Which condition is a contraindication for starting ramipril in an adult with hypertension?

• A. Bilateral renal artery stenosis
• B. Chronic kidney disease
• C. Hypotension
• D. Pregnancy

Answer: (A)

Blocking angiotensin II with ramipril lowers the pressure inside the glomerulus by dilating the efferent arteriole. In bilateral renal artery stenosis, both kidneys rely on angiotensin II to maintain glomerular filtration. If this mechanism is blocked, GFR can fall sharply, risking acute kidney injury or renal failure. That makes starting ramipril a clear contraindication in this setting.

Pregnancy is also a contraindication because ACE inhibitors can cause fetal harm, but in the context provided—the adult with hypertension—the most direct absolute contraindication due to hemodynamic risk is bilateral renal artery stenosis. Hypotension or chronic kidney disease require careful consideration and monitoring rather than an outright prohibition; they are contexts where ACE inhibitors can sometimes be used with caution, depending on the specifics of the case.