Heart failure
First line
Foundation therapy in HFrEF per 2023 alongside other ACE inhibitors. AIRE trial showed 27% mortality reduction in post-MI HF. Dose 2.5–10 mg once daily titrated from the minimum.
Angiotensin-converting enzyme inhibitor (ACE-I)
ATC code: C09AA05 (Ramipril)
A prodrug hydrolyzed in the liver to active ramiprilat. Competitive ACE inhibitor blocks angiotensin I conversion to angiotensin II and reduces aldosterone. Lowers peripheral vascular resistance and BP. Blocks bradykinin breakdown – source of endothelial benefits and the characteristic dry cough (5–20%). Active metabolite half-life 13–17 hours – once-daily dosing.
First line
Foundation therapy in HFrEF per 2023 alongside other ACE inhibitors. AIRE trial showed 27% mortality reduction in post-MI HF. Dose 2.5–10 mg once daily titrated from the minimum.
First line
First-line for hypertension per 2024. Dose 2.5–10 mg once daily. Particularly effective with concomitant T2D, HF, CKD, or post-MI. HOPE trial showed 22% reduction in cardiovascular events in high-risk patients.
The drug is promoted for these uses outside international guidelines. Each entry below is analyzed against AEMPS, FDA, EMA, Cochrane and major RCTs.
Not recommended
Ramipril is a long-acting ACE inhibitor. It is prescribed for hypertension, heart failure, diabetic nephropathy, and for secondary cardiovascular prevention after myocardial infarction or stroke ( 2023, SEH-LELHA; the HOPE 2000 trial demonstrated benefit at high CV risk). In anti-aging regimens, ramipril is given to healthy normotensives for anti-aging of vessels and for suppressing chronic inflammation of aging. In people with normal blood pressure and no confirmed high CV risk (diabetes, coronary disease, prior stroke), prophylactic use is not justified. The drug causes a dry cough, hyperkalemia, dizziness, and angioedema in predisposed people. If ramipril was prescribed to a healthy person, consider seeking a second opinion.
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Absolute contraindication. T2 and T3 use causes oligohydramnios, lung and kidney hypoplasia, limb contractures, fetal demise. In women on ACE-I planning pregnancy, switch in advance to labetalol or methyldopa.
Enalapril and captopril have more data and are preferred when an ACE-I is needed during lactation. Ramipril used with caution.
Reference information, not a clinical decision. Discuss feeding pauses or changes with your physician or an IBCLC.
Ramipril is evaluated for the following indications with varying evidence strength: Hypertension (evidence tier A), Heart failure (evidence tier A), Anti-aging and longevity (evidence tier F). See the full indication matrix with dosing and citations above on this page.
Common side effects of Ramipril (≥ 1 in 100): Dry cough (5–20%), Dizziness, Hypotension, Hyperkalemia, Elevated creatinine, Fatigue. See the Safety section for uncommon and serious reactions.
FDA category D. Absolute contraindication. T2 and T3 use causes oligohydramnios, lung and kidney hypoplasia, limb contractures, fetal demise. In women on ACE-I planning pregnancy, switch in advance to labetalol or methyldopa.
Enalapril and captopril have more data and are preferred when an ACE-I is needed during lactation. Ramipril used with caution.
Ramipril is contraindicated in: Ramipril or other ACE-I hypersensitivity; History of ACE-I angioedema; Pregnancy (all trimesters); Bilateral renal artery stenosis; Severe hepatic impairment. Full list in the Safety section.