What is the next step in managing a 46-year-old adult with a history of hypertension (HTN) on ramipril (angiotensin-converting enzyme inhibitor) 2.5 mg, who presents with elevated blood pressureاجر pressure of 150/90 mmHg?

Management of Uncontrolled Hypertension on Low-Dose ACE Inhibitor

Increase ramipril to 5 mg daily and reassess blood pressure in 2-4 weeks, as the current 2.5 mg dose is subtherapeutic for most patients with stage 2 hypertension (150/90 mmHg). 1, 2

Immediate Assessment

Before adjusting therapy, verify this is a true elevation:

• Confirm the elevated reading by taking at least 2 additional measurements during the same visit using a properly calibrated device with appropriate cuff size 2
• Assess for secondary causes if not previously evaluated, particularly in patients diagnosed before age 40 (though less urgent at age 46) 1
• Review medication adherence and inquire about substances that may elevate BP, including NSAIDs, decongestants, alcohol (>2 drinks/day for men), caffeine, and herbal supplements 1

Pharmacological Management Strategy

Step 1: Optimize Current ACE Inhibitor Dose

Increase ramipril from 2.5 mg to 5 mg once daily 3, 4, 5:

• The 2.5 mg dose achieves BP control in only 52% of patients, while 5 mg achieves control in approximately 70% 3
• Ramipril can be safely titrated up to 10 mg daily if needed 6, 3
• Monitor for potential side effects including cough (most common), hyperkalemia, and renal function changes 7

Step 2: If Inadequate Response After 2-4 Weeks

Add a calcium channel blocker (amlodipine 5 mg daily) OR a thiazide-like diuretic (chlorthalidone 12.5-25 mg or indapamide 2.5 mg daily) 1:

• The 2024 ESC guidelines recommend combination therapy as initial treatment for most patients with confirmed hypertension ≥140/90 mmHg 1
• Preferred combinations include a RAS blocker (ACE inhibitor or ARB) with either a dihydropyridine calcium channel blocker or thiazide/thiazide-like diuretic 1
• Use fixed-dose single-pill combinations when available to improve adherence 1

Step 3: If Still Uncontrolled on Two-Drug Combination

Escalate to three-drug combination: ACE inhibitor + calcium channel blocker + thiazide/thiazide-like diuretic, preferably as a single-pill combination 1

Blood Pressure Target

Target systolic BP of 120-129 mmHg (current guidelines for adults <65 years) 1, 2:

• This target reduces cardiovascular risk more effectively than the older <140/90 mmHg target 1
• If poorly tolerated, use the "as low as reasonably achievable" (ALARA) principle 1

Monitoring Requirements

Check the following at 2-4 weeks after dose adjustment 1, 2:

• Blood pressure measurement
• Serum creatinine and electrolytes (particularly potassium, as ACE inhibitors can cause hyperkalemia in ~1% of patients) 7
• Assess for symptoms of hypotension, though rare in uncomplicated hypertensive patients 7

Once BP is controlled, follow-up every 3-6 months with continued monitoring of renal function and electrolytes 2

Important Safety Considerations

Contraindications and Precautions with Ramipril:

• Do not combine with ARBs (dual RAS blockade increases risk of renal dysfunction without additional benefit) 7
• Avoid potassium supplements and potassium-sparing diuretics unless specifically indicated, due to hyperkalemia risk 7
• Monitor renal function closely if patient has any degree of renal impairment, as ACE inhibitors can cause transient increases in creatinine 7
• Discontinue immediately if pregnancy is detected (Category D in pregnancy) 7

Common Pitfalls to Avoid:

• Don't start with combination therapy in this patient who is already on monotherapy—first optimize the existing medication 1
• Don't add a second ACE inhibitor or combine with an ARB—this provides no benefit and increases harm 7
• Don't ignore lifestyle modifications: reinforce sodium restriction (<5 g/day), regular aerobic exercise (150 min/week), weight loss if overweight, and alcohol moderation 1, 2

Rationale for This Approach

The current ramipril dose of 2.5 mg is at the lower end of the therapeutic range and achieves adequate BP control in only about half of patients 3. Dose optimization is the logical first step before adding additional agents, as this approach is supported by decades of stepped-care evidence 1. The BP of 150/90 mmHg represents stage 2 hypertension requiring prompt pharmacological intensification to reduce cardiovascular risk 1, 2.