Comparative Effects of Ramipril on Ambulatory and Office Blood Pressures

Abstract

Abstract-In the HOPE-trial, the ACE inhibitor ramipril significantly reduced cardiovascular morbidity and mortality in patients at high risk for cardiovascular events. The benefit could only partly be attributed to the modest mean reduction of office blood pressure (OBP) during the study period (3/2 mm Hg). However, because according to the HOPE protocol ramipril was given once daily at bedtime and blood pressure was measured during the day, the 24-hour reduction of blood pressure may be underestimated based on OBP. Thirty-eight patients with peripheral arterial disease enrolled in the HOPE study underwent 24-hour ambulatory blood pressure (ABP) measurement before randomization and after 1 year. OBP was measured in the sitting position immediately before fitting the ABP measuring equipment to the patients. Ramipril did not significantly reduce OBP (8/2 mm Hg, PϭNS) or day ABP (6/2 mm Hg, PϭNS) after 1 year. Twenty-four-hour ABP was significantly reduced (10/4 mm Hg, Pϭ0.03), mainly because of a more pronounced blood pressure lowering effect during nighttime (17/8 mm Hg, PϽ0.001). The night/day ratio was also significantly lowered in the ramipril group. ABP shows greater falls, especially at night, than OBP during treatment with ramipril given once daily at bedtime. Although, OBP is the correct comparator when comparing with previous large intervention trials and epidemiological studies, the effects on cardiovascular morbidity and mortality seen with ramipril in the HOPE study may, to a larger extent than previously ascribed, relate to effects on blood pressure patterns over the 24-hour period.(Hypertension. 2001;38:e28-e32.)

Angiotensin II causes hypertension and cardiac hypertrophy through its receptors in the kidney

“…Although our data are clear-cut, they do not necessarily obviate the results of well-designed prospective clinical trials demonstrating beneficial effects of ACE inhibitors or ARBs on regression of LVH (29,30). Rather, they suggest that the benefits of these agents in LVH are not a consequence of blocking cellular actions of Ang II in the heart, but may be due to differences in the degree or pattern of blood pressure control that was achieved (56).…”

Nocturnal blood pressure and cardiovascular disease: a review of recent advances

“…44 This may partly be explained by a marked reduction in nocturnal BP (À17/À8 mm Hg), as shown in a small ABPM substudy of HOPE (mean age, 71 years; n¼38), 45 as well as by data showing that bedtime administration of ramipril could reduce nocturnal BP more efficiently than morning administration of ramipril. 46 Other evidence provided by the BP-lowering arm of the ABPM substudy of the Anglo-Scandinavian cardiac outcomes trial (mean age, 63 years; n¼1905) showed a more significant reduction of nocturnal BP with an amlodipine-perindopril regimen than with atenololthiazide, despite the fact that the daytime BP was higher in the former group, which might account for the lower cardiovascular events in the amlodipine-perindopril group.…”

Increased nighttime blood pressure or nondipping profile for prediction of cardiovascular outcomes

“…Till date, two large prospective randomized control trials have implemented nighttime administration of 51 ramipril was administered once daily at bedtime and resulted in an outstanding benefit on CV morbidity and mortality in high-vascular-risk subjects. In a small substudy of the HOPE trial, 52 in patients with peripheral arterial disease, 24-h systolic and diastolic BP levels were significantly reduced by 10 and 4 mm Hg, respectively, mainly because of a more pronounced systolic and diastolic BP-lowering effect during nighttime (that is, 17 and 8 mm Hg, respectively). The night-to-day ratio was also significantly decreased in the ramipril group.…”