Lancet. 2003 Sep 6;362(9386):782-8. Efficacy of perindopril in reduction of cardiovascular events among patients with stable coronary artery disease: randomised， double-blind， placebo-controlled， multicentre trial (the EUROPA study). Fox KM; EURopean trial On reduction of cardiac events with Perindopril in stable coronary Artery disease Investigators. Cardiology Department， Royal Brompton Hospital， Sydney Street， London SW3 6NP， UK. k.fox@rbh.nthames.nhs.uk

BACKGROUND: Treatment with angiotensin-converting-enzyme (ACE) inhibitors reduces the rate of cardiovascular events among patients with left-ventricular dysfunction and those at high risk of such events. We assessed whether the ACE inhibitor perindopril reduced cardiovascular risk in a low-risk population with stable coronary heart disease and no apparent heart failure.

METHODS: We recruited patients from October， 1997， to June， 2000. 13655 patients were registered with previous myocardial infarction (64%)， angiographic evidence of coronary artery disease (61%)， coronary revascularisation (55%)， or a positive stress test only (5%). After a run-in period of 4 weeks， in which all patients received perindopril， 12218 patients were randomly assigned perindopril 8 mg once daily (n=6110)， or matching placebo (n=6108). The mean follow-up was 4.2 years， and the primary endpoint was cardiovascular death， myocardial infarction， or cardiac arrest. Analysis was by intention to treat.

FINDINGS: Mean age of patients was 60 years (SD 9)， 85% were male， 92% were taking platelet inhibitors， 62% beta blockers， and 58% lipid-lowering therapy. 603 (10%) placebo and 488 (8%) perindopril patients experienced the primary endpoint， which yields a 20% relative risk reduction (95% CI 9-29， p=0.0003) with perindopril. These benefits were consistent in all predefined subgroups and secondary endpoints. Perindopril was well tolerated.

INTERPRETATION: Among patients with stable coronary heart disease without apparent heart failure， perindopril can significantly improve outcome. About 50 patients need to be treated for a period of 4 years to prevent one major cardiovascular event. Treatment with perindopril， on top of other preventive medications， should be considered in all patients with coronary heart disease.