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The Kidney in Cardiovascular Disease
The past quarter-century has seen remarkable advances in the prevention and treatment of cardiovascular disease. Observational studies have effectively identified modifiable risk factors, such as hypertension and hyperlipidemia. Well-designed randomized, controlled trials have unequivocally shown that treatment of these and other risk factors reduces cardiovascular disease and all-cause mortality. More recent clinical trials are now examining treatment in special populations and are investigating whether some agents may have unique “renoprotective” or “cardioprotective” effects that go beyond targeted reductions in known risk factors.
The Heart Outcomes and Prevention Evaluation (HOPE) study is an important trial demonstrating the ineffectiveness of 400 IU of vitamin E daily (1) and the effectiveness of the angiotensin-converting enzyme inhibitor ramipril in preventing cardiovascular disease events in 9297 high-risk patients (2). Of interest, the beneficial effects of ramipril were seen with a difference in systolic blood pressure of only 3 mm Hg between treatment and placebo groups at the end of the study [2]. The latter observation has increased speculation that angiotensin-converting enzyme inhibitors have beneficial effects on the systemic vasculature that are independent of blood pressure reduction itself. In this issue, Mann and colleagues present a post hoc analysis of patients from the HOPE trial that reports two additional findings: 1) Ramipril was safe and effective in reducing the risk for cardiovascular disease in patients with mild renal insufficiency, estimated by elevated serum creatinine concentration, and 2) mild renal insufficiency is an independent risk factor for cardiovascular disease (3).
The finding that ramipril was safe and effective in …
