Synopsis
Choose and review cardiovascular medicines by clinical purpose, haemodynamics and organ function, with safe initiation and a reasoned response to adverse effects.
- Name the therapeutic aim before changing treatment: relief of congestion or angina, blood-pressure reduction and prevention of heart-failure events are related but different goals.
- For uncomplicated hypertension where suitable, ramipril may start at 2.5 mg orally once daily and increase every 2–4 weeks to a maximum 10 mg daily; lower starting doses and renal limits apply to selected patients.
- Amlodipine usually starts at 5 mg orally once daily for hypertension or angina, increasing to 10 mg daily according to response; assess ankle oedema, dizziness and hepatic impairment before escalation.
Investigation priorities
Relate treatment intensity to pressure and postural symptoms.
Management branches
An adult has confirmed hypertension and an ACE inhibitor is an appropriate choice.
- Review the NICE hypertension selection pathway, existing medicines, pregnancy potential and previous angioedema. Confirm that the diagnosis and treatment target are established, and check baseline pressure, kidney function, sodium and potassium before prescribing.
- For a suitable adult, start ramipril 2.5 mg orally once daily. Consider 1.25 mg with medical supervision when clinically appropriate for greater first-dose hypotension risk, including relevant diuretic use, and apply the product’s renal dose limits.
Key medicines
Ramipril for selected adults with hypertensionUsually 2.5 mg orally once daily; increase at 2–4-week intervals according to response, to 10 mg daily maximum with suitable renal function. Selected first-dose-risk patients may start at 1.25 mg.This is the hypertension SmPC schedule, not every cardiac indication. CrCl 30–60 mL/min limits the maximum to 5 mg daily; CrCl 10–30 starts at 1.25 mg with maximum 5 mg. Avoid pregnancy and previous ACE-inhibitor angioedema. With hepatic impairment, initiate under close supervision and do not exceed 2.5 mg daily.
Amlodipine for hypertension or angina5 mg orally once daily initially, increasing if required and tolerated to a maximum 10 mg once daily; treatment continues with regular benefit and adverse-effect review.Assess oedema, headache and hypotension. Titrate cautiously in older adults; hepatic impairment requires cautious dose selection. It is not a substitute for disease-modifying HFrEF treatment and is unsuitable in shock or severe hypotension.