• Left ventricular systolic dysfunction
• Heart failure following myocardial infarction

Uncomplicated hypertension

• For this indication, follow BNF, not this guideline

• Tight aortic stenosis
• Bilateral renal artery stenosis
• Concurrent use of NSAID
• Pregnancy

• Before starting therapy, check renal function and electrolytes
• if eGFR <30, discuss with SpR/consultant
• Review any potassium-sparing agent or potassium supplement
• stop, if possible, to avoid dangerous hyperkalaemia
• Initiate ramipril therapy under close clinical supervision if:
• taking high doses of diuretics
• hyponatraemia or a low sodium diet
• hypotensive dehydrated

Left ventricular systolic dysfunction (LVSD)

Preparation and first dose

• Profound first-dose hypotension may occur in hypovolaemic patients
• ensure not excessively dehydrated
• Ensure patient is supine
• Give first dose of ramipril 1.25 mg oral
• If BP <90 mmHg systolic before starting or if symptomatic, check BP after 1 hr

Titration of dose

• If patient has symptomatic hypotension with ramipril, stop any non-prognostic medications that could induce hypotension
• In patients with LVSD and persistent BP >120 mmHg systolic:
• check no significant worsening of renal function in 24 hr
• aim to increase ramipril dosage (usually by doubling dose) every other day
• In other patients, titrate ramipril to target doses in a more cautious fashion
• For LVSD, aim to achieve target dose (10 mg daily or 5 mg 12-hrly) irrespective of speed of titration

LVF in MI

First doses

• If normotensive/hypertensive with no contra-indications, start treatment as soon as practical, if possible, within 24 hr of MI
• if eGFR >30, give ramipril 2.5 mg oral 12-hrly for 2 days
• if eGFR ≤30, start with 1.25 mg once daily for 2 days and recheck renal function

Titration of dose

• If tolerated, desired target dose is:
• if eGFR >60, ramipril 5mg 12-hrly
• if GFR ≤60, ramipril 5mg maximum daily dose
• If treatment not tolerated (symptomatic fall in BP or BP <90 mmHg), reduce dose by half
• Continue only if patient tolerates a maintenance dose of at least 2.5 mg oral 12-hrly
• in elderly or in patients with eGFR ≤30, 1.25 mg 12-hrly

• Check BP 6-hrly
• Recheck renal function 24 hr after increasing dosage

Worsening renal function

• Before suggesting that ramipril is the cause, assess patients to ensure
• not hypovolaemic (i.e. excessive diuretics)
• non-essential potentially nephrotoxic medications stopped/reduced as appropriate

• Inform GP that an ACEI (ramipril) has been introduced