From the Guidelines
Ramipril is the preferred Angiotensin-Converting Enzyme (ACE) inhibitor due to its strong evidence for reducing cardiovascular events in high-risk patients, as demonstrated in the HOPE trial 1.
Key Points
- Ramipril has a long half-life, allowing for once-daily dosing, and good tissue penetration, making it a convenient option for patients.
- The HOPE trial showed that ramipril reduced the incidence of cardiovascular death, myocardial infarction, and stroke in patients with coronary artery disease, diabetes, and/or left ventricular systolic dysfunction 1.
- Compared to other ACE inhibitors, ramipril demonstrates comparable efficacy, but its evidence from landmark trials like HOPE makes it a preferred choice for high-risk patients.
- All ACE inhibitors share similar side effect profiles, including dry cough, angioedema, hyperkalemia, and potential for acute kidney injury in certain patients.
Patient Factors to Consider
- Dosing convenience: Ramipril's once-daily dosing makes it a convenient option for patients.
- Cost and insurance coverage: The choice between ramipril and other ACE inhibitors may depend on specific patient factors, such as cost and insurance coverage.
- Renal impairment: When initiating ramipril, start at a lower dose (2.5 mg daily) in elderly patients or those with renal impairment, and monitor blood pressure, renal function, and potassium levels within 1-2 weeks of starting therapy.
Evidence Summary
The HOPE trial 1 and other studies 1 demonstrate the effectiveness of ramipril in reducing cardiovascular events in high-risk patients. While other ACE inhibitors, such as lisinopril, may have similar efficacy, ramipril's evidence from landmark trials makes it a preferred choice. The ALLHAT trial 1 compared the effectiveness of an ACE inhibitor (lisinopril) versus a calcium-channel blocker (amlodipine) versus a thiazide diuretic (chlorthalidone) as first-line therapy for mild to moderate hypertension, and found no differences between treatments in primary outcome or all-cause mortality. However, ramipril's strong evidence for cardiovascular protection makes it a preferred choice for high-risk patients.
From the FDA Drug Label
Ramipril has been compared with other ACE inhibitors, beta-blockers, and thiazide diuretics as monotherapy for hypertension. It was approximately as effective as other ACE inhibitors and as atenolol Ramipril was approximately as effective as other ACE inhibitors and as atenolol. In both Caucasians and Blacks, hydrochlorothiazide (25 or 50 mg) was significantly more effective than ramipril Ramipril was less effective in blacks than in Caucasians.
- Efficacy Comparison: Ramipril is approximately as effective as other Angiotensin-Converting Enzyme (ACE) inhibitors and atenolol in treating hypertension.
- Population-Specific Efficacy: Ramipril is less effective in blacks compared to Caucasians.
- Comparison with Other Antihypertensives: Ramipril is less effective than hydrochlorothiazide in both Caucasians and Blacks 2
From the Research
Comparison of Ramipril with Other ACE Inhibitors
- Ramipril exhibits similar pharmacodynamic properties to captopril and enalapril, and is a prodrug that is hydrolyzed after absorption to form the active metabolite ramiprilat 3, 4, 5.
- The antihypertensive efficacy of ramipril is comparable to that of other established ACE inhibitors, such as captopril and enalapril, as well as the beta-adrenoceptor antagonist atenolol 3, 4, 5.
- Ramipril has been shown to be effective in reducing blood pressure and maintaining satisfactory control during long-term treatment in patients with mild to moderate essential hypertension 3, 4.
- The drug has also been found to be beneficial in patients with moderate to severe congestive heart failure, and has been shown to reduce the risk of all-cause mortality in patients with clinical evidence of heart failure after acute myocardial infarction 4, 6.
Efficacy in Specific Patient Populations
- Ramipril has been found to be effective in patients with diabetes mellitus, and has been shown to decrease urinary albumin excretion in diabetic patients with nephropathy 4.
- The drug has also been found to be beneficial in patients with peripheral arterial disease (PAD) or renal insufficiency, and in women 7.
- Ramipril has been shown to reduce the incidence of stroke, myocardial infarction, and death due to cardiovascular disease in patients at high risk for the development of cardiovascular events 6, 7.