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Ramipril structure.svg
Clinical data
Trade namesAltace, others
License data
Routes of
By mouth
ATC code
Legal status
Legal status
Pharmacokinetic data
Protein binding73% (ramipril)
56% (ramiprilat)
MetabolismLiver, to ramiprilat
Elimination half-life13 to 17 hours
ExcretionKidney (60%) and fecal (40%)
  • (2S,3aS,6aS)-1-[(2S)-2-[[(2S)-1-Ethoxy-1-oxo-4-phenylbutan-2-yl]amino]propanoyl]-3,3a,4,5,6,6a-hexahydro-2H-cyclopenta[b]pyrrole-2-carboxylic acid
CAS Number
PubChem CID
CompTox Dashboard (EPA)
ECHA InfoCard100.170.726 Edit this at Wikidata
Chemical and physical data
Molar mass416.518 g·mol−1
3D model (JSmol)
Melting point109 °C (228 °F)
  • O=C(OCC)[C@@H](N[C@H](C(=O)N1[C@H](C(=O)O)C[C@@H]2CCC[C@H]12)C)CCc3ccccc3
  • InChI=1S/C23H32N2O5/c1-3-30-23(29)18(13-12-16-8-5-4-6-9-16)24-15(2)21(26)25-19-11-7-10-17(19)14-20(25)22(27)28/h4-6,8-9,15,17-20,24H,3,7,10-14H2,1-2H3,(H,27,28)/t15-,17-,18-,19-,20-/m0/s1 checkY

Ramipril, sold under the brand name Altace among others, is an ACE inhibitor type medication used to treat high blood pressure, heart failure, and diabetic kidney disease.[1] It can also be used as a preventative medication in patients over 55 years old to reduce the risk of having a heart attack, stroke or cardiovascular death in patients shown to be at high risk, such as some diabetics and patients with vascular disease.[2][3][4] It is a reasonable initial treatment for high blood pressure.[1] It is taken by mouth.[1]

Common side effects include headaches, dizziness, feeling tired, and cough.[1] Serious side effects may include liver problems, angioedema, kidney problems, and high blood potassium.[1] Use in pregnancy and breastfeeding is not recommended.[5] It is an ACE inhibitor and works by decreasing renin-angiotensin-aldosterone system activity.[1]

Ramipril was patented in 1981 and approved for medical use in 1989.[6] It is available as a generic medication.[7] In 2020, it was the 196th most commonly prescribed medication in the United States, with more than 2 million prescriptions.[8][9]

Structure and Activity Relationship[edit]

Ramipril is a pro-drug. The molecule must be hydrolyzed by the esterase at the OCH2CH3 and form a carboxylate. This carboxylate then interacts with the positive Zn+2 to inhibit the ACE enzyme. The COOH helps orient it with the enzyme. Ramipril is similar in structure to the Trandolapril ACE Inhibitor but it has a cyclopentane instead of cyclohexane.

Medical uses[edit]

Medical uses include:

  • High blood pressure
  • Congestive heart failure[10]
  • Following heart attack in people with evidence of heart failure
  • People over 55 years at high risk: prevention of heart attack, stroke, cardiovascular death, or in need of revascularization procedures
  • Prevent the onset and/or delay the progression of diabetic kidney disease, with or without proteinuria.[11] Randomized trial evidence suggests that a maximum tolerable dose prevents cardiovascular events and death in patients with diabetic kidney disease.


Contraindications to its use include volume-depleted patients, a history of angioedema while on an ACE inhibitor, pregnancy and hypotension.[citation needed]

People should not take ramipril (or any ACE inhibitors) if they have hyperkalemia. It is also recommended to avoid using salt-substitutes as this can further increase potassium levels in the blood.[1]

Ramipril can be considered in patients with bilateral or unilateral significant artery stenosis (RAS).[12] An early rise in serum creatinine above baseline is expected after initiation of therapy with Ramipril, however, monitoring serum biochemistry and renal function after initiation is crucial.[12][13] Treatment with Ramipril in some patients with significant narrowing in both kidneys can increase serum creatinine concentration (measured in the blood test), which returns to baseline upon therapy cessation.[14]

Significant adverse effects[15][edit]

  • Angioedema (less than 1% incidence) - This is one of the rarer adverse effects; it may lead to fluid buildup in the head and neck and sometimes the intestines (intestinal fluid buildup presents as abdominal pain). This medication would be contraindicated if patients have a history of idiopathic angioedema or have had it in response to an ACE inhibitor.
  • Cough (8 - 12% incidence) - This presents as a dry hacking cough and may have an onset of hours to 6 months after initiation. If this adverse effect is troublesome, you can consult your doctor about switching to a similar agent without the incidence of a cough. After discontinuing this medication, the cough may persist for up to 3 months.
  • Hyperkalemia (1% incidence) - This is an increase in potassium levels which can be troublesome if increased too much. For this reason, your doctor will often follow up with you in about 2-4 weeks after initiating this agent to ensure these levels are where they should be.

Other adverse effects[15][edit]

  • Hypotension (11% incidence)
  • Nausea and vomiting (2% incidence) - If you experience this, it can be mitigated by taking this medication with food
  • Dizziness (2 - 4% incidence)

Serious allergic reactions to this drug are unlikely, but immediate medical attention must be sought if they occur. Symptoms of a serious allergic reaction include, but are not limited to a rash or swelling of the face, mouth, tongue, or throat. In extreme cases, ramipril may lead to potentially fatal liver problems.

Mechanism of action[edit]

Ramipril 1.25-mg oral capsule,
letter codes and icons may differ

ACE inhibitors inhibit the actions of angiotensin converting enzyme (ACE), thereby lowering the production of angiotensin II and decreasing the breakdown of bradykinin. The decrease in angiotensin II results in relaxation of arteriole smooth muscle leading to a decrease in total peripheral resistance, reducing blood pressure as the blood is pumped through widened vessels. Its effect on bradykinin is responsible for the dry cough side effect.

Ramipril, a prodrug or precursor drug, is converted to the active metabolite ramiprilat by carboxylesterase 1.[16][17] Ramiprilat is mostly excreted by the kidneys. Its half-life is variable (3–16 hours), and is prolonged by heart and liver failure, as well as kidney failure.

Special populations[15][edit]

  • Black patients - Studies have shown that ACE inhibitors may be less effective at decreasing blood pressure in this population.
  • Surgical patients - When ace inhibitors are taken close to surgery, hypotension can develop. However, due to the drug's beneficial nature, discontinuing it before surgery is controversial. The recommendation is for the team treating you to be aware of this risk and monitor closely to ensure your safety.
  • Older adults - There should be additional monitoring due to the increased risk of hypotension.
  • Pregnant patients - Use is contraindicated since it increases the risk of fetal malformations.

Society and culture[edit]

US patent[edit]

The compound was protected by a patent which was assigned to the German pharmaceutical company Hoechst AG (since merged into Aventis) on 29 October 1991.[18] The patent was scheduled to expire on 29 October 2008. On 11 September 2007, in an appeal by the Indian company Lupin Ltd., the United States Court of Appeals for the Federal Circuit reversed a district court trial verdict and found that Aventis's patent on ramipril was invalid for "obviousness", opening this drug to generic manufacturers.

Brand names[edit]

Ramipril is marketed as Prilace by Arrow Pharmaceuticals in Australia, Ramipro by Westfield Pharma in the Philippines, Triatec by Sanofi-Aventis in Italy and United States and Altace by King Pharmaceuticals in the United States, Novapril by Pharmanova in Ghana, Ramitens by PharmaSwiss, Ampril by Krka in Slovenia, Corpril by Cemelog-BRS in Hungary, Piramil and Prilinda by Hemofarm in Serbia, by Lek in Poland and by Novartis and Opsonin Pharma Limited as Ramace in Bangladesh, and in Canada as Altace (Sonfi) and Ramipril (Pharmascience).

Ramipril is marketed in India under the brand names Cardace, Zigpril, Ramistar, Odipril and Zorem . Ramipril is marketed in Myanmar under brand name Endpril .


The Heart Outcomes and Prevention Evaluation trial[19][20] seemed to show ramipril possessed cardioprotective qualities which extended beyond its qualities as an antihypertensive. However, the trial and the interpretation of its results have been criticised.[21]

The Acute Infarction Ramipril Efficacy (AIRE) trial[16][22] showed a 27% reduction in mortality for patients receiving ramipril for chronic heart failure following a myocardial infarction.

Ramipril was found to have similar results as telmisartan, an angiotensin II receptor blocker.[23]


  1. ^ a b c d e f g "Ramipril Monograph for Professionals". Drugs.com. American Society of Health-System Pharmacists. Retrieved 3 March 2019.
  2. ^ Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G (January 2000). "Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients". The New England Journal of Medicine. 342 (3): 145–53. doi:10.1056/NEJM200001203420301. PMID 10639539.
  3. ^ "Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy". The Lancet. 355 (9200): 253–259. January 2000. doi:10.1016/S0140-6736(99)12323-7. S2CID 1863533.
  4. ^ Savarese G, Costanzo P, Cleland JG, Vassallo E, Ruggiero D, Rosano G, Perrone-Filardi P (January 2013). "A meta-analysis reporting effects of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in patients without heart failure". Journal of the American College of Cardiology. 61 (2): 131–42. doi:10.1016/j.jacc.2012.10.011. PMID 23219304.
  5. ^ "Ramipril Pregnancy and Breastfeeding Warnings". Drugs.com. Retrieved 3 March 2019.
  6. ^ Fischer J, Ganellin CR (2006). Analogue-based Drug Discovery. John Wiley & Sons. p. 469. ISBN 9783527607495.
  7. ^ British national formulary : BNF 76 (76 ed.). Pharmaceutical Press. 2018. pp. 172–173. ISBN 9780857113382.
  8. ^ "The Top 300 of 2020". ClinCalc. Retrieved 7 October 2022.
  9. ^ "Ramipril - Drug Usage Statistics". ClinCalc. Retrieved 7 October 2022.
  10. ^ Pilote L, Abrahamowicz M, Eisenberg M, Humphries K, Behlouli H, Tu JV (May 2008). "Effect of different angiotensin-converting-enzyme inhibitors on mortality among elderly patients with congestive heart failure". CMAJ. 178 (10): 1303–11. doi:10.1503/cmaj.060068. PMC 2335176. PMID 18458262.
  11. ^ Remuzzi G, Macia M, Ruggenenti P (April 2006). "Prevention and treatment of diabetic renal disease in type 2 diabetes: the BENEDICT study". Journal of the American Society of Nephrology. 2. 17 (4 Suppl 2): S90-7. doi:10.1681/ASN.2005121324. PMID 16565256.
  12. ^ a b Chrysochou, C.; Foley, R. N.; Young, J. F.; Khavandi, K.; Cheung, C. M.; Kalra, P. A. (1 April 2012). "Dispelling the myth: the use of renin-angiotensin blockade in atheromatous renovascular disease". Nephrology Dialysis Transplantation. 27 (4): 1403–1409. doi:10.1093/ndt/gfr496. ISSN 0931-0509.
  13. ^ Ahmed, Ali (July 2002). "Use of Angiotensin‐Converting Enzyme Inhibitors in Patients with Heart Failure and Renal Insufficiency: How Concerned Should We Be by the Rise in Serum Creatinine?". Journal of the American Geriatrics Society. 50 (7): 1297–1300. doi:10.1046/j.1532-5415.2002.50321.x. ISSN 0002-8614.
  14. ^ Chrysochou C, Foley RN, Young JF, Khavandi K, Cheung CM, Kalra PA (April 2012). "Dispelling the myth: the use of renin-angiotensin blockade in atheromatous renovascular disease". Nephrology, Dialysis, Transplantation. 27 (4): 1403–9. doi:10.1093/ndt/gfr496. PMID 21993376.
  15. ^ a b c Kluwer, Wolters. "Ramipril". Lexicomp. {{cite web}}: Missing or empty |url= (help)
  16. ^ a b Frampton JE, Peters DH (March 1995). "Ramipril. An updated review of its therapeutic use in essential hypertension and heart failure". Drugs. 49 (3): 440–66. doi:10.2165/00003495-199549030-00008. PMID 7774515.
  17. ^ Thomsen R, Rasmussen HB, Linnet K (January 2014). "In vitro drug metabolism by human carboxylesterase 1: focus on angiotensin-converting enzyme inhibitors". Drug Metabolism and Disposition. 42 (1): 126–33. doi:10.1124/dmd.113.053512. PMID 24141856. S2CID 206496779.
  18. ^ U.S. Patent 5,061,722
  19. ^ "Hypertension Online Slides - ramipril, mortality, kidney failure, HOPE". Archived from the original on 2 August 2012.
  20. ^ Ltd, BMJ Publishing Group (1 March 2000). "Ramipril reduced mortality and cardiovascular morbidity in high risk adults". BMJ Evidence-Based Medicine. 5 (2): 47. doi:10.1136/ebm.5.2.47 – via ebm.bmj.com.
  21. ^ Jafary F, Yusuf S, Nissen S. "Debate: Do ACE Inhibitors Have Unique Properties, Beyond Their Antihypertensive Effect?". Controversies in Cardiology II. MedScape.
  22. ^ "Effect of ramipril on mortality and morbidity of survivors of acute myocardial infarction with clinical evidence of heart failure. The Acute Infarction Ramipril Efficacy (AIRE) Study Investigators". Lancet. 342 (8875): 821–8. October 1993. doi:10.1016/0140-6736(93)92693-N. PMID 8104270. S2CID 5770772.
  23. ^ Yusuf S, Teo KK, Pogue J, Dyal L, Copland I, Schumacher H, et al. (April 2008). "Telmisartan, ramipril, or both in patients at high risk for vascular events". The New England Journal of Medicine. 358 (15): 1547–59. doi:10.1056/NEJMoa0801317. hdl:2437/81925. PMID 18378520.

External links[edit]

  • "Ramipril". Drug Information Portal. U.S. National Library of Medicine.