Commentary

Over the past decade, several studies have documented that ACE inhibitors reduce all cause mortality and probably CV morbidity in patients with left ventricular dysfunction and congestive heart failure. The HOPE study was designed to assess whether ACE inhibitors may also prevent CV events in a broader spectrum of high risk patients. This hypothesis was convincingly confirmed regardless of left ventricular function. Benefit was found across all subgroups and was additive to other therapies with proven secondary preventive effects. Furthermore, the preventive effect was beyond that expected from blood pressure lowering. The findings strongly support a direct CV protective effect of ramipril.

Of interest, patients with diabetes had the same relative benefit as patients without diabetes, despite the fact that the investigators had not required established CV disease for inclusion of the patients with diabetes. This finding strengthens the hypothesis that patients with diabetes should receive active preventive therapies. In a recent meta-analysis, Golan and colleagues¹ argued that treating all middle aged patients with type 2 diabetes with ACE inhibitors on the basis of the protective effects on the kidneys alone would be cost effective. Considering the HOPE study results, this strategy is even more justified. The 30% reduction in new onset diabetes is also important but needs to be confirmed. Ramipril was easy to introduce and often well tolerated. Direct treatment costs will certainly increase as ACE inhibitors are used more often. However, the HOPE study may also provide the basis for savings, for example, through fewer echocardiographic screening tests of left ventricular function after MI and fewer revascularisations.

In the light of available evidence, we recommend that all middle aged patients with either established CV disease or diabetes and 1 additional risk factor (which almost all middle aged patients with diabetes have) should be considered for treatment with ACE inhibitors.