Captopril prevention project—what shall we do about captopril and the risk of stroke?

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Abstract
Angiotensin-converting enzyme inhibitors (ACEI) are widely prescribed. In the US their prescription rate for hypertension places them third, behind calcium antagonists and diuretics but in front of beta blockers [1]. This success, in spite of the cough problem, is due to aggressive marketing based around putative cardioprotective and nephroprotective effects. The cardioprotective effect has been demonstrated by the reduction of overall cardiac morbidity and mortality in patients with congestive heart failure or post-infarction left ventricular dysfunction [2]. The nephroprotective effect is claimed for diabetic [3] and non-diabetic [4] renal patients on the basis of greater reduction of proteinuria and greater delay in the progression to end-stage renal failure when compared to conventional treatment, although blood-pressure-independent protection has not been convincingly shown [4]. Primary cardiovascular protection in hypertensive patients had, however, not been specifically tested. Therefore the results of the Captopril Prevention Project (CAPPP) [5], the first large trial evaluating ACEI for primary prevention in hypertensive patients, were eagerly awaited. Now the results are out. An intense discussion of the results and how they might influence our daily practice, seems warranted indeed.