five
years. The primary outcome was a composite of myocardial infarction, stroke,
or death from cardiovascular causes.
Results: Treatment with ramipril reduced
the rates of
death from cardiovascular causes (6.1%, vs 8.1 % in the placebo
group; relative risk, 0.75),
myocardial infarction (9.9 percent vs. 12.2 percent; relative
risk, 0.80; P<0.001),
stroke (3.4 percent vs. 4.9 percent; relative risk, 0.69;
death from any cause (10.4 percent vs. 12.2 percent; relative
risk, 0.84; P=0.006),
revascularization procedures (16.0 percent
vs. 18.6 percent; relative risk, 0.84; P<0.001),
cardiac arrest (0.8 percent vs. 1.2 percent;
relative risk, 0.63; P=0.03),
heart failure (7.4 percent vs. 9.4 percent;
relative risk, 0.78; P<0.001), and
complications related to diabetes (6.2 percent vs. 7.4 percent;
relative risk, 0.84; P=0.03).
Conclusions: Ramipril significantly reduces the rates of death,
myocardial infarction, and stroke in a broad range of high-risk patients
who are not known to have a low ejection fraction or heart failure.