with central chest pain. Physical examination was normal. The blood pressure measured 110/68 mmHg. The 12lead ECG was normal and the troponin T level was not raised. The blood sugar was normal. The cholesterol level on admission was 6.3 mmol/l. The patient underwent an exercise stress test that was positive. A subsequent coronary angiogram revealed an 80% stenosis in the proximal aspect of the left anterior descending artery that was successfully treated with a coronary artery stent. Echocardiography revealed a normal-sized left ventricle with good systolic function. The patient was discharged home on aspirin 75 mg daily, clopidogrel 75 mg daily and simvastatin 40 mg daily. He had been completely pain free
after the procedure, and an exercise stress test performed four weeks after the procedure was negative for myocardial ischaemia for 10 minutes
What other medication should the patient receive to improve his cardiovascular prognosis?
d. No further treatment required.
e. Isosorbide dinitrate.
The Heart Outcomes Prevention Evaluation Study (HOPE) evaluated the role of angiotensin-converting enzyme inhibitors (ramipril) in populations at high risk of cardiovascular events without any evidence of left ventricular dysfunction. The study assessed 9297 highrisk patients, defined as (1) aged >55 years; (2) history of coronary artery disease, stroke or peripheral vascular disease; or (3) diabetes mellitus and at least one risk factor for coronary artery disease including hypertension, increased total cholesterol, smoking and microalbuminuria. The patients were randomized to ramipril 10 mg daily or placebo. The primary outcome was a combined endpoint of myocardial infarction, stroke or cardiovascular death. The mean follow up was five years. Patients treated with ramipril had a 14% event rate of the combined morbidity and mortality endpoint whereas placebo-treated patients had a 17.8% event rate. The 21% decrease in events was seen in all pre-specified groups, indicating that ACE inhibitor therapy with ramipril significantly reduces morbidity and mortality in a high
risk population with normal left ventricular function. Based on this study all patients with coronary artery disease, cerebrovascular disease, peripheral vascular disease and diabetes mellitus plus one other risk factor for coronary artery disease should be prescribed an ACE inhibitor, specifically ramipril. The patient should remain on aspirin for life and take clopidogrel for a year following deployment of a stent. The CURE study showed that aspirin and clopidogrel together were associated with a lower incidence of myocardial infarction and death in patients with unstable angina and non-ST elevation myocardial infarction compared with aspirin alone for up to a year. The patient no longer has subjective or objective evidence of myocardial ischaemia, and in the absence of hypertension or left ventricular dysfunction there is no indication for a beta-blocker. Nitrates do not alter prognosis in coronary artery disease. There is no evidence as yet that angiotensin receptor blockers improve cardiovascular prognosis in patients with coronary artery disease in the absence of hypertension or left ventricular dysfunction.