Optimal Anti-ischemic Therapy: Newer Data from the HOPE, EUROPA and PEACE Trials

Abstract

Several trials have proposed ACE-inhibitors as the foundation of anti-ischemic secondary preventive therapy for both short and long-term benefit in systolic heart failure, and an important anti-ischemic therapy in ischemic heart disease, diabetic and renal disease patients. The results of the HOPE trial indicated that ramipril, with “tissue” ACE-inhibition features, would benefit a broad range of patients for both primary and secondary prevention of both ischemic and vascular disease, and was beneficial in all subgroups of atherosclerotic coronary disease, cerebrovascular disease, peripheral vascular disease, or diabetes with one cardiovascular risk factor. Subsequently, the EUROPA trial complemented the findings of the HOPE trial in indicating the unique ability of tissue ACE-inhibition, this time with use of perindopril, in preventing cardiovascular events. On the other hand, the findings of a third trial (PEACE) using trandolapril did not confirm these favorable effects, albeit in a lower risk group of patients with ischemic heart disease. Nevertheless, combined analysis of the results of all three trials indicated that there seems to be a significant reduction of cardiovascular events in all patients with ischemic heart disease treated with an ACE inhibitor even in the absence of systolic left ventricular dysfunction or evidence of heart failure. These unique findings of these landmark trials are herein discussed.