ACE Inhibitors


Article Author:
Amandeep Goyal
Austin Cusick


Article Editor:
Blair Thielemier


Editors In Chief:
Sherri Murrell


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
11/5/2019 7:51:13 AM

Indications

FDA approved

  1. Angiotensin-converting enzyme (ACE) inhibitors are useful as adjunctive therapy in systolic heart failure (HF). HF guidelines recommend ACE inhibitors to help prevent HF in patients with a reduced ejection fraction (EF) who also have a history of myocardial infarction (MI), to prevent HF in any patient with a reduced ejection fraction or to treat patients with HF and reduced EF.
  2. ACE inhibitors can be used for the treatment of hypertension (HTN) either alone or in conjunction with other antihypertensives in adults or children greater than six years old. Hypertension guidelines recommend the initiation of ACE inhibitors for the management of HTN to lower blood pressure (BP). Treatment recommendations in the following populations according to the American College of Cardiology are[1]:
  • Patients with daytime BP out of the office at greater than135 mmHg systolic or greater than 85 mmHg diastolic; this is substitutable with office blood pressure readings of over140/90 mmHg
  • Patients with an in-office or out of office BP exceeding 130 mmHg systolic or over 80 mmHg diastolic and the addition of the following factors
    • History of cardiovascular disease
    • Type 2 diabetes mellitus
    • Chronic kidney disease
    • Age 65 or older
  1. Patients with chronic kidney disease (CKD) and HTN:
  • Regardless of race or diabetes status, ACE inhibitors are recommended as initial therapy to improve kidney outcomes.
  • In the non-Black population with diabetes and without CKD, initial antihypertensive therapy should include either thiazide diuretic, calcium channel blocker (CCB), ACE inhibitor, or angiotensin receptor blocker (ARB).
  • In the Black population with diabetes and without CKD, initial antihypertensive therapy should include either a thiazide diuretic or CCB instead of an ACE inhibitor or ARB.
  1. Patients with coronary artery disease (CAD) and HTN:
  • ACE inhibitors are recommended as part of a regimen in patients with HTN and chronic stable angina if there is a history of left ventricular dysfunction, diabetes, or CKD.
  1. Patients with ST-elevated myocardial infarction (STEMI):
  • ACE inhibitors should be initiated within 24 hours of all STEMI, specifically in patients with anterior MI, heart failure, or left ventricular (LV) ejection fraction (EF) of 40% or less.

ACE inhibitors show efficacy in treatment due to the overall reduction of mortality in multiple patient disease states. There is evidence of mortality benefit in patients with hypertension, heart failure, Acute MI, and diabetes.[2][3][4][3]

Non-FDA approved

May delay the progression of nephropathy and reduce the risks of cardiovascular events in hypertensive patients with diabetes type I and type II. The addition of an ace inhibitor has shown a significant reduction in serum creatinine in both hypertensive patients and normotensive patients with albuminuria. Therapy has shown a significant decrease in the progression of diabetic nephropathy.[5][6]

Mechanism of Action

ACE is involved in the renin-angiotensin system (RAS) and stimulates the conversion of angiotensin I to angiotensin II. ACE inhibitors are competitive inhibitors of ACE, which prevents the conversion of angiotensin I to angiotensin II. Angiotensin II acts as a potent vasoconstrictor that, when inhibited, can reduce blood pressure by dilating vessels and decreasing aldosterone secretion.[7][2][3]

It is essential to understand the role of the RAS hormonal system in depth to appreciate the therapeutic effects of ace inhibitors and understand why this is a target for hypertensive therapy. Initially, afferent arteriole juxtaglomerular cells synthesize prorenin, which is actively cleaved to renin. Angiotensinogen produced from the liver is then cleaved by renin to form angiotensin I. The angiotensin I molecule is converted to angiotensin II by ACE. Angiotensin II is the molecule that has significant actions on various systems. Initially, Angiotensin II induces vasoconstriction, which ultimately increases systemic blood pressure.[8] Even further, Angiotensin II stimulates the adrenal cortex and the pituitary to produce Aldosterone and Anti-diuretic hormone (ADH), respectively. Aldosterone induces sodium reabsorption and, in turn, water reabsorption through internal mineralocorticoid receptor activity [9][10]; ADH increases the synthesis of aquaporin-2 channels in the collecting duct inducing selective reabsorption of water.

Administration

ACE inhibitors are most commonly oral agents, but intravenous forms are available. Medications most commonly end with the suffix -pril. Examples include lisinopril, ramipril, captopril.

Adverse Effects

Most Common Adverse Reactions

  • Dry Cough (10% to 20%)
  • Dizziness (12% to 19%)
  • Hypotension (7% to 11%)
  • Increased BUN and Cr (2% to 11%)
  • Syncope (5% to 7%)
  • Hyperkalemia (2% to 6%)

One percent to 10%: flushing, orthostatic effect, chest pain, altered sense of smell, fatigue, headache, alopecia, diaphoresis, erythema, pruritus, skin photosensitivity, Steven-Johnson Syndrome, toxic epidermal necrolysis, urticaria, diabetes mellitus, gout, SIADH, constipation, diarrhea, dysgeusia, flatulence, pancreatitis, xerostomia, impotence, bone marrow suppression, hemolytic anemia, leukopenia, neutropenia, thrombocytopenia, common cold, weakness, blurred vision, diplopia, photophobia, vision loss, tinnitus, cough.[4][11]

Hypotension can cause intolerance to therapy leading to discontinuation in a small population of patients, which is more common in patients with increased renin baseline levels. Allowing repletion of fluids and discontinuing diuretic medication before therapy can minimize hypotensive episodes.[12]

A slight reduction of glomerular filtration rate (GFR) is common when initiating therapy. GFR reduction can become severe in certain settings and co-morbidities. Patients with diseases affecting renal perfusion can cause further reduction of GFR to a severe level warranting discontinuation. Some co-morbidities can include heart failure, chronic kidney disease, and bilateral renal artery stenosis.[13]

Hyperkalemia from ACE inhibitors is a direct result of the mechanism of action. The blockade of angiotensin II prevents the downstream secretion of aldosterone. Aldosterone causes reabsorption of sodium and, subsequently, water. Consequently, protons and potassium get secreted into the urine. Without the secretion of potassium through aldosterone, potassium can easily increase in patients on ACE inhibitors.[14] Co-morbidities that decrease kidney function or medications that cause potassium retention increases the risk of hyperkalemia.

Commonly, patients on ACE inhibitors have reported dry cough between the one week of initiation up to six months, with some sources citing up to one year after initiation. Discontinuing therapy usually resolves the cough 1 to 4 days after but can be prolonged up to a month.[15] The concern for dry cough with therapy initiation is a decrease in compliance. Additionally, there is an increased propensity to develop bronchospasm in these patients.[16] ACE metabolizes bradykinin and other local molecules. Inhibiting ACE in the lung increases the concentration of kinins, causing bronchial irritation.[17] After discontinuation of ACE therapy, an angiotensin receptor blocker (ARB) can initiate as an alternate therapy. ARB’s have a lower incidence of cough recurrence compared to reinitiating ACE therapy.[18] If cough recurs on ARB therapy, switch to a different class entirely.

Angioedema is a rare but potentially life-threatening side effect of ACE inhibitor use. The side effect is a swelling of the face, lips, and upper airway in an episodic nature. The inflammation creates difficulty in the patient’s ability to maintain an airway; therefore, endotracheal intubation is necessary to secure the airway. The mechanism of angioedema is thought to be through an extensive accumulation of bradykinins in select individuals. Bradykinin induces prominent vasodilation and plasma extravasation into the local tissue. The primary treatment of ACE inhibitor-induced angioedema is discontinuation of ACE inhibitor therapy. It is also suggested to avoid ACE inhibitor therapy in individuals with hereditary angioedema or a history of angioedema episodes.

Any Injury

Less than 1%: Acute renal failure, anaphylactoid reactions, angioedema, anuria, arthralgia, arthritis, asthma, ataxia, azotemia, bronchitis, bronchospasm, cardiac arrest, cardiac arrhythmia, cerebrovascular accident, chills, confusion, cutaneous pseudolymphoma, dehydration, drowsiness, dyspepsia, dyspnea, dysuria, eosinophilia, eosinophilic pneumonitis, epistaxis, facial edema, fever, gastritis, hallucination, heartburn, hemoptysis, hepatic necrosis, hepatitis, herpes zoster, hypersomnia, hypervolemia, hypoglycemia, hyponatremia, increased erythrocyte sedimentation rate, insomnia, intestinal angioedema, irritability, laryngitis, leukocytosis, malaise, malignant neoplasm of lung, mastalgia, memory impairment, mood changes, muscle spasm, musculoskeletal pain, myalgia, myocardial infarction, oliguria, orthopnea, orthostatic hypotension, palpitations, paresthesia, paroxysmal nocturnal dyspnea, pemphigus, peripheral edema, peripheral neuropathy, pharyngitis, pleural effusion, pneumonia, positive ANA titer, psoriasis, pulmonary embolism, pulmonary infarct, pulmonary infiltrates, pyelonephritis, rhinitis, rhinorrhea, sinusitis, skin infection, skin lesion, skin rash, sore throat, systemic lupus erythematosus, transient ischemic attacks, tremor, uremia, urinary tract infection, vasculitis, vertigo, viral infection, visual hallucination, weight gain, weight loss, wheezing.

Pregnancy

The use of drugs that inhibit the renin-angiotensin system correlates with teratogenic effects such as oligohydramnios, decreased fetal renal function, anuria, renal failure, skull hypoplasia, and death.

The proposed mechanism behind oligohydramnios is evident at the level of the fetal kidney. The low-pressure hemodynamics of the fetus becomes easily disrupted with a decreased amount of angiotensin II. Fetal renal pressure becomes lower, reducing the ability to maintain GFR, leading to oligohydramnios and anuria.[19]

Contraindications

ACE inhibitors are contraindicated in a patient with a history of hypersensitivity to any ACE inhibitor or component of the formulation, angioedema related to previous treatment with ACE inhibitor, idiopathic or hereditary angioedema, or current use of aliskiren in a patient with diabetes mellitus. Also, consider drugs with cross-reactivity with ACE inhibitors.[20][21]

ACE inhibitors are not recommended in pregnant patients and require discontinuation as soon as pregnancy is detected.

Relative ContraindicationsUse with great caution in the following situations:

  • Patients with abnormal renal function. ACE inhibitors can cause elevation of potassium and worsen renal function in patients already on ACE inhibitors. If the patient has an abnormal but stable renal function, close monitoring is required while he or she is on an ACE inhibitor. If the renal function starts to decline, the clinician should discontinue the ACE inhibitor immediately.
  • Patients with aortic valve stenosis should not be administered afterload reducers like ACE inhibitors because it can lead to severe hypotension.
  • Similarly, patients who are dehydrated or have hypovolemia should not receive treatment with ACE inhibitors.

Monitoring

Typical parameters to monitor are BUN, serum creatinine, renal function, WBC, and potassium. If a patient has collagen vascular disease and/or renal impairment, periodically monitor complete blood count with differential to evaluate kidney erythropoietin production. In patients with hypotensive effects within 1 to 3 hours of initial dose or with increased dosages or preexisting hepatic impairment, consider baseline hepatic function tests. A white and red blood cell counts are necessary to evaluate for rare side effects of anemia, neutropenia, agranulocytosis, and thrombocytopenia.

Toxicity

When used at therapeutic doses, the risk of toxicity is rare. Toxicity is more likely when the drug is used in combination or at supratherapeutic doses.

When combining ACE inhibitors with other antihypertensive drugs, they have the potential to increase side effects like hyperkalemia, hypotension, and renal failure. One should pay more attention when the patient is given an ACE inhibitor and is already on a potassium-sparing diuretic, NSAIDs, cyclosporine, and anticoagulants.

All the presently available ACE inhibitors have similar antihypertensive effects at equivalent doses. The only ACE inhibitor that is different is captopril. This agent has a short duration of action and is more likely to induce side effects. It is the only ACE inhibitor to penetrate the blood-brain barrier and potentially cause confusion and lethargy.

Enhancing Healthcare Team Outcomes

Clinicians widely use ACE inhibitors in medicine for the treatment of hypertension, heart failure, and patients with chronic kidney disease. While effective, healthcare workers (nurse practitioners, physicians, and pharmacists) who prescribe these agents should be aware of their side effects and limitations. Patients also need to be monitored for their renal function and electrolyte levels regularly. Finally, the healthcare worker should be aware that these agents can produce a chronic dry cough, and the clinician should try another class of antihypertensive medication.[7][22][23][24]

Even though ACE inhibitors are among the oldest drug classes available, there is a threat that familiarity can lead to carelessness. That is why, like any other drug, these agents require the oversight and coordination of an interprofessional team. Pharmacists need to verify that dosing is appropriate, and check for drug interactions. Nursing will monitor and for female patients, emphasize that if they think they are pregnant or trying to get pregnant, that therapy will need to change to accommodate that. Nursing will also be taking blood pressure at every visit, and charting so the prescriber can determine if dosing or other changes may be for hypertensive control. The physician must remain informed by these findings from the other members of the interprofessional healthcare team, so he can take corrective action if necessary. Communication and collaboration among healthcare team members will make ACE inhibitor therapy more effective, leading to better patient outcomes. [Level V]


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ACE Inhibitors - Questions

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Which of the following is a common adverse effect of ACE inhibitors that leads to switching the drug to an angiotensin II receptor blocker?



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You are counseling a patient on eating a healthy diet to maintain his blood pressure, and notice that he is taking lisinopril, an angiotensin-converting enzyme inhibitor. What result will this medication have on his angiotensin I and angiotensin II levels?



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What is the peptide that has been linked to the vasodilatation caused by angiotensin-converting enzyme inhibitors?



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A patient on a thiazide has now become diabetic. Which of the following should now be used to treat the high blood pressure?



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What can be caused by ACE inhibitors when prescribed to patients with congestive heart failure?



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A 53-year-old male has diabetes mellitus. Over the past few visits you have noticed he has become hypertensive, and after a discussion with the patient, lisinopril is started. What effect would this have on the patient's urine sodium and potassium levels?



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Which is a contraindication for use of ACE inhibitors?



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What class of antihypertensive drug is lisinopril?



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Which of the following is not a function of ACE inhibitors?



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Angiotensin-converting-enzyme inhibitors can cause which of the following electrolyte imbalances?



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Which of the following drugs is found to be beneficial in delaying the progression of renal damage in patients with diabetes mellitus?



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Which of the following medications is contraindicated in females who are pregnant?



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Which of the following statements correctly describes the physiological action of ACE inhibitors?



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Select the medication that would be best for decreasing afterload due to a reduction in vascular resistance.



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A 62-year-old female with diabetes mellitus (DM) type 2 on metformin reports that her blood sugar is almost always in the 100's. Her hemoglobin A1c is 5.9 percent and her blood pressure is 145/95 mm Hg. Physical exam was normal including peripheral pulses, peripheral nerves, and the retina. Which of the following would be most appropriate?



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Which of the following medications is contraindicated to treat hypertension in pregnancy?



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What should be done for a female patient with chronic hypertension that is well controlled with her ACE inhibitor in pregnancy?



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What is not a teratogenic effect of ACE inhibitors?



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Which of following medications is the most beneficial to protect against renal failure in patients with diabetes mellitus?



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How do angiotensin converting enzyme (ACE) inhibitors decrease blood pressure?



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A patient was recently started on a new drug and his serum creatinine level started to increase. Which drug most likely caused a rise in serum creatinine levels?



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You have a patient with type 2 diabetes in the clinic and would like to start the patient on an angiotensin-converting enzyme inhibitor (ACE inhibitor). According to the National Diabetes Education Program, which one of the following groups of diabetic patients should receive this drug?



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You have a middle-aged patient with diabetes who has just been diagnosed with hypertension. His BUN is 10 and creatinine is 1.4, and you decide to start him on antihypertensive pharmacotherapy. Based on large epidemiology studies, 20% of patients will develop a dry, non-productive cough on the agent you chose. Which of the following drugs is the most likely antihypertensive agent?



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You have a middle-aged patient with diabetes and recently diagnosed hypertension, who was started on ramipril about a month ago. Which of the following is true about the medication class of which ramipril is a member?



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Which of the following represents a commonly encountered side effect when taking an ACE inhibitor?



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A 56-year-old male presents to the emergency department with crushing substernal chest pain, diaphoresis, and pain in his jaw and left arm. Troponin levels are elevated. After appropriate management, the patient is stabilized and eventually gets discharged from the hospital. He is placed on ACE inhibitors. Which of the following is expected?



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ACE Inhibitors - References

References

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