Effects of ramipril on coronary events in high-risk persons - Results of the Heart Outcomes Prevention Evaluation study

Background-In trials of patients with left ventricular dysfunction or heart failure, ACE inhibitor use was unexpectedly associated with reduced myocar dial infarction (MI). Using the Heart Outcomes Prevention Evaluation (HOPE) trial data, we tested prospectively whether ramipril, an ACE inhibitor, co uld reduce coronary events and revascularization procedures among patients with normal left ventricular function. Methods and Results-In the HOPE trial, 9297 high-risk men and women, greate r than or equal to 55 years of age with previous cardiovascular disease or diabetes plus I risk factor, were randomly assigned to ramipril (up to 10 m g/d), vitamin E (400 IU/d), their combination, or matching placebos. During the mean follow-up of 4.5 years, there were 482 (10.4%) patients with clin ical MI and unexpected cardiovascular death in the ramipril group compared with 604 (12.9%) in the placebo group [relative risk reduction (RRR), 21% ( 95% CI) (11,30); P<0.0003]. Ramipril was associated with a trend toward les s fatal MI and unexpected death [4.0% versus 4.7%; RRR, 16% (-3, 31)] and w ith a significant reduction in nonfatal MI [5.6% versus 7.2%; RRR, 23% (9,3 4)). Risk reductions in MI were documented in participants taking or not ta king <beta>-blockers, lipid lowering, and/or antiplatelet agents. Although ramipril had no impact on hospitalizations for unstable angina [11.9% versu s 12.2%; RRR, 3% (-9,14)], it reduced the risk of worsening and new angina [27.2% versus 30.0%; RRR, 12% (5,18); P<0.0014] and coronary revascularizat ions [12.5% versus 14.8%; RRR, 18%; (8,26) P<0.0005]. Conclusions-In this high-risk cohort, ramipril reduced the risk of MI, wors ening and new angina, and the occurrence of coronary revascularizations.