Morbidity and Mortality After Stroke—Eprosartan Compared With Nitrendipine for Secondary Prevention: Principal Results of a Prospective Randomized Controlled Study (MOSES)
To the Editor:
We read with interest the results of the MOSES trial published in the June issue of Stroke.1 In this article, Schrader et al showed that among hypertensive patients with ischemic stroke(s) or transient ischemic attack(s) (TIAs) randomized to either eprosartan or nitrendipine, patients in the eprosartan group were less likely to reach a primary composite end point of total mortality and all cardiovascular/cerebrovascular events, with an incidence density ratio of 0.79. We are concerned about the clinical interpretation of the composite outcome.
TIAs were included in both the primary composite end point and secondary end points for all cerebrovascular events. From a patient’s perspective, a TIA is not as clinically relevant as a stroke because a TIA is not disabling. Most cerebrovascular events in the MOSES trial were TIAs (66 in the eprosartan group versus 92 in the nitrendipine group). Only 36 ischemic strokes/intracerebral hemorrhages were seen in the eprosartan group, whereas 42 similar events were noted in the nitrendipine group. Without TIA, the difference between both groups may become marginal for cerebrovascular events. Furthermore, the accuracy of a diagnosis of TIA may not be as good as for stroke, particularly for nonneurologists. The MOSES study involved patients from internal medicine and general medicine practices. Although a blinded end point committee evaluated all events, a bedside assessment by a neurologist was not required.
In the context of the ACCESS, LIFE and VALUE trials, the MOSES study argues in favor of angiotensin receptor blockers in hypertensive patients and stroke or TIA.2,3,4 However, the key question is how this regimen, with or without a diuretic, compares to the proven combination of an angiotensin converting enzyme inhibitor and diuretic, defined by the PROGRESS study?5
Schrader J, Lüders S, Kulschewski A, Hammersen F, Plate K, Berger J, Zidek W, Dominiak P, Diener HC; MOSES Study group. Morbidity and mortality after stroke, eprosartan compared with nitrendipine for secondary prevention. Principal results of a prospective randomized controlled study (MOSES). Stroke. 2005; 36: 1218–1226.
Schrader JL, Lüders S, Kulschewski A, Berger J, Zidek W, Treib J, Einhaupl K, Diener HC, Dominiak P; for the Acute Candesartan Cilexetil Therapy in Stroke Survivors Study Group. The ACCESS Study: evaluation of acute candesartan cilexetil therapy in stroke survivors. Stroke. 2003; 34: 1699–1703.
Dahlof B, Devereux RB, Kjeldsen SE, Julius S, Beevers G, de Faire U, Fyhrquist F, Ibsen H, Kristiansson K, Lederballe-Pedersen O, Lindholm LH, Nieminen MS, Omvik P, Oparil S, Wedel H; for the LIFE Study Group. Cardiovascular morbidity and mortality in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. Lancet. 2002; 359: 995–1003.
Julius K, Kjeldsen SE, Weber M, Brunner HR, Ekman S, Hansson L, Hua T, Laragh J, McInnes GT, Mitchell L, Plat F, Schork A, Smith B, Zanchetti A; VALUE trial group.. Outcomes in hypertensive patients at high cardiovascular risk treated with regimens based on valsartan or amlodipine: the VALUE randomised trial. Lancet. 2004; 363: 2022–2031.