Review Question - QID 100606

The patient in this vignette should be started on an ACE inhibitor. First-dose hypotension is an adverse effect that can be seen when patients begin antihypertensive therapy with an ACE inhibitor.

ACE inhibitors are commonly used antihypertensive medications for patients with essential hypertension, diabetes, and post-MI patients. Caution must be taken with patients beginning ACE inhibitor therapy, as they have been known to cause first-dose hypotension, especially in individuals with hyponatremia and/or hypovolemia secondary to diuretics, low baseline blood pressure, high renin or aldosterone levels, renal impairment, or heart failure. It is important to screen for other blood pressure lowering medications in individuals being started on an ACE inhibitor.

Hall et al. discuss secondary prevention of coronary artery disease (CAD). In individuals who have had an MI or revascularization procedure, treatment of high blood pressure and dyslipidemia has been shown to reduce morbidity and mortality. ACE inhibitors have been shown to decrease cardiac events in this patient population.

Vítovec et al. discuss first-dose hypotension with ACE inhibitors. The incidence has been found to vary between 0.7-13.3%. To minimize this risk, the prescribing physician should consider titration techniques. Moreover, it has been found that specific ACE inhibitors seem to cause first-dose hypotension more consistently than others. Perindopril or fosinopril have been shown to have the most modest decrease in BP.

Illustration A depicts the mechanism of ACE inhibitors.
Illustration B demonstrates a diagram of the temporal monitoring of ACE inhibitors.

Incorrect Answers:
Answers 1,3-5: These effects are not considered to be adverse risks of ACE inhibitors that the patient should be made aware of prior to starting therapy.