Ramipril

Enalapril

Captopril

Lisinopril

The renin-angiotensin-aldosterone system in the kidneys in the system has a primary role in controlling blood pressure. Angiotensinogen is a protein released by the liver. Renin, an enzyme released from the kidneys, converts angiotensinogen into angiotensin I. Renin is released when the kidneys detect a fall in blood pressure. Angiotensin-converting enzyme (ACE), an enzyme released from the lungs, converts angiotensin I to angiotensin II.

Angiotensin II has various effects to increase blood pressure:

1. Sodium and water retention – this expands extracellular volume

2. Aldosterone secretion – from posterior pituitary which increases water reabsorption, expanding extracellular volume

3. Increased sympathetic nervous system action increases heart rate

4. Vasoconstriction – indirect effects on raising blood pressure

5. Hypertrophy – remodelling of the heart

Angiotensin-converting enzyme inhibitors inhibit ACE and so prevent the conversion from angiotensin I to angiotensin II.

Hypertension

Heart Failure

Diabetic Nephropathy

Chronic Kidney Disease

Myocardial Infarction

Prevention of Cardiovascular Disease

Cough

Headache

Muscle Cramps

GI Upset (diarrhoea and vomiting)

Mild Skin Rash

Blurred Vision

Stomatitis

Syncope

Hyperkalaemia

Angioedema (more common in Afro-Caribbean patients)

Hypersensitivity to ACE Inhibitors

Acute Kidney Injury

Bilateral Renal Artery Stenosis

Pregnancy

Breastfeeding

Hepatic Impairment

Ramipril is a prodrug, so patient requires monitoring in hepatic impairment

Renal Impairment

Check eGFR and electrolytes before and when increasing dose

Other Antihypertensives:

Calcium Channel Blockers

Beta-blockers

Angiotensin Receptor Blockers

Mineralocorticoid Receptor Antagonists

Allopurinol

NSAIDs (renal damage)

Anticoagulants

Diuretics (hyperkalaemia, hypotension)

Alcohol

1. https://bnf.nice.org.uk/drug/ramipril.html

2. https://bnf.nice.org.uk/drug-class/angiotensin-converting-enzyme-inhibitors.html

3. https://bnf.nice.org.uk/treatment-summary/drugs-affecting-the-renin-angiotensin-system.html