As researchers involved in the Heart Outcomes Prevention Evaluation (HOPE), we read with interest the article by Karen Tu and colleagues1 and Louise Pilote's accompanying commentary.2 As documented by Tu and colleagues for Ontario,1 the HOPE results have had a striking impact on the prescription of ramipril, but Pilote's speculation2 that HOPE's impact on practice is mostly in response to intense marketing ignores many relevant facts.
The HOPE study clearly demonstrated clinically important reductions in deaths, myocardial infarction, stroke, new heart failure, revascularization and nephropathy in a variety of subgroups.3 In addition to these benefits, the evidence for the use of ramipril in a variety of conditions is extensive.4,5,6,7 Furthermore, 4 independent analyses exploring the cost-effectiveness of ramipril8,9,10,11 found clear clinical benefits with no overall increase in health care costs. Such a combination is rare.
Many cardiologists and internists across Canada became familiar with ramipril through their participation in the HOPE trial. It is therefore not unexpected that the study's positive results would have influenced the practices of these physicians and their colleagues, as was the case for previous trials of thrombolytic agents and acetylsalicylic acid in acute myocardial infarction.
Undoubtedly, the manufacturers of therapies for which benefits have been demonstrated will promote those findings. This certainly has an impact on their revenues, but it is only appropriate that, in the presence of clear evidence that a simple, safe and cost-effective therapy results in major improve- ments in patients' health, efforts be made to ensure that the results are widely known. Such dissemination of information will benefit both patients and society as a whole.
Salim Yusuf Professor of Medicine McMaster University Hamilton, Ont. Gilles Dagenais Professor Emeritus Laval University Sainte-Foy, Que.
References
- 1.↵
Tu K, Mamdani MM, Jacka RM, Forde NJ, Rothwell DM, Tu JV. The striking effect of the Heart Outcomes Prevention Evaluation (HOPE) on ramipril prescribing in Ontario. CMAJ 2003;168(5):553-7.
- 2.↵
Pilote L. Ramipril use in Canada: HOPE or HYPE? [editorial]. CMAJ 2003;168(5):568-9.
- 3.↵
Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med 2000;342:145-53.
- 4.↵
Garg R, Yusuf S. Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure. Collaborative Group on ACE Inhibitor Trials. JAMA 1995;273:1450-6.
- 5.↵
Effect of ramipril on mortality and morbidity of survivors of acute myocardial infarction with clinical evidence of heart failure. Acute Infarction Ramipril Efficacy (AIRE) Study Investigators. Lancet 1993;342:821-8.
- 6.↵
Ruggenenti P, Perna A, Gherardi G, Gaspari F, Benini R, Remuzzi G. Renal function and requirement for dialysis in chronic nephropathy patients on long-term ramipril: REIN follow-up trial. Lancet 1998;352:1252-6.
- 7.↵
Wright JT Jr, Bakris G, Greene T, Agodoa LY, Appel LJ, Charleston J, et al. Effect of blood pressure lowering and antihypertensive drug class on progression of hypertensive kidney disease: results from the AASK trial. JAMA 2002; 288: 2421-31.
- 8.↵
Lamy A, Yusuf S, Pogue J, Gafni A. Cost implications of the use of ramipril in high-risk patients based on the Heart Outcomes Prevention Evaluation (HOPE) study. Circulation 2003; 107: 960-5.
- 9.↵
Bjorholt I, Andersson FL, Kahan T, Ostergren J. The cost-effectiveness of ramipril in the treatment of patients at high risk of cardiovascular events: a Swedish sub-study to the HOPE study. J Intern Med 2002;251:508-17.
- 10.↵
Caroll CA, Coen MM, Piepho RW. Economic impact of ramipril on hospitalization of high-risk cardiovascular patients. Ann Pharmacother 2003; 37: 327-31.
- 11.↵
Malik IS, Bhatia VK, Kooner JS. Cost effectiveness of ramipril treatment for cardiovascular risk reduction. Heart 2001;85:539-43.