BMJ  2003;327:681-682 (20 September), doi:10.1136/bmj.327.7416.681-c

Letter

Conundrum of the HOPE study

Time of taking ramipril may account for lack of relation between blood pressure and outcome

The first 150 words of the full text of this article appear below.

EDITOR—The conundrum of the HOPE (heart outcomes prevention evaluation) study is resolved.¹ Why was there no relation between blood pressure and outcome? Answer: Because ramipril was taken at bedtime.

Separate papers in the BMJ and Lancet reported that risk reduction for stroke and cardiovascular end points in the HOPE study were much greater than could be accounted for by the small reduction in measured blood pressure.^{2 3} Both papers suggested that ramipril had brought about a specific beneficial effect unrelated to blood pressure lowering. However, neither paper mentioned when the ACE inhibitor dose was taken in relation to blood pressure measurement.

A previous report by an overlapping authorship reported that HOPE "is the only large trial in which an antihypertensive agent, according to the study protocol, has been recommended to be given at bedtime" and that blood pressure was measured on the following day, between 12 and 18 hours . . . [Full text of this article]

University of Newcastle upon Tyne, Newcastle upon Tyne NE2 4HH roy.taylor@ncl.ac.uk

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