The HOPE Study (NEJM Jan 14 2000) was a factorial randomised controlled trial testing the effect of Vit. E (400 i.u. od) and/or an ACE inhibitor (ramipril, 10mg od) on cardiovascular outcomes in over 9000 high risk subjects aged >55 years (mean 66 yrs) over 4.5 years. Highly significant reductions in myocardial infarction (MI, 20%), stroke (31%), Cardiovascular death (26%), revascularisation (16%), heart failure (22%) and diabetic complications (17%) were associated with only a modest (3.3/1.5mmHg) reduction in arterial pressure (BP). The predictive power of baseline systolic blood pressure in the HOPE study was strong, and linear over a relatively narrow range of usual BP quartiles (124, 135, 141, 158mmHg), whereas diastolic BP was not predictive. Risk reduction was seen in all quartiles of usual SBP and DBP. For SBP quartiles there was (unusually) a strong trend (p=0.06) for greater relative risk reduction in the composite primary outcome of cardiovascular death, MI and Stroke, with higher baseline BP; this trend was highly significant (0.006) if heart failure and revascularisation was added to the primary end point. The relative risk reduction by ramipril was similar in the presence or absence of beta blockade, diuretics or calcium channel blockers, or of a prior history of hypertension. The question of the extent to which these benefits are related to the modest BP reduction will be dicussed in the light of prior trial data, including the recent STOP-2 study.