Letters

Preventing stroke with ramiprilauthors' reply

EDITOROur publication of the effects of ramipril on stroke should be taken in the context of the main publication that described the effects on a number of major clinical outcomes and provides the necessary information to calculate the number needed to treat. ^{1 2} When one considers all major vascular events prevented, the number needed to treat with ramipril to prevent one event is extremely small (table)

The side effects of ramipril are described in our main paper, and none of them offset the clinical benefits. Parmar's cost effectiveness analysis is incorrect as it does not take into account the prevention of vascular events and related hospitalisation.³ In a formal cost effectiveness analysis, the use of ramipril for five years is cost neutral.⁴

Yudkin speculates whether the benefits in the HOPE study can be achieved with other blood pressure lowering agents.³ This is not known. The HOPE results are supported by the heart failure trials in normotensive individuals and in two trials. Ramipril was superior to amlodipine in reducing mortality despite similar blood pressure lowering in the recent African American study of kidney disease and hypertension (AASK).⁵ The losartan intervention for endpoint reduction (LIFE) study showed that in people who have hypertension and left ventricular hypertrophy, losartan, an angiotensin-2 receptor blocker, significantly reduced major vascular events by 13% compared with atenolol, despite achieving similar blood pressure lowering.⁶ These data indicate that drugs that block the renin-angiotensin system have benefits beyond blood pressure lowering in people at high risk.

Salim Yusuf, director. 
yusufs{at}mcmaster.ca

Jackie Bosch, assistant clinical professor. 
Population Health Research Institute, McMaster University, 237 Barton Street East, Hamilton, ON, Canada L8L 2X2

Peter Sleight, professor emeritus of cardiovascular medicine. 
John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU