====== 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:
→ [[cardio:raas:acei|ACE Inhibitors]]

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===== 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.

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===== 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.

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===== Indications =====

==== Hypertension ====
• Effective once-daily ACE inhibitor

→ [[cardio:hypertension:start|Hypertension Module]]

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==== High Cardiovascular Risk (Without HF) ====
• Reduces MI, stroke, and cardiovascular death (HOPE trial)
• Used in patients with vascular disease or diabetes + risk factors

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==== Post-Myocardial Infarction with LV Dysfunction ====
• Reduces mortality (AIRE trial)
• Prevents ventricular remodeling

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==== Heart Failure (HFrEF) ====
• Mortality reduction
• Reduced hospitalization
• Class effect consistent with other ACE inhibitors

→ [[cardio:heart_failure:start|Heart Failure Module]]

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===== 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.

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===== Pharmacokinetics =====

• Prodrug → activated in liver
• Renally cleared
• Long half-life of active metabolite (~13–17 hours)

Dose adjustment required in renal impairment.

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===== Adverse Effects =====

Class Effects:
• Dry cough
• Hyperkalemia
• Hypotension
• Angioedema (rare)
• Mild creatinine elevation

No major pharmacologic difference from other ACE inhibitors.

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===== Monitoring =====

Monitor:
• Serum creatinine
• Potassium

Recheck labs 1–2 weeks after initiation or dose changes.

Mild creatinine rise (<30%) is expected.

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===== Contraindications =====

• Pregnancy
• History of ACE inhibitor–induced angioedema
• Bilateral renal artery stenosis

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===== 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.

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===== 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  

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Related:

→ [[cardio:raas:acei|ACE Inhibitors]]
→ [[cardio:raas:lisinopril|Lisinopril]]
→ [[cardio:heart_failure:start|Heart Failure Module]]
→ [[cardio:start|Return to CV Modules]]