Effects of an ACE Inhibitor, Ramipril, on Cardiovascular Events in High-Risk Patients (HOPE)

The HOPE trial expanded the role of ACE inhibitors from treating heart failure to preventing cardiovascular events in a much broader high-risk population.

Among more than 9,000 patients at high cardiovascular risk but without heart failure or reduced pumping function, ramipril significantly reduced cardiovascular death, heart attack, and stroke compared with placebo. The benefit appeared to exceed what blood-pressure lowering alone could explain, suggesting ACE inhibition protects blood vessels through additional mechanisms.

HOPE established ramipril — and ACE inhibitors generally — as a preventive therapy for high-risk patients with vascular disease or diabetes, a role they retain in guidelines today. It broadened the toolkit of proven cardiovascular prevention beyond cholesterol and antiplatelet drugs.

We rate the evidence strong. A large, well-conducted randomized trial with hard endpoints, HOPE is a landmark that durably shaped preventive cardiology.