What is the recommended dose of ramipril (Angiotensin-Converting Enzyme (ACE) inhibitor) for adults with hypertension or heart failure?

Ramipril Dosing for Hypertension and Heart Failure

Hypertension

For adults with hypertension, start ramipril at 2.5 mg once daily and titrate up to a usual maintenance range of 2.5-20 mg daily, with most patients controlled on 2.5-5 mg once daily. 1

Initial Dosing

• Standard starting dose: 2.5 mg once daily for patients not on diuretics 1
• Reduced starting dose: 1.25 mg once daily for patients with:
  • Renal impairment (creatinine clearance <40 mL/min) 1
  • Volume depletion or suspected renal artery stenosis 1
  • Concurrent diuretic therapy 1

Titration and Maintenance

• Adjust dose based on blood pressure response at intervals of at least 2 weeks 1
• Usual maintenance range: 2.5-20 mg daily (single dose or divided twice daily) 1
• In real-world practice, 41% of patients require only 2.5 mg and 81% are controlled on ≤5 mg once daily 2
• If antihypertensive effect diminishes toward end of dosing interval, consider increasing dose or switching to twice-daily administration 1
• Add a diuretic if blood pressure not controlled with ramipril alone 1

Evidence for Cardiovascular Protection

• In high-risk patients, ramipril 10 mg daily reduced MI, stroke, or cardiovascular death by 22% over 5 years 3
• Target blood pressure <130/80 mmHg is recommended for patients with stable ischemic heart disease and hypertension 3

Heart Failure Post-Myocardial Infarction

For patients with heart failure after MI, start ramipril at 2.5 mg twice daily and titrate to a target dose of 5 mg twice daily (10 mg total daily). 1

Initial Dosing

• Standard starting dose: 2.5 mg twice daily (5 mg/day total) 1
• Reduced starting dose: 1.25 mg twice daily for patients who become hypotensive 1
• Observe patient under medical supervision for at least 2 hours after initial dose, and until blood pressure stabilizes for an additional hour 1

Titration Strategy

• After one week at starting dose, increase toward target dose of 5 mg twice daily if tolerated 1
• Space dosage increases approximately 3 weeks apart 1
• Reduce concomitant diuretic dose if possible to minimize hypotension risk 1
• Hypotension after initial dose does not preclude careful subsequent titration 1

Renal Impairment Adjustments

• Initial dose: 1.25 mg once daily for heart failure patients with renal impairment 1
• May increase to 1.25 mg twice daily, up to maximum of 2.5 mg twice daily based on response and tolerability 1
• Maximum total daily dose: 5 mg for patients with creatinine clearance <40 mL/min 1

Important Monitoring and Precautions

Monitoring Parameters

• Check serum potassium and creatinine after 5-7 days of starting therapy 4
• Recheck every 5-7 days during titration until values are stable 4
• Monitor blood pressure, renal function, and electrolytes 1-2 weeks after each dose increment 4
• Follow-up at 3 months, then every 6 months thereafter 4

Acceptable Changes

• Creatinine increase up to 50% above baseline, or to 3 mg/dL (whichever is greater) is acceptable 4

Drug Interactions to Avoid

• Avoid NSAIDs and COX-2 inhibitors as they worsen renal function and reduce ACE inhibitor efficacy 4
• Avoid potassium-sparing diuretics during initiation unless specifically needed for persistent hypokalemia 4
• Do not combine with potassium supplements or salt substitutes without careful monitoring 1

Common Pitfalls

Many clinicians fail to titrate to target doses. The evidence clearly demonstrates that higher doses provide superior outcomes—ramipril 10 mg daily in cardiovascular protection trials showed significant mortality reduction 3, and in heart failure, higher ACE inhibitor doses reduce hospitalizations by 24% compared to low doses 4. Always attempt to reach target doses unless limited by side effects or contraindications.

ACE inhibitor-induced cough rarely requires discontinuation—only switch to an ARB if cough is proven ACE inhibitor-related through withdrawal and rechallenge 4.