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Updated: Jan 17 2021

ACE Inhibitors

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