Secondary prevention after acute myocardial infarction

Active Ingredient: Ramipril

Indication for Ramipril

Population group: only adults (18 years old or older)
Therapeutic intent: Preventive action

Reduction of mortality from the acute phase of myocardial infarction in patients with clinical signs of heart failure when started >48 hours following acute myocardial infarction.

For this indication, competent medicine agencies globally authorize below treatments:

2.5 mg twice daily for 3 days and thereafter 5 mg twice daily


Dosage regimens

Regimen A: Oral, 2.5 milligrams ramipril, 2 times daily, over the duration of 3 days. Afterwards, oral, 5 milligrams ramipril, 2 times daily.

Regimen B: Oral, 1.25 milligrams ramipril, 2 times daily, over the duration of 2 days. Afterwards, oral, 2.5 milligrams ramipril, 2 times daily, over the duration of 1 to 3 days. Afterwards, oral, 5 milligrams ramipril, 2 times daily.

Detailed description

Starting dose:

After 48 hours, following myocardial infarction in a clinically and haemodynamically stable patient, the starting dose is 2.5 mg twice daily for three days. If the initial 2.5 mg dose is not tolerated a dose of 1.25 mg twice a day should be given for two days before increasing to 2.5 mg and 5 mg twice a day. If the dose cannot be increased to 2.5 mg twice a day the treatment should be withdrawn.

Diuretic-treated patients:

Hypotension may occur following initiation of therapy with ramipril; this is more likely in patients who are being treated concurrently with diuretics. Caution is therefore recommended since these patients may be volume and/or salt depleted.

If possible, the diuretic should be discontinued 2 to 3 days before beginning therapy with ramipril.

In hypertensive patients in whom the diuretic is not discontinued, therapy with ramipril should be initiated with a 1.25 mg dose. Renal function and serum potassium should be monitored. The subsequent dosage of ramipril should be adjusted according to blood pressure target.

Titration and maintenance dose:

The daily dose is subsequently increased by doubling the dose at intervals of one to three days up to the target maintenance dose of 5 mg twice daily.

The maintenance dose is divided in 2 administrations per day where possible.

If the dose cannot be increased to 2.5 mg twice a day treatment should be withdrawn. Sufficient experience is still lacking in the treatment of patients with severe (NYHA IV) heart failure immediately after myocardial infarction. Should the decision be taken to treat these patients, it is recommended that therapy be started at 1.25 mg once daily and that particular caution be exercised in any dose increase.

Dosage considerations

It is recommended that ramipril is taken each day at the same time of the day.

Ramipril can be taken before, with or after meals, because food intake does not modify its bioavailability.

Active ingredient


Ramiprilat, the active metabolite of the prodrug ramipril, inhibits the enzyme dipeptidylcarboxypeptidase I (synonyms: angiotensin-converting enzyme; kininase II). In plasma and tissue this enzyme catalyses the conversion of angiotensin I to the active vasoconstrictor substance angiotensin II, as well as the breakdown of the active vasodilator bradykinin. Reduced angiotensin II formation and inhibition of bradykinin breakdown lead to vasodilatation.

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