From the Guidelines
Ramipril is a type of angiotensin-converting enzyme (ACE) inhibitor that is recommended for patients with heart failure with reduced ejection fraction (HFrEF) to reduce morbidity and mortality, as evidenced by the 2017 ACC/AHA/HFSA guideline update 1.
Mechanism of Action
Ramipril works by blocking the enzyme that converts angiotensin I to angiotensin II, a powerful vasoconstrictor, which causes blood vessels to relax and widen, lowering blood pressure and reducing the workload on the heart.
Clinical Uses
Ramipril is commonly prescribed to treat:
- Hypertension (high blood pressure)
- Heart failure
- To improve survival after heart attacks
- To prevent kidney problems in people with diabetes
- To reduce the risk of heart attacks, strokes, and death in high-risk patients
Dosage
Ramipril is typically taken orally once or twice daily, with dosages ranging from 1.25 mg to 20 mg per day depending on the condition being treated.
Benefits
The use of ACE inhibitors, such as ramipril, has been shown to reduce morbidity and mortality in patients with HFrEF, as well as reduce the risk of cardiovascular ischemic events in patients with peripheral artery disease (PAD) 1.
Side Effects
Ramipril can produce angioedema and should be given with caution to patients with low systemic blood pressures, renal insufficiency, or elevated serum potassium, and can also induce cough in up to 20% of patients 1.
Alternative Therapies
Angiotensin receptor blockers (ARBs) and angiotensin receptor-neprilysin inhibitors (ARNIs) are alternative therapies that can be used in patients who are intolerant to ACE inhibitors, as evidenced by the 2017 ACC/AHA/HFSA guideline update 1.
From the FDA Drug Label
Ramipril and ramiprilat inhibit ACE in human subjects and animals. The drug class of Ramipril is an Angiotensin-Converting Enzyme (ACE) inhibitor 2.
From the Research
Ramipril Classification
- Ramipril is classified as a long-acting angiotensin converting enzyme (ACE) inhibitor 3, 4, 5, 6, 7
- It is a prodrug that is hydrolysed in vivo to release the active metabolite ramiprilat, which has a long elimination half-life, permitting once-daily administration 3, 4, 6
- Ramipril is a second-generation ACE inhibitor 4
- It is a nonsulfhydryl ACE inhibitor, and its active metabolite ramiprilat is at least 23 times more lipophilic than enalaprilat 7
Therapeutic Use
- Ramipril is indicated in the treatment of hypertension, congestive cardiac failure (including that following acute myocardial infarction), nephropathy (with and without diabetes mellitus), and prevention of cardiovascular events (including myocardial infarction) in high-risk individuals 5, 6
- It has been shown to be effective in reducing blood pressure and maintaining satisfactory control during long-term treatment in hypertensive patients 3
- Ramipril has also been shown to be effective in patients with moderate to severe congestive heart failure, and in patients with clinical evidence of heart failure after acute myocardial infarction 3, 4
Pharmacological Properties
- Ramipril has a high potency and a slow dissociation of the ramipril-ACE complex, which explains its long duration of action and permits once-daily treatment 7
- The in vitro affinity of ramiprilat for the enzyme is 7 times higher than for enalaprilat and 47 times higher than for captopril 7
- Ramiprilat-ACE complex is very stable and dissociates 6 times more slowly than the enalaprilat-ACE complex and 22 times more slowly than the captopril-ACE complex 7