ACE inhibitors · Cardiovascular
Ramipril
Altace®(brand names vary by market)
A long-acting ACE inhibitor with outcome evidence across the cardiovascular spectrum.
Also: tablet
Mechanism
Prodrug (ramiprilat) that inhibits angiotensin-converting enzyme: less angiotensin II, less aldosterone, more bradykinin. Vasodilation, natriuresis, and the famous dry cough.
Open the interactive pathwayIndications
- Hypertension
- Heart failure with reduced ejection fraction
- Post myocardial infarction
- Vascular protection in high-risk patients
- Proteinuric chronic kidney disease
Formulations
Dosing concepts
Initiation
Start low in the volume-depleted or diuretic-treated patient; first-dose hypotension is a real phenomenon.
Renal function
A creatinine rise up to ~30% after starting is expected hemodynamics, not an automatic stop signal; a larger rise asks about renal artery stenosis or volume depletion.
Concepts, not prescribing instructions. Practice numbers live in current references and local protocols.
Pharmacokinetics
- Bioavailability
- ~50-60% (prodrug)
- Half-life
- 13-17 h (effective, ramiprilat)
- Elimination
- renal: Dose is reduced in significant renal impairment
Adverse effects
- Dry coughcommonBradykinin-mediated; class effect, resolves on stopping, does not respond to cough syrup.
- Hyperkalemiacommon & serious
- Hypotensioncommon
- Acute kidney injury in the wrong hemodynamicsserious
- AngioedemaseriousRare, can occur years into therapy, airway emergency.
Contraindications & precautions
Contraindications
- Pregnancy
- History of ACE-inhibitor angioedema
- Bilateral renal artery stenosis
Precautions
- Volume depletion
- Potassium above range
- Concurrent potassium-raising drugs
Interactions
- ACE inhibitors / ARBs + Potassium-sparing diuretics, K supplements, salt substitutescautionAdditive hyperkalemia, worst with renal impairment layered on top.
- ACE inhibitor / ARB + diuretic + NSAID (the 'triple whammy')avoidAcute kidney injury, classically in a dehydrated older adult who bought ibuprofen for a sore knee.
- ACE inhibitors / ARBs / thiazides + LithiumcautionLithium toxicity: tremor, confusion, ataxia, renal injury.
Monitoring
Serum creatinine and potassium
The two things this class moves · Baseline, 1-2 weeks after start or dose change, then periodically
Blood pressure
Effectiveness and hypotension
Cough, swelling of lips or tongue
Class adverse effects the patient reports before any lab does
Counselling points
- A dry tickly cough can develop; tell us rather than just stopping.
- Swelling of the lips, tongue or face is an emergency. Seek care immediately.
- Avoid becoming pregnant on this medication; discuss alternatives first.
- Do not add salt substitutes (they are potassium salts) without checking.
Clinical pearls
- Cough switches to an ARB; angioedema is a contraindication to rechallenge and a reason for caution even with ARBs.
- The 'triple whammy' (ACE inhibitor + diuretic + NSAID) is a classic prerenal AKI recipe.
References & review
- Ramipril product monograph (consult the current version for your market) (monograph)
- Goodman & Gilman's The Pharmacological Basis of Therapeutics, 14th ed. (reference-work)
Last reviewed 2026-08-15 · jurisdiction: global · drug information changes; verify against current references before practice use.