Ramipril

How it works

It inhibits angiotensin-converting enzyme, reducing angiotensin II formation and aldosterone, causing vasodilatation and lowering blood pressure and cardiac afterload.

Prescribing in practice

• In older people start at a low dose and uptitrate cautiously, as they are more prone to first-dose and symptomatic hypotension, acute kidney injury and hyperkalaemia, particularly with volume depletion, renovascular disease or concurrent NSAIDs or diuretics.
• Check renal function and potassium before starting and after dose changes; stop if there is a significant rise in creatinine or potassium.
• It is contraindicated in pregnancy and in those with a history of ACE-inhibitor angioedema.

Monitoring

Monitor blood pressure, renal function and serum potassium at baseline, after initiation and following each dose increase, especially in older patients.

Counselling the patient

• A dry cough can occur and may warrant switching to an alternative.
• Report dizziness, or swelling of the face, lips or tongue, urgently.
• Avoid over-the-counter anti-inflammatory painkillers without advice.

Evidence & guidelines

Landmark trials including HOPE established ramipril's cardiovascular benefit, and NICE supports ACE inhibitors across hypertension and heart failure with cautious titration in older adults.