A 67-year-old man with type 2 diabetes, well-controlled hypertension on amlodipine, hyperlipidemia on atorvastatin, and a prior transient ischemic attack 8 months ago comes in for chart review. He is asymptomatic. LVEF on recent echocardiogram is 62% with no wall-motion abnormalities. BP today is 126/76, HR 72. Which of the following medications is BEST supported by outcomes data to reduce this patient's risk of cardiovascular death, MI, and stroke?

Question

Accepted Answer

✅ A. Ramipril (Altace) 10 mg daily
This patient is the HOPE trial archetype: ≥55 years old, high cardiovascular risk (diabetes + prior TIA + HTN), with PRESERVED LV function and no heart failure. The landmark HOPE trial (N Engl J Med 2000) demonstrated that ramipril 10 mg daily reduced the composite of CV death, MI, and stroke by 22% and reduced all-cause mortality by 16% in high-risk patients WITHOUT heart failure or LV dysfunction. This "vascular-protective" effect extends the role of ACE inhibition beyond HTN and HFrEF and is the specific teaching point for ramipril on the boards.

❌ B. Carvedilol (Coreg) 12.5 mg BID
Carvedilol's outcome benefit is established in HFrEF and post-MI LV dysfunction. This patient has a preserved EF and no MI, so the mortality benefit does not apply.

❌ C. Digoxin (Lanoxin) 0.125 mg daily
Digoxin reduces HF hospitalizations in HFrEF but has no effect on mortality and is not indicated in a patient without HF or atrial fibrillation.

❌ D. Isosorbide mononitrate (Imdur) 30 mg daily
Long-acting nitrates are antianginal, not vasculoprotective, and have no documented reduction in MI or stroke risk in this setting.

:::pearl
HOPE trial → ramipril 10 mg reduces CV death/MI/stroke in high-risk patients WITHOUT HF. "Vascular ACE protection" is the ramipril-specific teaching.
:::

Ramipril

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