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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