Management of coronary artery disease: implications of the EUROPA trial

The recent EUropean trial on Reduction Of cardiac events with Perindopril in stable coronary Artery disease (EUROPA) examined the effect of treatment with the angiotensin-converting enzyme (ACE) inhibitor perindopril in 12,218 patients with stable coronary artery disease (CAD). After 4.2 years, treatment with perindopril 8 mg once daily resulted in a 20% relative risk reduction in the primary end point, a composite of cardiovascular death, non-fatal myocardial infarction, and cardiac arrest (p=0.0003). Risk reductions were also observed for secondary end points, including fatal and non-fatal myocardial infarction (24% reduction, p<0.001) and hospitalisation for heart failure (39% reduction, p=0.002). These benefits were observed on top of standard recommended preventive therapies such as antiplatelet agents, beta blockers and lipid-lowering drugs. Benefits were consistent for all patients with CAD, irrespective of the presence or absence of risk factors such as age, diabetes, hypertension, previous myocardial infarction, or previous revascularisation. Perindopril, a lipophilic tissue ACE inhibitor which binds strongly to ACE, has several anti-atherogenic actions and vascular properties which may contribute to its protective effect. EUROPA is the first trial to show the benefit of ACE inhibition in a broad population often seen in daily clinical practice. The results suggest that perindopril should be added to other recommended preventive treatments in all patients with CAD.