Ramipril for the Treatment of COVID-19: RAMIC, a Randomized, Double-Blind, Placebo-Controlled Clinical Trial

INTRODUCTION

Retrospective studies report that angiotensin-converting enzyme inhibitors (ACEIs) may reduce the severity of COVID-19, but prospective data on de novo treatment with ACEIs are limited. The RAMIC trial was a randomized, multicenter, placebo-controlled, double-blind, allocation-concealed clinical trial to examine the efficacy of de novo ramipril versus placebo for the treatment of COVID-19.

METHODS

Eligible participants were aged 18 years and older with a confirmed diagnosis of SARS-CoV-2 infection, recruited from urgent care clinics, emergency departments, and hospital inpatient wards at eight sites in the USA. Participants were randomly assigned to daily ramipril 2.5 mg or placebo orally in a 2:1 ratio, using permuted block randomization. Analyses were conducted on an intention-to-treat basis. The primary outcome was a composite of mortality, intensive care unit (ICU) admission, or invasive mechanical ventilation by day 14.

RESULTS

Between 27 May 2020 and 19 April 2021, a total of 114 participants (51% female) were randomized to ramipril (n = 79) or placebo (n = 35). The overall mean (± SD) age and BMI were 45 (± 15) years and 33 (± 8) kg/m2. Two participants in the ramipril group required ICU admission and one died, compared with none in the placebo group. There were no significant differences between ramipril and placebo in the primary endpoint (ICU admission, mechanical ventilation, or death) (3% versus 0%, p = 1.00) or adverse events (27% versus 29%, p = 0.82). The study was terminated early because of a low event rate and subsequent Emergency Use Authorization of therapies for COVID-19.

CONCLUSION

De novo ramipril was not different compared with placebo in improving or worsening clinical outcomes from COVID-19 but appeared safe in non-critically ill patients with COVID-19.

TRIAL REGISTRATION

Clinicaltrials.gov NCT04366050.

Abstract P254: Hypertension: A proposed Mechanistic Pathway for Arterial System Remodeling

Arterial properties change during hypertension (HTN) development. The time course of the changes can be used as a marker of vascular remodeling in the development of HTN.

Study Aim: To determine whether pressure induced changes in vascular properties result in alterations in pressure-flow patterns that impact the load for ventricular function: input & characteristic impedance, A rterial C ompliance (AC)= SV/PP (stroke volume)/(pulse pressure), AC=Tau/peripheral resistance (PR), and PP were investigated.

Methods: Pressure and flow relations were investigated in dogs during the development of renal-HTN over 4-weeks (Wks). The sensitivity of hemodynamic markers of vascular remodeling was evaluated by changes in AC= SV/PP, and by AC= Tau/PR and PP.

Results: All BP components increased during the development of HTN. Changes in Input Impedance, increased through Wks 2 to 4. Increases in the steady component of the cardiac cycle were reflected by peripheral PR, and changes in the pulsatile component were reflected by changes in AC=SV/PP, and AC=Tau /RP; and changes in characteristic impedance. PP and PAP increased by Week 2, reflection of the cardiac and arterial workloads and vascular Tension RP that progressed through Wk 4

Conclusion: Reliable and accessible markers that indicate changes in arterial pressure, flow & volume, are: PP and AC (SV/PP), and AC (Tau /TPR). These variables detected increases in the heart-load and alterations in pressure-flow patterns that impair cardiovascular-function resulting in HTN-CVD; input and characteristic impedance, also provides remodeling information about the arterial system but are not readily available to clinicians.