Heart & Cardiology/Hypertension


QUESTION: Hello Doctor -

I have a question for my Mom.
She is 75 years old lady.

She has been having hypertension for several years and been on hypertension medications.

She was taking Nifedipine XL 30 Mg one in the morning.
And, Ramipril 5 Mg twice a daily (one in morning and one in evening)

For last few weeks her blood pressure was not in control with current medications. Her blood pressure elevated in the range of 165-175 systolic.

Her doctor increased the dosage of the medications. Now, she is taking Nifedipine XL 30 Mg one in the morning and Ramipril 10 Mg twice daily.
She has been taking Ramipril total 20 Mg in a day for couple of weeks and now her blood pressure in the range of 130-150 (systolic).

My question is -

1) what is the max dose of Ramipril given in a day? Is 20 mg in a day is a max dose?

2) Her creatinine level was 1.1 mg/dL on her last blood report on 09/06/14. Her eGFR was 58 Ml/Min/1.73 on 08/10/14.
Is the current Ramipril dose of 20 Mg is too much for her current Kidney function. Does Ramipril affect kidney function?

3) What blood pressure drug has less effect on kidneys?

I greatly appreciate your time and expert advice.

Best Regards



20mg per day is the maximum dose of ramipril for hypertension. As in this case, it is usually given as 10mg twice a day.

Her GFR is a little reduced however it is actually the case that ACE inhibitors such as ramipril are actually protective of the kidneys and can delay the progression of chronic kidney disease. The use of ACE inhibitors may by design make the kidney numbers a little worse, however they are considered protective over the long term. It therefore turns out that this is often the drug of choice in kidney disease.

The combination of a calcium channel blocker such as nifedipine (amlodipine is more well studied) and an ACE inhibitor such as ramipril is certainly a reasonable combination. However further medications may need to be used to ensure that blood pressure is in the desired range. This is important as control of blood pressure turns out to be one of the most important factors in halting the progression of kidney disease.

Hope that was helpful,

---------- FOLLOW-UP ----------

QUESTION: Hello Dr. Ahmed-

Thank you very much for your answer.

She has been on 20 Mg Ramipril and 30 Mg nifedipine in a day for 2-3 weeks.
Before, she was 10 Mg Ramipril and 30 Mg nifedipine in a day.

What could be the possible causes for her blood pressure rise and not controlled with 10 Mg Ramipril and 30 Mg nifedipine?

What kind of tests you would suggest for further evaluation?

Thanks again for your time and expert advice.

Best Regards


Hi, here are some informative links http://blog.myheart.net/2013/06/27/hypertension-part-1-the-why/ and http://blog.myheart.net/2013/07/02/hypertension-part-2-treatment-with-lifestyle-

Many people require several medicines to control blood pressure, in fact there is a whole population known as resistant hypertensives who need more than three medicines at optimal doses to control blood pressure.

The most common cause is just essential hypertension, but if people are labeled as resistant hypertensives then there are several secondary causes of hypertension that can be considered such as hyperaldosteronism and renal artery stenosis. Unless there are clear signs of a secondary cause present then at this point, another agent would be added rather than a search for a secondary cause.

Firstly she likely has to have another agent added, preferably a diuretic, and all drugs at optimal doses.  More importantly she needs to make lifestyle changes. Sodium restriction is important as sodium intake can limit the effect of the antihypertensive medications. Exercise is also known to be able to lead to reductions in blood pressure. Finally blood pressure readings should be averaged over several readings and ideally a diary kept to monitor blood pressure and also response to treatment.

Hope that was helpful,

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Mustafa Ahmed MD


Cardiology, Interventional Cardiology, Cardiac Surgery, Hypertension, Pulmonary Embolism, Structural and Valve Disease


Board Certification Internal Medicine and Cardiology Interventional and Structural Cardiology


Multiple Publications In High Quality Peer Reviewed Journals. Internationally Recognized.

MD from The Royal Victoria University of Manchester, England Medicine, Cardiology, Interventional Cardiology, Research Training - University of Alabama

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