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Use of ramipril in preventing stroke: double blind randomised trial

BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7339.699 (Published 23 March 2002) Cite this as: BMJ 2002;324:699
  1. Jackie Bosch, assistant professor (jackie{at}ccc.mcmaster.ca)a,
  2. Salim Yusuf, professor of medicinea,
  3. Janice Pogue, senior statisticiana,
  4. Peter Sleight, professor emeritusb,
  5. Eva Lonn, associate professor of medicinea,
  6. Badrudin Rangoonwala, medical consultantc,
  7. Richard Davies, associate professord,
  8. Jan Ostergren, researchere,
  9. Jeff Probstfield, professor of medicinef the HOPE Investigators
  1. a Canadian Cardiovascular Collaboration, McMaster University, 237 Barton St E, Hamilton, ON, Canada L8L 2X2
  2. b Cardiac Department, John Radcliffe Hospital, Oxford OX3 9DU
  3. c Dahlien Weg 11, D65719 Hofheim-Taunus, Germany
  4. d University of Ottawa Heart Institute, 40 Ruskin St, Ottawa, ON, Canada K1Y 4W7
  5. e Karolinska Institute, Stockholm, Sweden SE-171 77
  6. f University of Washington, 1124 Columbia Street, Seattle, WA 98104, USA
  1. Correspondence to: J Bosch
  • Accepted 5 November 2001

Abstract

Objective: To determine the effect of the angiotensin converting enzyme inhibitor ramipril on the secondary prevention of stroke.

Design: Randomised controlled trial with 2×2 factorial design.

Setting: 267 hospitals in 19 countries.

Participants: 9297 patients with vascular disease or diabetes plus an additional risk factor, followed for 4.5 years as part of the HOPE study.

Outcome measures: Stroke (confirmed by computed tomography or magnetic resonance imaging when available), transient ischaemic attack, and cognitive function. Blood pressure was recorded at entry to the study, after 2 years, and at the end of the study.

Results: Reduction in blood pressure was modest (3.8 mm Hg systolic and 2.8 mm Hg diastolic). The relative risk of any stroke was reduced by 32% (156 v 226) in the ramipril group compared with the placebo group, and the relative risk of fatal stroke was reduced by 61% (17 v 44). Benefits were consistent across baseline blood pressures, drugs used, and subgroups defined by the presence or absence of previous stroke, coronary artery disease, peripheral arterial disease, diabetes, or hypertension. Significantly fewer patients on ramipril had cognitive or functional impairment.

Conclusion: Ramipril reduces the incidence of stroke in patients at high risk, despite a modest reduction in blood pressure.

What is already known on this topic

What is already known on this topic Treatment with aspirin and lowering blood pressure reduce the incidence of stroke

What this study adds

What this study adds Ramipril, an angiotensin converting enzyme inhibitor, reduces strokes in patients at high risk whose blood pressure is not elevated, despite only a modest lowering of blood pressure

The benefits are observed even when patients receive aspirin and other blood pressure lowering treatments

Footnotes

  • Funding The HOPE study was funded by the Medical Research Council of Canada (now Canadian Institutes for Health Research), Hoechst-Marion Roussel (now Aventis), AstraZeneca, King Pharmaceuticals, Natural Source Vitamin E Association, Negma, and the Heart and Stroke Foundation of Ontario. SY was supported by a senior scientist award of the Medical Research Council of Canada and a Heart and Stroke Foundation of Ontario research chair.

  • Competing interests All authors have acted as consultants and have received funding for research from the above sponsors, as well as having attended and presented papers at symposia with support from the sponsoring agencies.

  • Accepted 5 November 2001
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