Updated: 6/22/2018

ACE Inhibitors

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Questions
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Evidence
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Snapshot
  • A 67-year-old Caucasian man presents to his primary care physician for follow-up of his hypertension. He was recently started on a lisinopril for chronic hypertension. He has been monitoring his blood pressure at home and they have all been within the normal range. However, he reports a new cough that began a few days after starting lisinopril.
Introduction
 

 
  • Mechanism of action
    • inhibits angiotensin-converting enzyme (ACE)
      • ↓ angiotensin II (AT II)
        • recall that AT II increases blood pressure by constricting renal and peripheral vasculature and increasing sodium reasorption in the kidney
        • ↓ AT II prevents constriction of efferent arterioles and ↓ glomerular filtration rate (GFR)
      • ↓ negative feedback and ↑ renin
      • ↑ bradykinin, a potent vasodilator
        • ACE normally degrades/inactivates bradykinin
  • Clinical use
    • hypertension
      • prevents heart remodeling
    • heart failure (this medication decreases mortality)
    • proteinuria 
    • diabetic nephropathy
  • Toxicity
    • cough
    • angioedema
      • due to ↑ bradykinin
      • contraindicated in patients with C1 esterase inhibitor deficiency
    • teratogenic effects on fetuses
      • disrupts fetal renal development
      • contraindicated in pregnant woman
    • ↑ creatinine (↓ GFR)
      • contraindicated in bilateral renal artery stenosis because ACE inhibitors may further ↓ GFR and cause renal failure 
    • hyperkalemia
    • hypotension
  • Medications
    • captopril
    • lisinopril
    • enalapril
    • ramipril
 

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Questions (10)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M1.RL.4768) A 64-year-old African American female comes to the physician’s office for a routine check-up. The patient’s past medical history is significant for hypertension, diabetes, and osteoarthritis in her right knee. Her medications include metformin, glimepiride, lisinopril, metoprolol, hydrochlorothiazide, and ibuprofen as needed. Her only complaint is an unremitting cough that started about 3 weeks ago and she has noticed some swelling around her mouth. The drug most likely responsible for her recent symptoms most directly affects which part of the kidney? Review Topic

QID: 109082
1

Distal convoluted tubule

8%

(12/142)

2

Juxtaglomerular cells

13%

(19/142)

3

Afferent arteriole

13%

(19/142)

4

Efferent arteriole

56%

(80/142)

5

Collecting duct

6%

(8/142)

M1

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PREFERRED RESPONSE 4
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(M1.RL.20) A 66-year-old male with a history of diabetes, hypertension, and chronic kidney disease presents to the emergency department with severe fatigue, muscle weakness, and palpitations. He states that it seemed to start yesterday and has progressed since that time. The emergency physician obtains an EKG which is demonstrated in Figure A. The patient comments that a few days ago he visited his primary care physician during which some of his blood pressure medications were changed. Which of the following medications was most likely added during that visit? Review Topic

QID: 105630
FIGURES:
1

Lisinopril

40%

(29/72)

2

Furosemide

19%

(14/72)

3

Hydrochlorothiazide

19%

(14/72)

4

Nifedipine

12%

(9/72)

5

Hydralazine

7%

(5/72)

M1

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PREFERRED RESPONSE 1

(M1.RL.246) A physician is choosing whether to prescribe losartan or lisinopril to treat hypertension in a 56-year-old male. Relative to losartan, one would expect treatment with lisinopril to produce which of the following changes in the circulating levels of these peptides? Review Topic

QID: 100762
1

Bradykinin increase; angiotensin II decrease

100%

(16/16)

2

Renin decrease; angiotensin 1 increase

0%

(0/16)

3

Aldosterone increase; bradykinin decrease

0%

(0/16)

4

Renin decrease; angiotensin II increase

0%

(0/16)

5

Angiotensin II increase; bradykinin decrease

0%

(0/16)

M1

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PREFERRED RESPONSE 1

(M1.RL.75) A 46-year-old woman with a history of type II diabetes mellitus is started on lisinopril for newly diagnosed hypertension by her primary care physician. At a follow-up appointment several weeks later, she reports decreased urine output, and she is noted to have generalized edema. Her creatinine is elevated compared to baseline. Given her presentation, which of the following changes in renal arteriolar blood flow and glomerular filtration rate (GFR) have likely occurred? Review Topic

QID: 106863
1

Renal afferent arteriole vasoconstriction; decreased GFR

14%

(2/14)

2

Renal afferent arteriole vasodilation; increased GFR

0%

(0/14)

3

Renal efferent arteriole vasoconstriction; increased GFR

29%

(4/14)

4

Renal efferent arteriole vasodilation; decreased GFR

50%

(7/14)

5

Renal efferent arteriole vasodilation; no change in GFR

0%

(0/14)

M1

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PREFERRED RESPONSE 4

(M1.RL.22) A 47-year-old female with a history of mild asthma, type II diabetes, hypertension, and hyperlipidemia presents to clinic complaining of swelling in her lips (Image A). She has had no changes to her medications within the past two years. Vital signs are stable. Physical exam is notable for significant erythema around and swelling of the lips. The remainder of her exam is unremarkable. What is the mechanism of action of the drug that has caused her current symptoms? Review Topic

QID: 104233
FIGURES:
1

Inhibition of angiotensin-converting enzyme

60%

(6/10)

2

Inhibition of HMG-CoA reductase

20%

(2/10)

3

Stimulation of the Beta 2 receptor

0%

(0/10)

4

Inhibition of the Na/K/Cl triple transporter of the thick ascending limb

10%

(1/10)

5

Inhibition of voltage-dependent L-type calcium channels

10%

(1/10)

M1

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PREFERRED RESPONSE 1

(M1.RL.10) A 58-year-old male with a history of congestive heart failure and hypertension comes to you with the chief complaint of new-onset cough as well as increased serum potassium in the setting of a new medication. Which of the following medications is most likely responsible for these findings? Review Topic

QID: 100964
1

Furosemide

4%

(3/80)

2

Metoprolol

2%

(2/80)

3

Amiodarone

10%

(8/80)

4

Digoxin

2%

(2/80)

5

Lisinopril

79%

(63/80)

M1

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PREFERRED RESPONSE 5

(M1.RL.82) A 78-year-old Caucasian male actor presents to your office complaining of a dry, non-productive cough. He has a history of hypertension, diabetes, and coronary artery disease and he follows a complicated regimen of medications to treat his multiple co-morbidities. Which of the following medications is most likely to be associated with his chief complaint? Review Topic

QID: 100598
1

Aspirin

0%

(0/14)

2

Lisinopril

93%

(13/14)

3

Hydrochlorothiazide

0%

(0/14)

4

Metoprolol

0%

(0/14)

5

Nifedipine

7%

(1/14)

M1

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PREFERRED RESPONSE 2
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