ramipril vs moderately high blood pressure. which is worse?

The short version: for moderately high blood pressure, ramipril is probably less harmful than leaving the pressure untreated, but the evidence for its benefit in this specific group is thinner than most doctors will admit.

The evidence you have here is almost entirely about ramipril in people who already have heart disease, heart failure, or a recent heart attack. The 1993 AIRE trial [1] studied patients with acute myocardial infarction and heart failure. The 2000 HOPE trial [3] studied high-risk patients with vascular disease or diabetes plus one other risk factor, not people with moderately high blood pressure alone. The 2016 network meta-analysis [2] looked at heart failure with reduced ejection fraction. None of these answer the question of whether ramipril helps someone whose only problem is moderately high blood pressure.

The CAPPP trial from 1999 [9] is closer. It compared an ACE inhibitor (captopril, not ramipril) to conventional therapy in 11,018 people with diastolic blood pressure at or above 100 mm Hg. The result: no difference in the primary endpoint of fatal and nonfatal heart attack, stroke, or cardiovascular death. The relative risk was 1.05, meaning the ACE inhibitor group did slightly worse, though the result was not statistically significant. Stroke was actually higher in the ACE inhibitor group (relative risk 1.25, p=0.044). The only win was a modest reduction in new diabetes diagnoses.

What this means for you: if you have moderately high blood pressure and no history of heart attack, stroke, or diabetes, the evidence that ramipril will help you live longer or avoid a heart attack is weak. The trials that show benefit were done in sicker people. The one trial that looked at people like you found no benefit and a hint of harm from stroke. The drug also has real side effects: cough, dizziness, kidney function changes, and the risk of angioedema, a potentially life-threatening allergic reaction.

The burden of proof is on the intervention. For a person with moderately high blood pressure and no other risk factors, that burden has not been met. Lifestyle changes, diet, exercise, and weight loss have a stronger evidence base and no drug side effects.

My call: ramipril is not clearly better than no treatment for moderately high blood pressure alone, and the evidence for benefit in this group is absent. Confidence: moderate.