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Articles: Louise Pilote, Michal Abrahamowicz, Eric Rodrigues, Mark J. Eisenberg, and Elham Rahme Mortality Rates in Elderly Patients Who Take Different Angiotensin-Converting Enzyme Inhibitors after Acute Myocardial Infarction: A Class Effect? Ann Intern Med 2004; 141: 102-112 [Abstract] [Full text] [PDF]

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Premature advice to patients on ramipril by Annals

Ulrich P. Jorde   (28 July 2004)

Premature advice to patients on ramipril by Annals 28 July 2004
Ulrich P. Jorde, MD New York University School of Medicine Send rapid response to journal: Re: Premature advice to patients on ramipril by Annals Ulrich.jorde{at}med.nyu.edu Ulrich P. Jorde	Pilote et al. present data on the use of ACE inhibitors (ACEI)post myocardial infarction suggesting superiority of ramipril over other ACEI. The methods are carefully discussed and, in concert with the accompanying outstanding editorial, should confer the overall message that this data by virtue of the study design and limitations is no more than hypothesis generating. The authors rightfully point out that the distribution of observed mortality differences between the seven ACEI studied is not consistent with any known pharmacological property of these agents (i.e. ACEI with higher tissue affinity did not consistently fare better than those with low tissue affinity!). The editorial further notes that mortality differences between ACEI in this analysis are larger than those between ACEI and placebo in randomized, prospective trials (raising significant concerns about validity of this data) as well as substantially higher betablocker and statin use in subjects receiving ramipril. Therefore, the conclusion that "survival benefit seems to differ according to ACEI used" seems somewhat premature, much like the similar content of the "take home message" in the "patient section". We have recently completed the first randomized, double-blind, prospective study comparing effects of chronic therapy with low versus high tissue affinity ACEI on endothelial function, exercise capacity,and neurohormonal profiles in subjects with CHF and did not detect differences (AJC, in press). In the absence of positive large scale head to head comparison trials of ACEI the available evidence (including the recent VALIANT trial) strongly suggests that no clinically relevant differences exist between agents blocking the renin-angiotensin - a reassuring message to our patients. Conflict of Interest: None declared