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(Stroke. 2003;34:e156.)
© 2003 American Heart Association, Inc.

Letters to the Editor

Stroke Prevention: Indapamide, a Forgotten Option?

Service of Internal Medicine B, "San Cecilio" Clinic Hospital, Granada, Spain

An extract of the first 250 words of the full text is provided, because this article has no abstract.

To the Editor:

We have read with interest the article by MacWalter et al,¹ the comment made by Fournier et al,² and the authors’ reply. We would like to comment.

We disagree with some of the comments made by MacWalter et al. The recommendation of the use of angiotensin-converting enzyme inhibitors (ACEIs) cannot be made on the basis of the findings of PROGRESS.³ The risk reduction observed with perindopril was a nonsignificant 5%. As has been described elsewhere, the lack of a factorial design, which must have included a group on indapamide alone, makes it impossible to know how much, if any, of the reduction observed with the combination therapy is attributable to perindopril.^4,5

We agree that the use of ACEI might be beneficial, but, although members of a drug class share main actions, they may have clinically important differences in terms of efficacy and safety,⁶ which might explain the differences encountered with the efficacy of ramipril⁷ and perindopril alone.³ Comparative clinical effectiveness can be determined only by large randomized outcome trials comparing these 2 drugs head-to-head, and without that information we cannot recommend the use of perindopril. In the view of the beneficial effects of ramipril⁷ and indapamide,⁵ it will be very interesting to know if the combination therapy with ramipril and indapamide is more effective than with each drug separately.

Finally, we would like to remark that it is now clear, in opposition to MacWalter et al, that indapamide is renoprotective. Since Gambardella et al published in 1991 . . . [Full Text of this Article]

Ronald S. MacWalter, MD, FRCP

Department of Medicine

Suzanne Y.S. Wong, MRCP; Kenneth Y.K. Wong, MRCP Allan D. Struthers, MD, FRCP

Department of Clinical Pharmacology and Therapeutics, Ninewells Hospital and Medical School, Dundee, UK