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. 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. It is a reasonable initial treatment for high blood pressure. It is taken by mouth. Common side effects include headaches, dizziness, feeling tired, and cough. Serious side effects may include liver problems, angioedema, kidney problems, and high blood potassium. Use in pregnancy and breastfeeding is not recommended. It is an ACE inhibitor and works by decreasing renin-angiotensin-aldosterone system activity. Ramipril was patented in 1981 and approved for medical use in 1989. It is available as a generic medication. In 2020, it was the 196th most commonly prescribed medication in the United States, with more than 2million prescriptions. Structure and Activity Relationship 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 Medical uses include: High blood pressure Congestive heart failure 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 need of revascularization procedures To prevent the onset and progression of kidney damage due to diabetes with or without protein in the urine. Randomized trial evidence suggests that a maximum tolerable dose prevents cardiovascular events and death in patients with diabetic kidney disease. Contraindications Contraindications to its use include volume-depleted patients, a history of angioedema while on an ACE inhibitor, pregnancy and hypotension. 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. Ramipril can be considered safe and well-tolerated for most people with renovascular disease (narrowing of the artery to one or both kidneys) only if close blood test monitoring is available at the start of therapy. Treatment with Ramipril in