HOPE study results

The results of the HOPE and EUROPA study suggest a new clinical direction in the use of ACE inhibitors to slow the progression of atherosclerosis-related diseases. However, if we strictly rely on the principles of evidence-based medicine, we can talk about the protective effect of perindopril in treating patients with stable ischemic heart disease (CHD) and the universal protective effect of ramipril in treating all patients with clinical manifestations of atherosclerosis (CHD, strokes, peripheral atherosclerosis). Can the protective effect of ramipril and perindopril, associated with slowing the progression of atherosclerosis, be transferred to the entire class of ACE inhibitors? The answer must be negative, because in relation to other drugs in this regard there is no evidence base. Moreover,in the placebo-controlled PEACE study involving 8290 patients with stable angina without signs of heart failure, the addition of 4 mg of trandolapril during basic therapy did not lead to an additional reduction of complications [53]. Similarly, in the placebo-controlled study CAMELOT, which involved 1991 patients with stable coronary artery disease without signs of heart failure, the addition of 20 mg of enalapril to the main therapy did not lead to a more pronounced decrease in complicationswhich involved 1991 patients with stable coronary artery disease with no signs of heart failure, the addition of 20 mg of enalapril to the main therapy did not lead to a more pronounced decrease in complications compared with the patientwhich involved 1991 patients with stable coronary artery disease with no signs of heart failure, the addition of 20 mg of enalapril to the main therapy did not lead to a more pronounced decrease in complications compared with the patient placebo therapy . It is not by chance that only ramipril and perindopril are recommended in the European guidelines for the diagnosis and treatment of stable angina for these patients in terms of slowing the progression of the disease and improving the prognosis of this category of patients from an ACE inhibitor [55]. Similarly, in the second revision of the Russian recommendations on chronic heart failure for the prevention of this disease in patients with coronary artery disease, the prescription of either ramipril or perindopril is recommended as having an evidence base [35]. Moreover, ramipril has an evidence base in relation to the anti-atherogenic effect. The SECURE study, which was carried out within the framework of HOPE, studied the effect of ramipril and vitamin E on the condition of the carotid arteries, examined using the ultrasound method. Was shown,that long-term ramipril therapy delayed the progression of carotid atherosclerosis in patients with atherosclerosis or diabetes mellitus who did not have heart failure [56]. Largely due to this research, in the latest European guidelines for the treatment of AH 2007, a new niche for the use of ACE inhibitors has appeared – a concomitant terosclerosis of the carotid arteries . In another program MICRO-HOPE in the framework of the study NORE in 3577 patients with type 2 diabetes mellitus ramipril reduced the risk of microvascular complications of diabetes mellitus, such as chronic renal failure by 24% (p = 0.027) and retinopathy by 22% (p = 0.024) [57]. In a double-blind, randomized trial of AASK, a pronounced nephroprotective effect of ramipril was demonstrated. In the case of 1094 patients with hypertensive nephropathy (glomerular filtration rate (GFR) within 20–65 ml / min), ramipril at a dose of 2.5–10 mg is more effective than amlodipine and metoprolol slowed the decrease in GFR, the development of chronic renal failure and prolonged the life of patients [58]. Thus, the above studies indicate a powerful vazoprotective effect of ramipril, which has important clinical significance. In clinical practice, in addition to the traditional use of ramipril in hypertension and heart failure,It is necessary to provide patients with practically any manifestations of atherosclerosis – coronary, cerebral and great vessels, as well as patients with nephropathy. At present, an effective generic generic of ramipril – charter has appeared on the Russian pharmaceutical market. A preliminary analysis of a recently completed proprietary study indicates a high antihypertensive efficacy and safety of the charter. Summing up, the overview of international and Russian data presented above makes it possible to take a fresh look at the possibilities of an ACE inhibitor. Traditional niches for the use of ACE inhibitors (hypertension, cardiac insufficiency, diabetic nephropathy) have expanded in recent years thanks to the powerful vasoprotective effect of ACE inhibitors, which opens up new clinical possibilities for their use – in terms of slowing the progression of diseasesassociated with atherosclerosis. At the same time, it is necessary to understand that this effect is not inherent in the whole class of drugs, but is characteristic only of ramipril (charter) and perindopril. At least, based on evidence from evidence-based medicine, a protective effect on the progress of cardiovascular diseases can only be talked about these two drugs.