A comprehensive assessment of the avoidability of long-term complications of diabetes. A case-control study. SID-AMD Italian Study Group for the Implementation of the St. Vincent Declaration

OBJECTIVE

To identify and quantify risk factors for the development of long-term diabetic complications (i.e., critical limb ischemia, amputation, chronic renal failure [creatinine > 3 mg/dl], dialysis treatment, proliferative retinopathy, blindness), with particular emphasis on those variables that, being related to quality of care, can be considered avoidable.

RESEARCH DESIGN AND METHODS

We designed a case-control study that enrolled 886 patients with long-term diabetic complications and 1,888 control subjects without complications from 35 diabetic outpatient clinics and 49 general practitioners offices during a 6-month period. Selected socioeconomic, pathophysiologic, self-care, health care, and lifestyle information were collected for all patients.

RESULTS

A logistic regression analysis showed that several factors are related to the development of major diabetic complications. Among patient characteristics, male sex (odds ratio [OR] = 1.8, 95% CI 1.4-2.3) and age (OR = 1.7, 95% Cl 1.2-2.4 for patients between 50 and 69 years of age as opposed to those younger than 50 years of age) were associated with an increased risk of complication. Among clinical variables, the type and the duration of diabetes were the most important predictors of diabetic complications. The presence of hypertension was also associated with the development of diabetic complications, particularly when it was poorly controlled by treatment (OR = 3.1, 95% CI 2.3-4.3). Patients who needed help to reach a health care facility and those who did not regularly attend such a facility were at higher risk of developing complications (OR = 1.5, 95% CI 1.2-1.9; OR = 1.7, 95% CI 1.3-2.2, respectively). Educational aspects were also related to the outcome: patients who did not receive any kind of educational intervention had an increased risk of developing complications (OR = 4.1, 95% CI 1.7-9.7), while self-management of insulin therapy had a protective effect (OR = 0.6, 95% CI 0.5-0.8). The summary attributable risk related to avoidable risk factors (i.e., uncontrolled hypertension, poor compliance with visit scheduling, inadequate diabetes education, no self-management of insulin treatment) was 0.39.

CONCLUSIONS

Our data suggest that, by removing avoidable risk factors, the number of diabetic complications considered could be reduced by more than one-third. The case-control methodology represents an efficient way of monitoring clinical practice and relating it to important outcomes. It can be of help for policy makers in identifying the more effective strategies and in tailoring specific interventions aimed at improving the quality of the care delivered to diabetic patients.

Feasibility of randomised clinical trials in rare diseases: the case of polycythemia vera

Although it has long been recognised as the only reliable instrument for producing scientific evidence on the benefit/risk profile of therapeutic interventions, the technology of randomised clinical trials (RCT) is far from being the backbone of medical knowledge. Randomised clinical trials in polycythemia vera have been carried out when their methodology was being built up and, therefore, was rather unsatisfactory. Now we have aggressive cytoreductive treatments with chemotherapeutic agents loaded with doubts on long-term safety, while phlebotomy and preventive antiplatelet therapy are left to personal preferences because of debatable results of old, low-power clinical trials. A complex profile of uncertainties requires a simple, but articulated strategy of care and research to allow at the same time a reasonable transfer of the best available validated knowledge and a timely investigation of the most relevant questions. Without doubts, multi-country, collaborative RCTs is the key (not isolated or abstract) element of the current scenario. The declared background hypothesis is the willingness of a medical caring community of being, at the same time and with the same patients, a research community. The trial design comes in as the simplest technical way to deal with uncertainty. Data to be collected, criteria, contents, intensity of follow-up, and documentation of the events are exactly the same as those which are planned and adopted in routine care. One of the greatest achievements of the multicenter trials with this orientation has been to produce a "core" of data and practices, on which the main analyses will be made, but which at the same time reflect an optimal level of assistance to the majority of patients. The purpose of this paper is therefore twofold: a) to provide a brief methodological review of the controlled evidence available for the direction of therapeutic practice for PV: b) to outline and discuss the opportunity, general design, and feasibility of research strategies where a comparative large-scale trial between therapeutic alternatives could play a central role.

Health services: an Italian market

One of the glories of Italy is its capacity to surprise. In out-of-the-way places extraordinary things are suddenly encountered; and this is hardly less true of science than of architecture or music or painting. Italian medicine can boast excellence in many quiet spots. Yet Italy's record in medical science and practice is perceived to be below par, and one reason may be a lack of central coordination--forgivable in a country that had fifty governments in half a century. The latest administration offers a rare chance of political stability and the prospect of reforms. In this profile of Italian medicine The Lancet's guide was Dr Giuseppe Remuzzi, whose central coordination was exemplary.

[Experimenting curing-caring experimenting. Notes to prevent confusion]

Children, as well as adults, can be subjects of clinical trials. An overview of the history and development of clinical experimentation through the main scientific publications is briefly outlined. A chart of children rights is also presented and discussed. Children's rights range from the right of being included in clinical trials to the right of being participants in a research that complies, without being overwhelmed, with formal rules. The maximum respect for the child is assumed if innovative questions are asked and independence and autonomy of judgement of researches are observed.

Meta-analysis, clinical trials, and transferability of research results into practice. The case of cholesterol-lowering interventions in the secondary prevention of coronary heart disease

OBJECTIVE

To evaluate, in the comprehensive scenario of "evidence-based" medicine, the transferability of the results of published randomized clinical trials and meta-analyses on cholesterol-lowering interventions to clinical practice.

METHOD

Overview of randomized clinical trials on cholesterol-lowering interventions in the secondary prevention of coronary heart disease.

RESULTS

The present overview on secondary prevention of coronary heart disease included 34 trials with cholesterol-lowering interventions in 24968 individuals. There was a 12.5% mortality in the group that was allocated active intervention and a 17.2% mortality in the control group (risk reduction, 13%; 95% confidence interval, -19% to -6%). Coronary and cardiovascular odds of deaths were significantly reduced. No clear association was found between noncoronary mortality and cholesterol-lowering interventions. Baseline total cholesterol levels had no clear influence on total mortality. Intermediate (10%-20%) and high ( > 20%) total cholesterol reductions were associated with similar reductions in the odds of death (-23% and -30%, respectively). No conclusion could be reached for patients who were less represented in the studies (ie, women and elderly persons). Patients with more complicated baseline clinical conditions (eg, congestive heart failure) had little nonsignificant benefit from cholesterol-lowering interventions.

CONCLUSIONS

The effect of cholesterol-lowering interventions at least in the secondary prevention of coronary heart disease can be considered as established, but the transferability of such results to real-life patients remains the critical, unanswered question.

Family history and socioeconomic factors as predictors of myocardial infarction, unstable angina and stroke in an Italian population. PROGETTO 3A Investigators

A comprehensive case-control study was conducted in an Italian region in order to compare the influence of family history of cardiovascular events, socioeconomic factors, social networks, and their joint associations with major risk factors, on the risk, of myocardial infarction (MI), unstable angina (UA) and ischemic stroke (IS). A total of 513 patients with MI, 178 with UA, 237 with IS, and 928 hospitalised controls were recruited. The odds ratio (OR) of MI for two or more relatives with a positive history of MI was 3.6 (95% CI: 1.8-7.3). Family history of MI was predictive for UA (OR = 5.8; 95% CI: 1.2-28.7), but not for IS. A family history of stroke was more associated with the risk of MI than of IS. After adjustment for known risk factors, the OR of MI for more educated people was 2.1 (1.3-3.6) compared with less-educated people. Large family size seemed to be protective for MI. The effect of major risk factors on MI ranged from additive (diabetes) to multiplicative jointly with high education and family history of MI. A family history of stroke increased IS risk threefold jointly with smoking and hyperlipidemia, and eightfold with diabetes. Besides a family history of MI and IS, in this community a higher educational status seems to better identify groups at increased risk of MI. The joint associations have important preventive implications since by identifying high-risk individuals (for MI and IS) a more careful assessment and control of risk factors amenable to intervention may be performed.

How informed general practitioners manage mild hypertension: a survey of readers of drug bulletins in 7 countries. International Society of Drug Bulletins (ISDB)

OBJECTIVE

To determine whether general practitioners (GP) who are readers of independent drug bulletins can be used as an international epidemiological observatory of the criteria adopted by "well informed" doctors in various countries in the management of mild hypertension.

DESIGN

Questionnaire study of GPs' diagnostic criteria for mild hypertension, routine investigation and management of patients with this diagnosis.

PARTICIPANTS

206 GPs readers of independent drug bulletins in 7 countries, comprising 95 known systematic readers of a local bulletin and 111 randomly selected regular subscribers.

MAIN OUTCOME MEASURES

Response rate to the questionnaire. Diagnostic criteria, routine investigations, and treatment used for patients with mild hypertension.

RESULTS

The study required two months for planning and implementation. Four countries out of eleven had a response rate < or = 50% and were excluded; the frequency of responses from other countries was 69%. The average diastolic blood pressure (DBP) considered diagnostic of mild hypertension range from 94 mm Hg (lower threshold) to 106 (upper threshold). A minority (17%) of GPs routinely request the minimum recommended laboratory tests to assess patients. GPs routinely advise non-drug measures before starting a drug. Most would not start drug treatment in patients without other risk factors and a DBP below 100 mmHg. The top first choice drugs were diuretics and beta-adrenoceptor blockers. Half of the doctors were able to quote some published guide to the management of mild hypertension, and 18% cited a relevant trial. Attitudes in diagnosing and treating mild hypertension differed widely between GPs and countries.

CONCLUSIONS

GP readers of drug bulletins can be used quickly and inexpensively to assess the extent to which recommended diagnostic and therapeutic practices are accepted by "well informed" doctors. The results suggest that attitudes in managing mild hypertension vary widely among GPs and countries and differ remarkably from the recommendations of published guidelines.

A positive relation between high hemoglobin values and the risk of ischemic stroke. Progetto 3A Investigators

We examined the relationship between the hemoglobin concentration and the risk of ischemic stroke using data from a hospital-based case-control study. A total of 143 patients (age 30-69 years) with a diagnosis of cerebral infarction confirmed by computerized tomography scan and 143 age- and sex-matched controls entered the study. Hemoglobin was higher in the patients with stroke (14.2 +/- 1.6 g/l, mean +/- SD) than in controls (13.7 +/- 1.6 g/l; p < 0.05). Compared with subjects with hemoglobin levels of less than 13 g/l (reference category), the relative risk of ischemic stroke, after allowance for potential risk factors, was 2.0 (95% CI 0.8-4.9) for the 13-13.9 g/l quartile, 2.8 (95% CI 1.2-6.5) for the 14-14.9 g/l quartile, and 3.2 (95% CI 1.4-7.4) for the 14 + g/l quartile (chi 2 for linear trend 7.27, p < 0.01). We conclude that the hemoglobin concentration may be an indicator of risk for ischemic stroke.

[Evaluation of family satisfaction in pediatric oncology]

The satisfaction for the care receveid following the diagnosis of acute linfoblastic leukemia in the Pediatric Division of the San Gerardo Hospital of Monza was explored with a questionnaire to the families of patients diagnosed from January 1984. 217 questionnaires were returned (59.2%); 67% were completed by both parents. Parents expressed overall a very high satisfaction for several areas of care: 93.8% for the information about diagnosis; 83% approved the use of the word "leukemia". Judgements on technical competence and communication skills of the health care professionals were analyzed separately for hospitalized and day-hospital patients, and for survivors and dead: results were highly positive for both groups. The expected higher of missing data for the questions related to satisfaction for communication on relapses, highlights the difficulty and the emotional load of the question. Data were discussed by the health care team as well as parents in order to obtain a feedback and practical suggestions for further improvement of care.

Report on management of renale failure in Europe, XXVI, 1995. Rare diseases in renal replacement therapy in the ERA-EDTA Registry

The proportion of centres returning the ERA-EDTA Registry questionnaires has decreased considerably in recent years. Demographic information, based on the response rate of centres in 1994 (44%), does not allow reasonable projections for management of renal failure in Europe. To encourage the participation of non-responding centres, the timing was right to show the powerful impact of the ERA-EDTA Registry as a supra-national registry, by studying patients in renal replacement therapy (RRT) suffering from rare diseases. Four such diseases, Fabry's disease, nephropathy due to cyclosporin (CsA), nephropathy due to cisplatin and scleroderma, were studied using the records of 440665 patients on file up to 31 December 1993. There were 83 patients with Fabry's disease (0.0188%), 85 patients with CsA nephropathy (0.0193%), 120 patients with cisplatin nephropathy (0.0272%) and 625 patients with scleroderma (0.142%). Scleroderma was introduced as a primary renal disease (PRD) in the ERA-EDTA Registry in 1977. Seven patients were accepted for RRT in that year, whereas the number increased to over 50 new patients per year after 1986. More than half of the patients were aged over 55 years, and 68% of them were women. Survival rate of dialysis patients suffering from scleroderma was 22% at 5 years, compared to 51% in patients with standard primary renal diseases. The main causes of death were cardiovascular complications (41%), cachexia (15%) and infection (10%). Survival of first graft in a small number of 28 patients was 44% at 3 years, compared to 60% in standard PRD. Patient survival after first transplant, however, was higher by 32% at 3 years compared to that of dialysis patients. Cisplatin nephropathy was introduced as a PRD in the ERA-EDTA Registry in 1985, and since then six to 19 new patients have been accepted for RRT each year. The main reason for undergoing cisplatin treatment was ovarian (32%) and testicular cancer (21%), and the mean interval from treatment to RRT was 21.5 months, ranging widely from 0.1 to 131 months. Patient survival on dialysis was 22% at 5 years, compared to 51% in patients with standard PRD. Malignancy and cachexia accounted for over 60% of the total number of deaths. CsA nephropathy was introduced as a PRD in the ERA-EDTA Registry in 1985 and, despite its rarity, is of particular interest as a new iatrogenic entity resulting from CsA administration, mainly in solid organ transplantation. In 1985, two new patients commenced RRT in Europe, and the number increased to 59 in 1991-93. The main reason for undergoing CsA treatment was heart (68%) and liver transplant (22%), and the mean interval from treatment to RRT was 50.2 months, ranging from 5 to 90 months. Patient survival on dialysis was 46% at 4 years, compared to 58% in patients with standard primary nephropathies. Cardiovascular causes (48%) and infection (17%) were the main causes of death. Fabry's disease was introduced as a PRD in the ERA-EDTA Registry in 1985, and since the four to 13 new patients per year have commenced RRT in Europe. It is a sex-linked recessive disorder primarily affecting males (87%), and the mean age at start of RRT was 38 years. Proteinuria, skin lesions and painful paresthesiae were the most common presenting symptoms, and over 70% of the patients were hypertensive and had significant cardiovascular problems at RRT. Patient survival on dialysis was 41% at 5 years, compared to 68% in patients with standard primary nephropathies. Cardiovascular complications (48%) and cachexia (17%) were the main causes of death. Graft survival at 3 years in 33 patients was not inferior to that of patients with standard nephropathies (72% vs 69%), and patient survival after transplantation was comparable to that of patients under 55 years of age with standard PRD. (ABSTRACT TRUNCATED)

[Psychological characteristics of patients with infarction: results of the GISSI-2. Italian Group for the Study of Survival in Myocardial Infarction (GISSI)]

OBJECTIVE

To provide a thorough psychological examination of patients with documented myocardial infarction (MI) enrolled in a multicenter randomized clinical trial (GISSI-2). The psychosocial variables examined include: state variables (anxiety, health-related fears, depression), psychophysical well-being in the three months preceding the acute event (depressive mood, impaired sense of well-being, perceived stress) and trait variables (Type-A Behavior (TAB), neuroticism, introversion/extroversion, social anxiety and feelings of guilt in interpersonal relationships).

POPULATION AND SETTING

A total of 2705 patients (12.5% females) admitted to 166 Italian Coronary Care Units.

METHODS

Patients were administered the CBA-H, a standardized questionnaire with dichotomous responses (true/false), for a total of 152-item grouped into 16 scales. For each scale, the frequency of scores above cut-off values was computed and compared to patients' clinical and sociodemographic profile.

RESULTS

Over one third of all patients scored above the clinical cut-off for anxiety and health-related fears, and 15% showed a depressive pattern. Forty percent of patients reported depressive mood and a diminished sense of well-being in the past three months preceding MI, and more than half perceived themselves as stressed. About one third of the sample overtly exhibited TAB traits and half reported neuroticism scores in the clinical range. One half of our sample could be identified as extrovert, and 14% as introverted. Feelings of guilt and social anxiety were registered respectively in 40% and 12% of the sample. A worse psychological profile was associated to female gender, older age, lower education, living alone and a worse cardiac asset.

CONCLUSION

The study has documented the association between clinical, sociodemographic and psychological variables in a large sample of patients with IMA. While the impact of psychological variables upon patients' clinical outcome is to be evaluated, these data may be helpful in promoting the comprehensive and effective care of IMA patients.

Acute myocardial infarction treatments in 58 Italian hospitals: a drug utilization survey

OBJECTIVES

To provide an updated and comprehensive profile of therapeutic practice in the management of acute myocardial infarction (AMI) in a sample of Italian hospitals, and to test the possible role of a network of hospital pharmacists in providing drug utilization data.

DESIGN

Prospective drug utilization survey. Participating pharmacists collected information on patients consecutively admitted to the hospital with a suspected AMI. The form reproduced those adopted in the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto miocardico trials.

SETTING

Fifty-eight general hospitals in Italy belonging to the National Health Service, 6 of which are teaching hospitals. Thirty-four hospitals recruited patients from a coronary care unit, 10 from intensive monitoring beds in cardiology wards, and 14 from an intensive care unit.

PARTICIPANTS

The study population consisted of patients consecutively admitted with a suspected AMI from May 31 through July 5, 1993.

MAIN OUTCOME MEASURES

The management of AMI in terms of the use of drugs and nonpharmacologic treatments is described.

RESULTS

Of the 676 patients recruited for the study, 47.8% received thrombolytic therapy; alteplase was the preferred agent (55.4% of treated patients). The use of thrombolytic therapy varied significantly according to different demographic and clinical parameters such as age, sex, delay from the onset of symptoms to admission, and Killip scale class. During the first day of hospitalization 63.9% of patients received aspirin, 83.3% received nitrates, 24.8% received beta-blockers, and 77.1% received heparin therapy.

CONCLUSIONS

Thrombolytic therapy was prescribed in a higher percentage of patients than is reported in the US, but lower than that reported in large trials. That a low percentage of patients who experienced a long delay between the onset of symptoms and admission as well as elderly patients received thrombolytic therapy reflects the lower expectations of clinicians for these subgroups of patients. A low proportion of patients received aspirin therapy. This study showed that in Italy an institutional network of hospital pharmacists could be interested observers of therapeutic practice, but further training is needed before high-quality data can be collected.

Attributable risks for nonfatal myocardial infarction in Italy. GISSI-EFRIM investigators. Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico. Epidemiologia dei Fattori di Rischio dell'Infarto Miocardico

BACKGROUND

The proportions of nonfatal acute myocardial infarctions (AMI) in Italy attributable to cigarette smoking, body mass, serum cholesterol level, hypertension, diabetes, and family history of AMI (attributable risks, AR) were estimated using data from a case-control study on 614 incident cases of AMI before age 75 with no history of ischemic heart disease and 792 control subjects admitted to the same hospitals where cases were identified for acute, nonneoplastic, cardio- or cerebrovascular conditions not known or suspected to be related to cigarette smoking.

METHODS

The study was conducted between September 1988 and June 1989 within the framework of the GISSI-2 clinical trial. We assumed a multiplicative model and thus the risk attributable to several factors combined is not the sum of those attributable to the single factors.

RESULTS

Overall the AR of smoking was 49%, and for cholesterol, body mass, family history of AMI, hypertension, and diabetes the AR were 49, 16, 14, 13, and 6%, respectively. Together these factors explained 85% of AMI cases. Though differences emerged for each single factor, the proportion of AMI explained by the six factors together was approximately the same for both sexes, while these factors accounted for 97% of AMI cases before age 50 (and smoking alone for 70%) and for 80% after age 50.

CONCLUSIONS

This study confirms that interventions on well-defined risk factors could, in principle, lead to the avoidance of the great majority of myocardial infarctions in this population (i.e., about 80% before age 75 and about 95% before age 50).

A trial of goal-oriented hemodynamic therapy in critically ill patients. SvO2 Collaborative Group

BACKGROUND

Hemodynamic therapy to raise the cardiac index and oxygen delivery to supranormal may improve outcomes in critically ill patients. We studied whether increasing the cardiac index to a supranormal level (cardiac-index group) or increasing mixed venous oxygen saturation to a normal level (oxygen-saturation group) would decrease morbidity and mortality among critically ill patients, as compared with a control group in which the target was a normal cardiac index.

METHODS

A total of 10,726 patients in 56 intensive care units were screened, among whom 762 patients belonging to predefined diagnostic categories with acute physiology scores of 11 or higher were randomly assigned to the three groups (252 to the control group, 253 to the cardiac-index group, and 257 to the oxygen-saturation group).

RESULTS

The hemodynamic targets were reached by 94.3 percent of the control group, 44.9 percent of the cardiac-index group, and 66.7 percent of the oxygen-saturation group (P < 0.001). Mortality was 48.4, 48.6, and 52.1 percent, respectively (P = 0.638), up to the time of discharge from the intensive care unit and 62.3, 61.7, and 63.8 percent (P = 0.875) at six months. Among patients who survived, the number of dysfunctional organs and the length of the stay in the intensive care unit were similar in the three groups. No differences in mortality among the three groups were found for any diagnostic category. A subgroup analysis of the patients in whom hemodynamic targets were reached revealed similar mortality rates: 44.8, 40.4, and 39.0 percent, respectively (P = 0.478).

CONCLUSIONS

Hemodynamic therapy aimed at achieving supranormal values for the cardiac index or normal values for mixed venous oxygen saturation does not reduce morbidity or mortality among critically ill patients.

Parental and primary care physicians' views on the management of chronic diseases: a study in Italy. The Italian Collaborative Group on Paediatric Chronic Diseases

A survey on the burden and quality of care and the parental and primary care physicians' views on management of eight chronic illnesses and disabilities was conducted from 1990 to 1993. Data were collected on 993 children and adolescents from family interviews and physicians' postal questionnaires. Approximately 70% of patients used two or more services for care management and 149 children were treated outside their region. Only 36% of the physicians were case managers and half of these agreed that better communication with other care providers could facilitate their role. A wide difference in parental satisfaction was found between medical and disabling conditions. Approximately 90% of the parents expressed satisfaction with care for children with coeliac disease (112/120), asthma (80/89) and diabetes (98/111), whereas approximately one-third of parents of children with cerebral palsy and Down's syndrome were dissatisfied (88/242 and 72/189, respectively). Primary care physicians expressed similar satisfaction with case management. Distance from hospital, the need for more information on disease management and financial aid were the sources of greatest dissatisfaction. Children with disabling diseases had more problems integrating at school than children with other chronic disorders. Closer interaction between health services, providers and families is necessary to manage the needs of disabled (Italian) children better.

[Lisinopril: myocardial infarction, the first 24 hours, in patients with stable hemodynamic status. The GISSI-3 study; results at 6 weeks]

The GISSI-3 study is a multicentre randomised trial, the aim of which is to assess the efficacy of lisinopril, of transdermic glyceryl trinitrate and their association on survival and left ventricular function after acute myocardial infarction. Between June 1991 and July 1993, 19,394 patients were randomised in 200 Italian coronary care units. The patients were eligible if admitted within 24 hours of the onset of symptoms, if they had a stable haemodynamic status and in the absence of contraindications to the study drugs. Using a factorial protocol, these patients were randomised to receive either oral lisinopril (5 mg/day as a starting dose followed by 5 mg at the 24th hour and then 10 mg/day) glyceryl trinitrate alone (intravenously for 24 hours followed by 10 mg by transdermic patch) or the association of the two drugs or neither (control group). The principal criteria were global mortality and a parameter of combined events. The combined parameter was defined as the number of deaths plus the number of late (after the 4th day of hospital admission) cases of clinical cardiac failure or of severe left ventricular dysfunction without clinical signs of cardiac failure. Complete clinical information and a six-week follow-up were obtained in 18,895 (97.4%) of randomised patients. The global mortality at 6 weeks was 6.7%. The results of GISSI-3 show that treatment with lisinopril started (in addition to conventional therapy) in clinically stable patients during the first 24 hours of myocardial infarction and continued for 6 weeks significantly reduces (p = 0.03) global mortality at 6 weeks (6.3% in the lisinopril group versus 7.1% in the group without lisinopril), which results in 8 lives saved for every 1,000 patients treated. This "gain in lives" is observed from the first day of treatment. At 6 weeks, the combined morbidity-mortality was 15.6% in the lisinopril group, compared with 17% in the group without lisinopril, a significant reduction of 8%. In patients receiving glyceryl trinitrate, the 6 week mortality was 6.5% (617/9,453) compared with 6.9% (653/9,442) in the group not receiving this treatment; this difference was not significant. There was no significant difference in combined morbidity-mortality between these two groups (15.9 vs 16.7% respectively). The beneficial effect of lisinopril alone or associated with glyceryl trinitrate was also demonstrated on the combined parameter in high risk subgroups (elderly patients and women).(ABSTRACT TRUNCATED AT 400 WORDS)