Problem CAD, stroke, PVD or DM
Format Double-blinded multi-center RCT
Treatment Telmisartan or Ramipril or both
Control Nil
Population 25620
Inclusion criteria Previous history of
-DM with end-organ damage
Exclusion criteria CCF
EF < 40%
Follow-up Median 56 months
Primary endpoint Composite of death from cardiovascular causes, myocardial infarction, stroke, or hospitalization for heart failure.
Secondary endpoint(s) Composite of death from cardiovascular causes, myocardial infarction, or stroke (N.B. Primary outcome of HOPE)
Details After written informed consent was obtained, patients entered a single-blind run-in period in which they received 2.5 mg of ramipril once daily for 3 days, followed by 40 mg of telmisartan and 2.5 mg of ramipril once daily for 7 days and then 5 mg of ramipril plus 40 mg of telmisartan for 11 to 18 days. Of the 29,019 patients who entered the run-in period, 3399 (11.7%) were excluded from the study: 1123 (3.9%) had poor compliance, 597 (2.1%) withdrew from the study, 492 (1.7%) had symptomatic hypotension, 223 (0.8%) had an elevated potassium level, 64 (0.2%) had an elevated creatinine level, 872 (3.0%) had other reasons for exclusion, and 27 (0.1%) died.
Brief summary: Telmisartan non-inferior to Ramipril. No benefit from both agents.
PAPER: Telmisartan, ramipril, or both in patients at high risk for vascular events.
Date 10 Apr 2008
Journal N Engl J Med. 2008 Apr 10;358(15):1547-59.
Information Termisartan vs. Ramipril vs. BOTH
-No significant difference in composite of CV death/MI/CVA/CCF admission
-No significant difference in secondary outcomes
--EXCEPT rate of renal impairment - Combination vs. Ramipril RR 1.33; p<0.001

Impression of telmisartan
-Equally as effective as ramipril (non-superior)
-Reduced cough/angioedema; increased hypotensive symptoms
-No advantage in combination; increased risk of harm vs. ramipril