Brief comments on the issue of cardiovascular risk in diabetic patients

I have recently read very carefully the whole supplement to your journal (November 2003) dedicated to “New Directions in Hypertension: Beyond JNC VI.” In the fourth article1 the author refers to the article “Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE Study and MICRO-HOPE Substudy.”2 He mentions once on page 43S and also in the legend to Fig. 2 in his article that the ramipril group was compared with the amlodipine group. This is incorrect, as it is known that in the HOPE study and in the MICRO-HOPE substudy, involving 3577 diabetic patients, the active drug ramipril 10 mg/day was compared with placebo. Similar percentages of the two groups were taking various nonstudy antihypertensive drugs, as the HOPE study was not exclusively a hypertension trial. The author also mentions the impressive reductions in the nephropathy and cardiovascular endpoints in the group of ramipril as compared with the placebo group. The points that are not stated are 1) that in the whole trial, the blood pressure was slightly higher and statistically significant in the placebo group, and, something quite unusual in clinical trials, 2) the placebo group finished the trial with a mean systolic blood pressure that was higher than the baseline value.