Ramipril

How it works

It inhibits ACE, reducing the conversion of angiotensin I to angiotensin II, thereby causing vasodilatation, lowering aldosterone and reducing blood pressure and cardiac afterload.

Prescribing in practice

• Angioedema is an uncommon but potentially life-threatening reaction that mandates immediate, permanent discontinuation, and the drug is contraindicated in pregnancy.
• Check renal function and potassium before starting and after dose changes, as it can cause hyperkalaemia and acute kidney injury, particularly with NSAIDs, potassium-sparing agents or renal artery stenosis.
• Counsel on the common dry cough and the risk of first-dose hypotension, especially in volume-depleted patients or those on diuretics.

Monitoring

Monitor blood pressure, renal function and serum potassium before initiation and after each dose increase, and periodically thereafter.

Counselling the patient

• A persistent dry cough can occur; tell your doctor if it troubles you.
• Do not use this medicine if you are or might become pregnant.
• Report any swelling of the face, lips or throat immediately.

Evidence & guidelines

Ramipril's cardiovascular benefit is supported by the HOPE trial and it is recommended in NICE hypertension and heart failure guidance.