Presented by:Nuthan Y12PHD0430

ACE Inhibitors ACE Inhibitors are medications that belong in the

class of medications known as antihypertensive medications.

ACE Inhibitors work on the Renin-Angiotensin-Aldosterone System

Renin-Angiotensin-Aldosterone System A system which works to increase blood pressure

when the pressure within the kidneys drops. As a result of low blood pressure and/or oxygenation

in the nephron, renin is released from the juxtaglomerular cells.

Renin travels to the liver via the cardiovascular system and combines with angiotensinogen to form angiotensin I.

Angiotensin I travels through the cardiovascular system and arrives at the lungs where it is changed into Angiotensin II.

The alveoli use Angiotensin Converting Enzyme also known as kinase II to cause this conversion.

Renin-Angiotensin-Aldosterone System cont.

Angiotensin II is a powerful vasoconstrictor which causes a rise in peripheral resistance and increases pressure.

Angiotensin II works to increase the release of aldosterone from the adrenal glands.

Aldosterone causes renal retention of sodium and water, which further increases blood pressure by increasing volume.

Mechanism of Action for ACE Inhibitors ACE Inhibitors work in the lungs to inhibit

Angiotensin Converting Enzyme from turning Angiotensin I into Angiotensin II.

These medications cause an increase of bradykinin, which inhibits kinase II, another name for Angiotensin Converting Enzyme.

Blood Pressure is decreased due to a decrease in blood volume, peripheral resistance, and cardiac load.

ACE Inhibitors, inhibit vasoconstriction and release of aldosterone which inhibits the retention of sodium and water.

Indications For Use Hypertension-used especially for malignant

hypertension and hypertension secondary to renal arterial stenosis.

Benefits of Using an ACE Inhibitor as they:

Do not interfere with cardiovascular reflexes

Do not interfere with patients who have asthma, like beta-blockers do.

Do not decrease potassium levels.

Do not cause lethargy, weakness and sexual dysfunction.

“ACE inhibitors reduce the risk of cardiovascular mortality caused by hypertension.”

Indications For Use cont. Heart Failure

By decreasing arteriolar tone region blood flow to the heart improves.

By decreasing afterload, cardiac output increases.

Venous dilation increases causing a decrease in pulmonary congestion and peripheral edema.

Dilates the vessels of the kidneys increasing renal flow and helps to excrete sodium and water. This helps to decrease edema and blood volume.

Prevents pathologic changes in the heart that result from reducing the angiotensin II levels in the heart.

Indications For Use cont. Myocardial Infarction (MI)

Decreases the chance of heart failure after an MI.

Should be given for 6 weeks post MI. If heart failure occurs it should be considered for permanent use.

Nephropathy Slows renal disease of diabetic or nondiabetic origins

Decreases glomerular filtration pressure.

Indications For Use cont. Type 2 Diabetes

Decreases morbidity in high risk patients.

Increased levels of angiotensin II have a correlation to type 2 diabetes.

ACE inhibitors increase kinin levels, which increase production of prostaglandins and nitric oxide.

Prostaglandins and nitric oxide improve muscular sensitivity to insulin.

May preserve pancreatic function and prevent onset of diabetes especially with people who have hypertension.

Common Trade NamesGeneric Name Trade Name

benazepril

captopril

enalapril

enalaprilat

fosinopril

lisinopril

moexipril

perinodopril

quinapril

ramipril

Lotensin

Capoten

Vasotec

Vasotec IV

Monopril

Prinivil, Zestril

Univasc

Aceon

Accupril

Altace

Benazepril: 10 mg once daily in patients initial dose (not on a diuretic). Usual dose: 20-40 mg in a single or 2 divided doses.

Captopril: HFrEF (Heart failure with reduced ejection fraction)/ HTN/Left ventricular dysfunction after myocardial infarction (LVD after MI): 6.25-12.5 mg three times a day (with diuretic) with goal of 50 mg three times a day for HFrEF. Diabetic nephropathy: 25 mg three times a day.

Enalapril: HFrEF/HTN: 2.5-5 mg once or twice daily, increased up to 40 mg/day every 1-2 weeks in 2.5 mg intervals. IV : 1.25 mg/dose every 6 hours

Fosinopril: HFrEF/HTN: 10 mg daily initially, then titrate to effect (max dose 40 mg daily). Usual dose: 20-40 mg daily.

Moexipril: Hypertension: 7.5 mg once daily (not on a diuretic) or 3.75 mg once daily (when combined with a diuretic). Administer 1 hr prior to meal. Maintenance: 7.5-30 mg daily in 1-2 divided doses

Perindopril: HTN: Initial: 4 mg daily; titrate to desired effect every 1-2 weeks to a max dose of 16 mg/day. Usual dose 4-8 mg/day in 2 divided doses. Stable coronary artery disease (CAD): Initial: 4 mg once daily for 2 weeks then increase to 8 mg once daily as tolerated.

Quinapril: HTN: 10-20 mg daily initially. Initial dose may be reduced to 5 mg daily (if patient on a diuretic). Range: 10-40 mg once daily. HFrEF: 5 mg once or twice daily; titrate to desired effect every week to a dose of 20-40 mg daily in 2 divided doses.

Lisinopril: HTN: Initial 10 mg daily (no diuretic) or 5 mg daily (if on diuretic). Dose range: 10-40 mg daily. HFrEF: Initial: 2.5-5 mg once daily; titrate by 10 mg increments every 2 weeks to target of 20-40 mg/day. Acute MI: 5mg immediately, uptitratedto 10mg daily

Ramipril: HTN: 2.5-5 mg once daily (max dose of 20 mg/day). Left ventricular dysfunction (LVD) post-MI: 2.5 mg twice-daily; titrate to 5 mg twice daily as tolerated. Reduced risk of stoke, MI and death Initial: 2.5 mg once daily for first week, then 5 mg once daily for weeks 2-4, then titrate to 10 mg once daily as tolerated.

Trandolapril: CHF/LVD Initial: 1 mg/day, titrate to 4 mg/day as tolerated. HTN: 1 mg/day initially (may use 2 mg/day in black patients) max dose=8mg/day; titrate to desired effect in 1 week intervals.

Side effects: Altered sense of taste (Metallic taste)

Allergic skin rashes

Fatigue

Dizziness

Dry cough

Headaches

Adverse Effects First-Dose Hypotension

Usually occurs with initial dose.

Worse in patients with severe hypertension, or are on diuretics, or are sodium or volume depleted.

Cough “Persistent, dry, irritating, nonproductive cough can

develop with all ACE inhibitors.”

Due to rise in bradykinin which occurs due to inhibition of kinase II.

Occurs in 5-10% of patients and is more common in women and the elderly.

Adverse Effects cont. Hyperkalemia

Potassium levels rise due to the inhibition of aldosterone, which causes potassium to be retained by the kidneys.

Renal Failure Can cause renal insufficiency in people who have bilateral

renal artery stenosis, because dropping the pressure in the renal arteries in these patients can cause glomerularfiltration to fail.

Fetal Injury (Teratogenicity) In the second and third trimesters a fetus can experience

hypotension, hyperkalemia, skull hypoplasia, renal failure, and death. Recent evidence also implies 1st trimester exposure has increased teratogenic risk.

Drug Interactions Antihypertensive agents

Can cause an increased effect of medications especially with diuretics.

Potassium increasing medications Cause an increased risk of hyperkalemia due to the

suppression of aldosterone. (ACEIs, NSAIDs, ARBs &Potassium-sparing diuretics )

Lithium Increases to risk of lithium toxicity.

Allopurinol Increases hypersensitivity to medication

NSAIDS (Ibuprofen, Naproxen) Reduce antihypertensive effects of medication.

Considerations Encourage lifestyle changes

Weight loss Quit smoking Decrease alcohol intake Encourage exercise to help lower blood pressure

Monitor Renal Function BUN, Creatinine, and Potassium levels

Monitor for decreased fluid volume which can bottom our blood pressure

Excessive sweating Diarrhea Vomiting Dehydration

Considerations cont. Monitor for 1st-dose hypotension

May have to stop other antihypertensive medications at initiation of ACE inhibitors.

May have to give these medications in lower doses going forward.

Discontinue diuretics for 2-3 days prior to starting an ACE inhibitor.

Monitor BP for several hours and if patient becomes hypotensive lay patient supine and consider discussing IV bolus of saline with the MD.

Educate Patient Educate the patient about the medication including name

adverse effects, drug interactions. Educate the patient about the signs of hypotension,

hyperkalemia, and renal failure. If patient is taking lithium discuss the signs of lithium toxicity.

References Karch, A. (2011). Focus on nursing pharmacology (5th

ed.). Philadephia, PA: Wolters Kluwer | Lippincott Williams & Wilkins.

Lehne, R. (2007). Pharmacology for nursing care (6th ed.). St. Louis, MO: Saunders|Elsevier.

Solski, L. V. & Longyhore. (2008). Prevention of type 2 diabetes mellitus with angiotensin-converting-enzyme inhibitors. American Journal of Health-System Pharmacy, 65(10): 935-40.

Waterfield, J. (2008). ACE inhibitors: use, action, and prescribing rationale. Nurse Prescribing, 6(3): 110-4.

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