Study of antihypertensive effect of ramipril alone and in combination with telmisartan

Mustafa Raja, Ajay Kumar Shukla, Astha Agnihotri


Background: Hypertension is one of the leading causes of the global burden of disease. Hypertension has been associated with increased risk of cardiovascular diseases, including coronary heart disease (CHD), congestive heart failure (CHF), ischemic and hemorrhagic stroke, renal failure, and peripheral arterial disease. Majority of the hypertensive population are still either untreated or inadequately treated. Aims and objectives of the study were to compare ramipril alone and in combination with telmisartan as an antihypertensive in mild to moderate hypertension.

Methods: This study was a hospital based prospective, comparative randomized, observational study conducted over a period of one year. The subjects of this study had mild to moderate hypertension selected from outpatient department of department of General Medicine of a tertiary care hospital. For the purpose of this study, equal numbers of subjects were randomly allocated equally between two groups: one group on ramipril alone and the other group on combination of ramipril and telmisartan. Patients were assessed for the blood pressure (BP) reduction during follow-up period of 6-months.

Results: Ramipril alone and in combination with telmisartan, both were associated with significant reduction of systolic BP (SBP), diastolic BP (DBP), and mean BP (MBP) from beginning to the end of study. Combination of ramipril with telmisartan was more effective than ramipril in lowering SBP during 4 to 12 weeks but at the end of study both drug groups were found to be equally effective antihypertensive. Both ramipril alone and in combination with telmisartan were equally effective in lowering DBP and MBP from beginning to end of study.

Conclusions: There was a significant reduction of SBP, DBP, and MBP from beginning to the end of study with both ramipril alone and in combination with telmisartan. Ramipril alone and in combination with telmisartan, both were equally effective antihypertensive for mild to moderate hypertension.


ACE inhibitors, ARBs, Hypertension, RAS

Full Text:



Kotchen TA, Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson J, et al. Hypertensive vascular disease. In:. Harrison’s Principles of Internal Medicine. 19th Ed. New York, NY: McGraw-Hill; 2015:1622-1623.

Thomas M, Hoffman BB. Treatment of Myocardial Ischemia and Hypertension. In: Brunton LB, Chabner BA, Knollman BC, editors. Goodman and Gilman’s The Pharmacological Basis of Therapeutics. 12th Ed. New York, NY: McGraw-Hill; 2011:733-738.

Unger T. The rationale for choosing telmisartan and ramipril in the ONTARGET programme. European Heart Journal Supplements. 2009;11:3-8.

Ruilope LM, Rosei EA, Bakris GL, Mancia G, Poulter NR, Taddei S, et al. Angiotensin receptor blockers: therapeutic targets and cardiovascular protection. Blood Press. 2005;14:196-209.

Unger T. Targeting cardiovascular protection: the concept of dual renin–angiotensin system control. Medscape J Med. 2008;10:S4.

Steckelings UM, Kaschina E, Unger T. The AT2 receptor-a matter of love and hate. Peptides. 2005;26:1401-9.

Fleming I, Kohlstedt K, Busse R. New faces to the renin–angiotensin system. Physiology (Bethesda). 2005;20:91-5.

Kohlstedt K, Busse R, Fleming I. Signaling via the angiotensin converting enzyme enhances the expression of cyclooxygenase-2 in endothelial cells. Hypertension. 2005;45:126-32.

Kohlstedt K, Brandes RP, Muller-Esterl W, Busse R, Fleming I. Angiotensin-converting enzyme is involved in outside-in signaling in endothelial cells. Circ Res. 2004;94:60-7.

MacFadyen RJ, Lee AF, Morton JJ, Pringle SD, Struthers AD. How often are angiotensin II and aldosterone concentrations raised during chronic ACE inhibitor treatment in cardiac failure? Heart. 1999;82:57-61.

Swedberg K, Eneroth P, Kjekshus J, Wilhelmsen L. Hormones regulating cardiovascular function in patients with severe congestive heart failure and their relation to mortality. CONSENSUS Trial Study Group. Circulation. 1990;82:1730-6.

Ravid D, Lishner M, Lang R, Ravid M. Angiotensin-converting enzyme inhibitors and cough: a prospective evaluation in hypertension and in congestive heart failure. J Clin Pharmacol. 1994;34:1116-20.

Sierra A. Angiotensin receptor blockers in hypertension and cardiovascular diseases. Cardiovasc Hematol Agents Med Chem. 2006;4:67-73.

Williams B, Lacourcière Y, Schumacher H, Gosse P, Neutel JM. Antihypertensive efficacy of telmisartan vs ramipril over the 24-h dosing period, including the critical early morning hours: A pooled analysis of the PRISMA I and II randomized trials. J Hum Hypertens. 2009;23:610-9.

Neutel J, Smith DH. Evaluation of angiotensin II receptor blockers for 24-hour blood pressure control: Meta-analysis of a clinical database. J Clin Hypertens (Greenwich). 2003;5(1):58-63.

Neutel JM. Use of ambulatory blood pressure monitoring to evaluate the selective angiotensin II receptor antagonist, telmisartan, and other antihypertensive drugs. Blood Press Monit. 2000;5(1):S35-40.

White WB. Improving blood pressure control and clinical outcomes through initial use of combination therapy in stage 2 hypertension Blood Press Monit. 2008;13(2):123-9.

Ruilope LM, Aldigier JC, Ponticelli C, Oddou-Stock P, Botteri F, Mann JF. Safety of the combination of valsartan and benazepril in patients with chronic renal disease. European Group for the Investigation of Valsartan in Chronic Renal Disease. J Hypertens. 2000;18(1):89-95.

Mogensen CE, Neldam S, Tikkanen I, Oren S, Viskoper R, Watts RW, et al. Randomised controlled trial of dual blockade of renin–angiotensin system in patients with hypertension, microalbuminuria, and non-insulin dependent diabetes: the candesartan and lisinopril microalbuminuria (CALM) study. BMJ 2000;321:1440-4.

Azizi M, Ménard J. Combined blockade of the renin-angiotensin system with angiotensin-converting enzyme inhibitors and angiotensin ii type 1 receptor antagonists. Circulation. 2004;109:2492-9.

European Society of Hypertension-European Society of Cardiology Guidelines Committee 2003 European society of hypertension-European society of cardiology guidelines for the management of arterial hypertension. J Hypertens. 2003;21(6):1011-53.

Yusuf S, Teo KK, Pogue J, Dyal L, Copland I. ONTARGET Investigators. Telmisartan, ramipril, or both in patients at high risk for vascular events. N Engl J Med. 2008;358(15):1547-59.

Raja M, Shukla AK, Mehani R, Agnihotri A. Comparative study of telmisartan and ramipril as an antihypertensive in mild to moderate hypertension. Natl J Physiol Pharm Pharmacol; 2016:6.

Izzo JL, Weinberg MS, Hainer JW, Kerkering J, Tou CK. AMAZE. Antihypertensive efficacy of candesartan-lisinopril in combination vs. up-titration of lisinopril: the AMAZE trials. J Clin Hypertens (Greenwich). 2004;6(9):485-93.

Phillips CO, Kashani A, Ko DK, Francis G, Krumholz HM. Adverse effects of combination angiotensin II receptor blockers plus angiotensin-converting enzyme inhibitors for left ventricular dysfunction: a quantitative review of data from randomized clinical trials. Arch Intern Med. 2007;167(18):1930-6.

Stergiou GS, Skeva II, Baibas NM, Roussias LG, Kalkana CB, Achimastos AD, et al. Additive hypotensive effect of angiotensin-converting enzyme inhibition and angiotensin-receptor antagonism in essential hypertension J Cardiovasc Pharmacol. 2000;35(6):937-41.

Sengul AM, Altuntas Y, Kurklu A, Aydin L. Beneficial effect of lisinopril plus telmisartan in patients with type 2 diabetes, microalbuminuria and hypertension. Diabetes Res Clin Pract. 2006;71(2):210-19.

McMurray JJ, Ostergren J, Swedberg K. Effects of candesartan in patients with chronic heart failure and reduced left-ventricular systolic function taking angiotensin-converting-enzyme inhibitors: the CHARM-Added trial. 2003;362(9386):767-71.

Jacobsen P, Andersen S, Rossing K, Jensen BR, Parving HH. Dual blockade of the renin-angiotensin system versus maximal recommended dose of ACE inhibition in diabetic nephropathy. Kidney Int. 2003;63(5):1874-80.

Knudsen ST, Andersen NH, Poulsen SH, Eiskjaer H, Hansen KW, Helleberg K, et al. Pulse pressure lowering effect of dual blockade with candesartan and lisinopril vs. high-dose ACE inhibition in hypertensive type 2 diabetic subjects: a CALM II study post-hoc analysis. Am J Hypertens. 2008;21(2):172-6.

Andersen NH, Poulsen PL, Knudsen ST. Long-term dual blockade with candesartan and lisinopril in hypertensive patients with diabetes: the CALM II study. Diabetes Care. 2005;28(2):273-7.