By: Thomas Pickering, MD, DPhil, FRCP, Director of Integrative and Behavioral Cardiology Program
of the Cardiovascular Institute at Mount Sinai School of Medicine, New York.

High blood pressure and diabetes commonly coexist and make a bad combination, because of a greatly increased risk of heart disease and other vascular complications. This risk is particularly high in women. The Heart Outcomes Prevention Evaluation study (HOPE) has examined the effects of an ACE inhibitor (ramipril - marketed in the US as Altace) to protect people at high risk of heart and vascular disease.

The participants in HOPE were all aged 55 years or more, had already suffered from one heart attack, or had one major risk factor such as hypertension, high cholesterol, or smoking. There were 9,541 participants altogether, of whom 3,654 had diabetes. They were randomly allocated to receive either ramipril (10 milligrams daily) or matching placebo (inert pills). The study was stopped six months ahead of schedule (after four and a half years) because it was clear that the ramipril group were having less events. Overall, ramipril lowered the rate of events in the diabetics by 25% (in comparison with the rate in the placebo group); heart attacks were reduced by 22%; strokes by 33%; coronary bypass surgery and angioplasty by 17%; and diabetic nephropathy (kidney disease) by 24%. These benefits were seen in both people with and without hypertension, and so did not depend on the reduction of blood pressure.

Doctor’s comments

We have posted the results of the main HOPE study elsewhere on our pages, which showed a similar benefit in patients without diabetes. ACE inhibitors are recommended for the treatment of hypertensive diabetics by JNC VI (the official US recommendations on the treatment of hypertension), and the HOPE findings support this recommendation. What is of particular interest in the HOPE results is that most of the participants did not have high blood pressure, and the reduction of pressure from ramipril was only 2 mmHg systolic and 1 mmHg diastolic. The authors of the study suggest that the benefits of ramipril may be due to a protective effect on the inner wall (endothelium) of the arteries in addition to the reduction of blood pressure. Diabetes is one of the major causes of kidney failure leading to dialysis, and HOPE also provides further evidence that ACE inhibitors help to protect the kidneys in people with diabetes.

Where it was published