Louise Pilote1 implies that physicians who prescribed ramipril to more of their diabetic patients after the results of the HOPE study were publicized did so primarily because of marketing hype rather than solid research evidence. As a clinical epidemiologist and diabetes specialist, I am baffled by this position. The HOPE study2,3 was by far the largest clinical trial evaluating an ACE inhibitor and enrolled a much broader clinical population than its predecessors. It included a prespecified subgroup of 3577 diabetic participants, possibly more than the total number of diabetic subjects enrolled in all previous ACE inhibitor trials. Diabetic (and nondiabetic) subjects assigned to receive ramipril had statistically and clinically significant risk reductions for major cardiovascular events. Strikingly, the results were homogeneous across all subgroups examined: male and female; with and without previous cardiovascular disease; younger than 65 years of age and 65 years and older; and with and without hypertension, microalbuminuria or dyslipidemia (or any combination of these comorbidities). Therefore, the HOPE study provided excellent evidence to support the use of ramipril in many diabetic patients who would not previously have been considered candidates for an ACE inhibitor. The HOPE study results are widely generalizable to older patients with diabetes because the great majority of such patients would have met the inclusion criteria for the study. The same cannot be said for any other ACE inhibitor trial.
Increased prescription of ramipril for diabetic patients based on the HOPE results represents not hype, but implementation of high-quality evidence from a large, adequately powered randomized trial.
Ronald J. Sigal Clinical Epidemiology Program Ottawa Health Research Institute Ottawa, Ont.