1. SUNY Empire State College Jason Gabari RN PCCN

2. Learning Objectives Discuss the reason for using ACE Inhibitors and themechanism by which they work. Identify three common adverse effects of using ACEInhibitors. Identify three considerations for educating a patienton the use of ACE Inhibitors 3. ACE Inhibitors ACE Inhibitors are medications that belong in theclass of medications known as antihypertensivemedications. ACE Inhibitors work on the Renin-Angiotensin-Aldosterone System 4. Renin-Angiotensin-Aldosterone System A system which works to increase blood pressure when thepressure within the kidneys drops. As a result of low blood pressure and/or oxygenation in thenephron, renin is released from the juxtaglomerular cells. Renin travels to the liver via the cardiovascular system andcombines with angiotensinogen to form angiotensin I. Angiotensin I travels through the cardiovascular systemand arrives at the lungs where it is changed intoAngiotensin II. The alveoli use Angiotensin Converting Enzyme alsoknown as kinase II to cause this conversion.(Karch, 2012, pg. 671) 5. Renin-Angiotensin-Aldosterone System cont. Angiotensin II is a powerful vasoconstrictor whichcauses a rise in peripheral resistance and increasespressure. Angiotensin II works to increase the release ofaldosterone from the adrenal glands. Aldosterone causes renal retention of sodium andwater, which further increases blood pressure byincreasing volume. (Karch, 2012, pg. 671) 6. Mechanism of Action for ACE Inhibitors ACE Inhibitors work in the lungs to inhibitAngiotensin Converting Enzyme from turningAngiotensin I into Angiotensin II. These medications cause an increase ofbradykinin, which inhibits kinase II, another name forAngiotensin Converting Enzyme. (Lehne, 2007, pg.464) Blood Pressure is decreased due to a decrease in bloodvolume, peripheral resistance, and cardiac load. ACE Inhibitors, inhibit vasoconstriction and release ofaldosterone which inhibits the retention of sodiumand water. 7. Indications For Use Hypertension-used especially for malignant hypertension and hypertension secondary to renal arterial stenosis. Benefits of Using an ACE Inhibitor Do not interfere with cardiovascular reflexes Do not interfere with patients who have asthma like beta-blockers Do not decrease potassium levels. Do not cause lethargy, weakness and sexual dysfunction. ACE inhibitors reduce the risk of cardiovascular mortalitycaused by hypertension. (Lehne, ,2007, pg. 465) 8. Indications For Use cont. Heart Failure By decreasing arteriolar tone region blood flow to the heartimproves. By decreasing afterload, cardiac output increases. Venous dilation increases causing a decrease in pulmonarycongestion and peripheral edema. Dilates the vessels of the kidneys increasing renal flow andhelps to excrete sodium and water. This helps to decreaseedema and blood volume. Prevents pathologic changes in the heart that result fromreducing the angiotensin II levels in the heart.(Lehne, 2007, pg. 465) 9. Indications For Use cont. Myocardial Infarction (MI) Decreases the chance of heart failure after an MI. Should be given for 6 weeks post MI. If heart failure occurs itshould be considered for permanent use. Nephropathy Slows renal disease of diabetic or nondiabetic origins Decreases glomerular filtration pressure. 10. Indications For Use cont. Type 2 Diabetes Decreases morbidity in high risk patients. Increased levels of angiotensin II have a correlation to type 2diabetes. ACE inhibitors increase kinin levels, which increaseproduction of prostaglandins and nitric oxide. Prostaglandins and nitric oxide improve muscular sensitivityto insulin. (Solski & Longyhore, 2008, pg. 936) May preserve pancreatic function and prevent onset ofdiabetes especially with people who have hypertension. 11. Common Trade NamesGeneric Name Trade Name benazepril Lotensin captopril Capoten enalapril Vasotec enalaprilat Vasotec IV fosinopril Monopril lisinopril Prinivil, Zestril moexipril Univasc perinodopril Aceon quinapril Accupril ramipril Altace 12. Adverse Effects First-Dose Hypotension Usually occurs with initial dose. Worse in patients with severe hypertension, or are ondiuretics, or are sodium or volume depleted. Cough Persistent, dry, irritating, nonproductive cough can developwith all ACE inhibitors. (Lehne, 2007, pg. 466) Due to rise in bradykinin which occurs due to inhibition ofkinase II. Occurs in 5-10% of patients and is more common in womenand the elderly. 13. Adverse Effects cont. Hyperkalemia Potassium levels rise due to the inhibition ofaldosterone, which causes potassium to be retained by thekidneys. Renal Failure Can cause renal insufficiency in people who have bilateralrenal artery stenosis, because dropping the pressure in therenal arteries in these patients can cause glomerularfiltration to fail. Fetal Injury In the second and third trimesters a fetus can experiencehypotension, hyperkalemia, skull hypoplasia, renalfailure, and death. 14. Drug Interactions Antihypertensive agents Can cause an increased effect of medications especially withdiuretics. Potassium increasing medications Cause an increased risk of hyperkalemia due to the suppression ofaldosterone. Lithium Increases to risk of lithium toxicity. Allopurinol Increases hypersensitivity to medication NSAIDS Reduce antihypertensive effects of medication. 15. Nursing Considerations Encourage lifestyle changes Weight loss Quit smoking Decrease alcohol intake Encourage exercise to help lower blood pressure Monitor Renal Function BUN, Creatinine, and Potassium levels Monitor for decreased fluid volume which can bottom ourblood pressure Excessive sweating Diarrhea Vomiting Dehydration 16. Nursing Considerations cont. Monitor for 1st-dose hypotension May have to stop other antihypertensive medications at initiation of ACE inhibitors. May have to give these medications in lower doses going forward. Discontinue diuretics for 2-3 days prior to starting an ACE inhibitor. Monitor BP for several hours and if patient becomes hypotensive lay patient supine and consider discussing IV bolus of saline with the MD. Educate Patient Teach the patient about the medication including name adverse effects, drug interactions. Teach the patient about the signs of hypotension, hyperkalemia, and renal failure. If patient is taking lithium discuss the signs of lithium toxicity. 17. Test Questions1.Which of these patients would most likely be treatedwith an ACE inhibitor? a) A 38-year old women who has become hypertensive inthe last trimester of her pregnancy. b) A 78-year old man who just had a heart attack and is inrenal failure. c) A 60-year old man who is a diabetic and suffers fromhypertension. d) A 72-year old female with a history of hypertenstionwho comes to the ER in septic shock. 18. Test Questions2. Which statement by a patient taking ACE inhibitors demonstrates the patients understanding of the medication?a) I dont need to exercise because the medication will make me better.b) If I feel weak or faint I should take my medication, because it will make me feel better.c) I can use salt substitutes instead of the real thing.d) If I develop a cough that does not go away I should call my doctor. 19. Test Questions1. Which of these lab values would be a contraindication for taking an ACE inhibitor? a) Potassium 3.3 b) Potassium 5.6 c) BUN 10 d) Creatinine 1.2 20. Test Answers with Rationale1. c is the correct answer. a, b, and d all have contraindications for giving an ACE inhibitor.2. d is the correct answer. a is wrong because exercise should be encouraged. b is wrong because weakness and syncope are signs that the patient may be hypotensive. c is wrong because salt substitutes are high in potassium and should be used with caution in patients on ACE inhibitors.3. a is the right answer. Hyperkalemia is a contraindication for ACE inhibitors. 21. References Karch, A. (2011). Focus on nursing pharmacology (5thed.). Philadephia, PA: Wolters Kluwer | LippincottWilliams & Wilkins. Lehne, R. (2007). Pharmacology for nursing care (6th ed.).St. Louis, MO: Saunders|Elsevier. Solski, L. V. & Longyhore. (2008). Prevention of type 2diabetes mellitus with angiotensin-converting-enzyme inhibitors. American Journal of Health-System Pharmacy, 65(10): 935-40. Waterfield, J. (2008). ACE inhibitors: use, action, andprescribing rationale. Nurse Prescribing, 6(3): 110-4.