Updated: 1/17/2021

ACE Inhibitors

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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
    • myocardial infarction
      • 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
    • hyponatremia
    • metabolic acidosis
    • hypotension
  • Medications
    • captopril
    • lisinopril
    • enalapril
    • ramipril
 

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Questions (10)
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(M1.RL.17.4768) 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? Tested Concept

QID: 109082
1

Distal convoluted tubule

8%

(15/185)

2

Juxtaglomerular cells

13%

(24/185)

3

Afferent arteriole

13%

(24/185)

4

Efferent arteriole

57%

(106/185)

5

Collecting duct

5%

(10/185)

M 1 C

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(M1.RL.15.20) 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? Tested Concept

QID: 105630
FIGURES:
1

Lisinopril

41%

(48/118)

2

Furosemide

17%

(20/118)

3

Hydrochlorothiazide

19%

(22/118)

4

Nifedipine

14%

(16/118)

5

Hydralazine

8%

(9/118)

M 1 B

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(M1.RL.14.75) 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? Tested Concept

QID: 106863
1

Renal afferent arteriole vasoconstriction; decreased GFR

29%

(20/70)

2

Renal afferent arteriole vasodilation; increased GFR

3%

(2/70)

3

Renal efferent arteriole vasoconstriction; increased GFR

13%

(9/70)

4

Renal efferent arteriole vasodilation; decreased GFR

53%

(37/70)

5

Renal efferent arteriole vasodilation; no change in GFR

1%

(1/70)

M 4 D

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(M1.RL.14.22) 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? Tested Concept

QID: 104233
FIGURES:
1

Inhibition of angiotensin-converting enzyme

71%

(61/86)

2

Inhibition of HMG-CoA reductase

13%

(11/86)

3

Stimulation of the Beta 2 receptor

2%

(2/86)

4

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

10%

(9/86)

5

Inhibition of voltage-dependent L-type calcium channels

2%

(2/86)

M 1 D

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(M1.RL.13.10) 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? Tested Concept

QID: 100964
1

Furosemide

3%

(4/123)

2

Metoprolol

2%

(2/123)

3

Amiodarone

8%

(10/123)

4

Digoxin

3%

(4/123)

5

Lisinopril

82%

(101/123)

M 3 E

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(M1.RL.13.82) 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? Tested Concept

QID: 100598
1

Aspirin

0%

(0/44)

2

Lisinopril

95%

(42/44)

3

Hydrochlorothiazide

2%

(1/44)

4

Metoprolol

0%

(0/44)

5

Nifedipine

2%

(1/44)

M 3 E

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(M1.RL.12.246) 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? Tested Concept

QID: 100762
1

Bradykinin increase; angiotensin II decrease

81%

(57/70)

2

Renin decrease; angiotensin 1 increase

1%

(1/70)

3

Aldosterone increase; bradykinin decrease

4%

(3/70)

4

Renin decrease; angiotensin II increase

6%

(4/70)

5

Angiotensin II increase; bradykinin decrease

6%

(4/70)

M 1 E

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Evidence (12)
Topic COMMENTS (3)
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