The news recently contained reports of a study in which a drug of the ACE-inhibitor type (ramipril) produced quite dramatic results in people at risk of heart or blood vessel disease (cardiovascular disease) - ramipril cut the risk of cardiac death, heart attack and stroke by about 22%. It also cut the occurrence of new cases of diabetes by over 30%.

This was the HOPE study (Heart Outcomes Prevention Evaluation study). The participants (there were almost 10,000 of them) included a large number of people with type II diabetes. To be entered, these diabetics had to have one major cardiovascular risk factor - e.g. a raised "bad" cholesterol level, a low "good" cholesterol level, high blood pressure, smoking, or traces of protein in the urine. Over 3,500 people fit these conditions.

Their mean age was 65 years, 37% were women, and over half of them had a history of high blood pressure. They were given either ramipril (one tablet a day) or a matching sugar pill (placebo) for 4½ years. At the end of this time the numbers of heart attacks, stroke or of death from cardiovascular causes were counted. In addition, examinations were made to determine if they had developed obvious kidney disease.

At the end of the treatment period over two-thirds of the participants were still taking medication (ramipril or placebo). The reasons for stopping were the same in both groups, except for cough (a known side effect of ACE inhibitors), which was slightly more common in the ramipril group. The likelihood of cardiovascular death, heart attack, or stroke was reduced by 25%. Individual risk reductions were: heart attack - 22%, stroke - 33%, cardiovascular death - 37%. These benefits were already clear-cut after two years of treatment with ramipril.

Although blood pressure was slightly lower in the participants taking ramipril, the beneficial effect of the drug on the cardiovascular events remained the same after adjusting for the blood pressure changes.

Importantly, kidney disease was also found to be less likely in the diabetics taking ramipril; the risk of it developing during the study period was reduced by 24%.

This study showed that a drug normally prescribed for high blood pressure - an ACE inhibitor, ramipril - was able to reduce the risk of major cardiac events by 25% to 30% in older diabetics. We can express the results another way; if 15 high-risk diabetics were treated with ramipril for over four years, one of them would be stopped from having a major event such as death, heart attack, stroke or kidney disease.

Obviously this type of drug has benefits beyond just lowering blood pressure. It now remains to be seen if ACE inhibitors carry similar benefits in diabetics who are not, at this time, at obvious risk of cardiac events. In the meantime, older diabetics can do much to reduce their risk of complications by tight control of their blood sugar. This may involve use of one of the newer orally acting drugs.