HOPE FOR THE HEART

November 11, 1999
		Ramipril, widely used to lower blood pressure, may also be successful in preventing heart attacks and diabetes. Ray Suarez talks with the chief of cardiology at Northwestern University Medical Center, Dr. Robert Bonow. The Health Unit is a partnership with the Henry J. Kaiser Family Foundation.

RealAudio: Jim Lehrer describes his heart attack in a 1985 special "My Heart, Your Heart." July 20, 1999: Aldactone found surprisingly effective. May 27, 1999: Seeking hospitals for heart care. Nov. 11, 1998: Gains in the fight against Heart Disease. April 13, 1998: Smoking and Heart Disease. June 19, 1997: Estrogen and Heart Disease. April 3, 1997: Heart disease risks. Browse the NewsHour's coverage of Health     New England Journal of Medicine early relase on Ramipril American Heart Association McMaster University Northwestern University Medical Center	JIM LEHRER: Ray Suarez has the heart story. RAY SUAREZ: There was big news yesterday in the battle against heart disease. A new study of a common blood pressure drug, Ramipril, found it may have a significant effect in preventing death and other problems related to heart disease. The study, released at a meeting of the American Heart Association, looked at more than 9200 people in 19 countries. The study found that Ramipril cut deaths from heart disease by 22 percent, reduced heart attacks by more than 20 percent, cut new diabetes cases by 30 percent and resulted in 14 percent fewer coronary artery bypass operations. For more on the study we're joined by Dr. Robert Bonow, the chief of cardiology at Northwestern University Medical Center. He oversaw scientific sessions at the meeting of the American Heart Association.
	Ramipril: A known commodity
	Dr. Bonow, maybe we should begin by talking about how this drug works, what it does once it's introduced into the human body that helps achieve these effects. DR. ROBERT BONOW, Northwestern University Medical Center: This is one of a family of drugs called ACE inhibitors. And the ACE inhibitors have been with us for over a decade or two to treat high blood pressure, and it's also been demonstrated in patients who have advanced forms of heart disease, who've had heart attacks and damaged hearts, that these drugs also prolong life and prevent death in patients who have heart failure. This new study demonstrates for the first time that we can extend that knowledge and treat patients with very early forms of heart disease and blood vessel problems, and, as you pointed out, prevent death and heart attack and stroke, as well. These drugs have multiple possible actions in addition to lowering blood pressure. We know that they also have effects that tend to stabilize the plaques inside arteries in patients who have atherosclerosis, and it would appear that this stabilizing effect to prevent the plaques from breaking up or by preventing blood clots from forming on those plaques is what's responsible for the effects that were observed in this very important study. RAY SUAREZ: You mentioned that this is already a quite familiar drug to people in your specialty for treating high blood pressure. When a drug is familiar and has been tested for another human malady, is it a shorter process to get it fully ramped up and ready to go into regular use when we find a new application for it? DR. ROBERT BONOW: That's very true. This drug, again, is a - one of the family of drugs called ACE inhibitors. ACE inhibitors have been with us for fifteen/twenty years - there are eleven or so such compounds. And they're approved for various purposes and once these drugs are approved for other purposes it's much easier to get them scrutinized and then evaluated and approved for new uses, such as these. RAY SUAREZ: Do you have to become - people like you have to become part of a new test just to do further clinical trials, or does the current study already go a long way toward completing whatever needs to be done, as far as a vetting process? DR. ROBERT BONOW: Well, there are other trials such as this particular trial already underway using other drugs in the class of ACE inhibitors. This particular trial, however, was truly a landmark study because it was very conclusive in its findings. As you pointed out, over 9200 patients, the reduction in death and heart attack and stroke, need for bypass surgery was not minimal; it was, as you pointed out, 20 to 25 percent in various categories of patients. One important finding of this study, again, was that it was looking at patients who did not have advanced forms of heart disease, but early evidence of atherosclerosis in the coronary arteries, and, in fact, there was a subset of patients in whom there was no evidence of any disease in the coronary arteries but a group of patients who had several risk factors for coronary disease, in particular, patients with diabetes, who had something else in addition to the diabetes, such as high blood pressure, a smoking history, or a high cholesterol. So a diabetic patient with a single risk factor in this study was shown to benefit dramatically to the same extent that we've been talking about in patients who have severe forms of heart disease -- this would suggest that early identification of such patients, early treatment would go a long way to preventing heart attacks and the disability that follows. RAY SUAREZ: So you could start taking this drug as a form of prophylactic treatment, long-term treatment? I noticed in the study there were very few side effects. DR. ROBERT BONOW: This is a very safe family of drugs. There are some side effects. They're usually not serious. But one sees maybe five to seven percent of patients who develop a clot, but the clot is totally reversible if you stop the drug; it's not permanent. Some patients develop swelling, something called angioedema, but that also is reversible if you stop the drug promptly, with no long-term effects. So it's a very safe class of drugs.
	The philosophical and business effects
	RAY SUAREZ: While it's undoubtedly good news whenever we find a weapon to treat a serious killer of people, not only in the United States but around the world, I wonder on a more philosophical level whether this isn't something of a double-edged sword, because we know how much lifestyle changes, how far they can go into helping people live longer lives, treat their heart better over the long run, but every time we find a new drug, this may be sort of a safety net, where we say, look, it's much easier to take this drug than to eat better, live better, exercise more. DR. ROBERT BONOW: I'm glad you brought that up, because I think one cannot emphasize that point enough. We tend to look for simple answers. You know, if we have a drug that lowers cholesterol, then maybe we can eat anything we want to eat, and if we have a drug that makes us lose weight, then we don't have to exercise. The points you make are very, very important. And I think it's the kind of thing that we need to keep emphasizing. Here we have a drug that appears to be effective in lowering the risk of heart attack, stroke, and death. But we still need to do all the other things that we know also work. We need to be eating correctly; we need to be not smoking; we need to be exercising more; and if we have a high cholesterol, we should be taking whatever therapy is required to bring down the cholesterol. If there is high blood pressure, that should be controlled as well. So we need to bring into play all of the reversible risk factors, have them identified, and treated, and, as you point out, this is just one more way of trying to address this big problem, but it's not the only answer. RAY SUAREZ: Let's talk a little bit about the business side of all of this. Because this is a drug that has been known for quite some time, does this mean that it's further down the road toward being reproduced as a generic, toward finding wider use in those parts of the world where drugs are often very expensive or hard to get? DR. ROBERT BONOW: Yeah. This one is a drug that has been available for a number of years. I suspect that not knowing exactly how close it is to becoming generic, it may be reaching that threshold. That will lead to some competition on the business side and probably drugs that are less expensive. My understanding is that taking this drug would cost in the order of $35-$40 per month. It's not that expensive. But there probably will be cheaper forms as well. Now, of course, there are other ACE inhibitors besides Ramipril. What we don't know is whether the other ACE inhibitors have similar effects because they have not been studied as well as this drug was studied in this particular trial. So right now, Ramipril is the drug that appears to be the one that would be the agent in focus for treating patients such as these. RAY SUAREZ: Dr. Robert Bonow, thanks for being with us. DR. ROBERT BONOW: Thank you.