Ramipril
Ramipril is a long-acting ACE inhibitor used in hypertension, heart failure, post–myocardial infarction care, and vascular risk reduction.
It has strong cardiovascular outcome data and is highly exam-relevant.
Class: → ACE Inhibitors
Mechanism of Action
• Inhibits Angiotensin-Converting Enzyme (ACE) • ↓ Angiotensin II • ↓ Aldosterone • ↑ Bradykinin
Net Effects: • ↓ Systemic vascular resistance (afterload) • Mild ↓ preload • ↓ Ventricular remodeling • ↓ Vascular inflammation • ↓ Blood pressure
Mechanism identical to other ACE inhibitors.
Unique Features
• Prodrug → converted to ramiprilat • Long-acting (once-daily dosing) • Strong evidence in high-risk vascular patients (HOPE trial) • Mortality benefit post-MI (AIRE trial)
Ramipril is one of the most outcome-supported ACE inhibitors.
Indications
Hypertension
High Cardiovascular Risk (Without HF)
• Reduces MI, stroke, and cardiovascular death (HOPE trial) • Used in patients with vascular disease or diabetes + risk factors
Post-Myocardial Infarction with LV Dysfunction
• Reduces mortality (AIRE trial) • Prevents ventricular remodeling
Heart Failure (HFrEF)
• Mortality reduction • Reduced hospitalization • Class effect consistent with other ACE inhibitors
Dosing
Hypertension: • Start: 2.5–5 mg once daily • Usual range: 5–10 mg once daily • Max: 10 mg daily
Heart Failure / Post-MI: • Start low (1.25–2.5 mg daily) • Titrate to 10 mg daily as tolerated
Once-daily dosing.
Pharmacokinetics
• Prodrug → activated in liver • Renally cleared • Long half-life of active metabolite (~13–17 hours)
Dose adjustment required in renal impairment.
Adverse Effects
Class Effects: • Dry cough • Hyperkalemia • Hypotension • Angioedema (rare) • Mild creatinine elevation
No major pharmacologic difference from other ACE inhibitors.
Monitoring
Monitor: • Serum creatinine • Potassium
Recheck labs 1–2 weeks after initiation or dose changes.
Mild creatinine rise (<30%) is expected.
Contraindications
• Pregnancy • History of ACE inhibitor–induced angioedema • Bilateral renal artery stenosis
Landmark Trials
HOPE Trial: • Reduced MI, stroke, and CV death in high-risk patients
AIRE Trial: • Reduced mortality post-MI with LV dysfunction
Ramipril has some of the strongest outcome data among ACE inhibitors.
Clinical Pearls
✔ Strong vascular protection data (HOPE) ✔ Mortality reduction post-MI (AIRE) ✔ Once-daily dosing ✔ One of the most outcome-supported ACE inhibitors ✔ Monitor potassium and renal function
Related:
→ ACE Inhibitors → Lisinopril → Heart Failure Module → Return to CV Modules