Ramipril

After age 40 we should be doing everything we can to reduce your risk of heart attack. That’s why we constantly encourage our patients to:

• Stop smoking
• Exercise daily
• Eat properly
• Maintain ideal body weight
• Take an aspirin daily (in most cases)

It is the responsibility of each patient to do these things for themselves. The only help we can offer is education and encouragement.

It is, however, our responsibility to make sure that our patients’ chronic medical conditions are properly managed. Hypertension, high cholesterol, and diabetes can increase the risk of heart disease, so we strive to keep these conditions under the best possible control.

For some patients, we may also prescribe a blood pressure medicine called ramipril, even if they don’t have high blood pressure. There is new, compelling evidence that this drug can reduce the risk of death from heart attack by an extra 25%, totally independent of its blood pressure lowering effect.

If you’d like to understand better why we often recommend ramipril, you might want to read the following article:

“Effects of angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high risk patients,” by Salim Yusuf and 6 others, for the Heart Outcomes Prevention Evaluation Study investigators, New England Journal of Medicine, 342(3):145-53, 20 January 2000.

Abstract: “Background. Angiotensin-converting-enzyme inhibitors improve the outcome among patients with left ventricular dysfunction, whether or not they have heart failure. We assessed the role of angiotensin-converting-enzyme inhibitor, ramipril, in patients who were at high risk for cardiovascular events but who did not have left ventricular dysfunction or heart failure. Methods. A total of 9297 high-risk patients (55 years of age or older) who had evidence of vascular disease or diabetes plus one other cardiovascular risk factor and who were not known to have a low ejection fraction or heart failure were randomly assigned to receive ramipril (10 mg once per day orally) or matching placebo for a mean of five years. The primary outcome was a composite of myocardial infarction, stroke, or death from cardiovascular causes. The trial was a two-by-two factorial study evaluating both ramipril and vitamin E. The effects of vitamin E are reported in a companion paper. Results. A total of 651 patients who were assigned to receive ramipril (14.0 percent) reached the primary end point, as compared with 826 patients who were assigned to receive placebo (17.8 percent) (relative risk, 0.78; 95 percent confidence interval, 0.70 to 0.86; P<0.001). Treatment with ramipril reduced the rates of death from cardiovascular causes (6.1 percent, as compared with 8.1 percent in the placebo group; relative risk, 0.74; P<0.001), myocardial infarction (9.9 percent vs. 12.3 percent; relative risk, 0.80; P<0.001), stroke (3.4 percent vs. 4.9 percent; relative risk, 0.68; P<0.001), death from any cause (10.4 percent vs. 12.2 percent; relative risk, 0.84; P=0.005), revascularization procedures (16.0 percent vs. 18.3 percent; relative risk, 0.85; P=0.002), cardiac arrest (0.8 percent vs. 1.3 percent; relative risk, 0.63; P=0.03), heart failure (9.0 percent vs. 11.5 percent; relative risk, 0.77; P<0.001), and complications related to diabetes (6.4 percent vs 7.6 percent; relative risk, 0.84; P=0.03). Conclusions. Ramipril significantly reduces the rates of death, myocardial infarction, and stroke in a broad range of high-risk patients who are not known to have a low ejection fraction or heart failure.“

I know it’s a little hard to understand because of all the medical terminology; but this key phrase sums it up: “Treatment with ramipril reduced the rates of death from cardiovascular causes (6.1 percent, as compared with 8.1 percent in the placebo group).” That’s a decrease of approximately 25%; or to say it another way, in this study, out of every four expected heart attack deaths, one of them simply didn’t happen.

The original article can be viewed on the website of the New England Journal of Medicine.