Ongoing trials of angiotensin-converting enzyme inhibition: what they can tell us

Abundant evidence has accumulated showing that angiotensin converting enzyme (ACE) inhibitors reduce long-term cardiovascular morbidity and mortality rates in patients with heart failure and myocardial infarction. Fewer completed trials have assessed their potential benefits in this regard in hypertensive subjects, but evidence of benefit is beginning to accrue from studies examining patients with hypertension, particularly in the presence of diabetes and after infarction. Ongoing trials of blood pressure (BP) lowering using ACE inhibition fall into three main categories: 1) those comparing ACE inhibitors with older drugs such as diuretics and β blockers; 2) those examining more aggressive versus less aggressive lowering of BP; and 3) those investigating BP lowering in patients at high risk for a cardiac event. Among those in the last group is the Perindopril Protection Against Recurrent Stroke Study (PROGRESS), which examines the effects of perindopril-based ACE inhibitor therapy in both normotensive and hypertensive patients who have survived a stroke. This trial is particularly important because it serves as a model for studies of BP lowering across a wide range of BP and BP-related conditions.