ACE inhibitors a.k.a "angiotensin converting enzyme inhibitors"

Question 1

ACE inhibitor means …

Answer 1

Angiotensin converting enzyme inhibitor

Question 2

MOA
ACE inhibitor

Answer 2

• block angiotensin I conversion to angiotensin II
• inhibit breakdown of bradykinin (contribute to vasodilation)
• reduce sodium retention
• reduced aldosterone (hormone that controls sodium and water retension and therefore controls BP)

ACE inhibitors block conversion of angiotensin I to angiotensin II and also inhibit the breakdown of bradykinin. They reduce the effects of angiotensin II-induced vasoconstriction, sodium retention and aldosterone release. They also reduce the effect of angiotensin II on sympathetic nervous activity and growth factors.
## water follows salt … increased salt = increased BP, decreased salt = decreased BP

Question 3

Indication
ACE inhibitors

Answer 3

Hypertension

Chronic heart failure with reduced ejection fraction as part of standard treatment

Diabetic nephropathy

Prevention of progressive renal failure in patients with persistent proteinuria (>1 g daily)

Post MI

Question 4

Adverse reactions
ACE inhibitors

Answer 4

• hypotension
• headache
• dizziness
• cough (dry / non productive)
• hyperkalaemia
• fatigue
• nausea
• renal impairment

Question 5

Practice points

Answer 5

*You may feel dizzy when you start taking this medicine. Get up gradually from sitting or lying to minimise this effect; sit or lie down if you become dizzy or light-headed.

Do not take potassium supplements while you are taking this medicine unless your doctor tells you to.*

When starting an ACE inhibitor:
* stop potassium supplements and potassium-sparing diuretics
* in heart failure, consider reducing dose or withholding other diuretics for 24 hours before starting an ACE inhibitor
* review use of NSAIDs (including selective COX‑2 inhibitors)
* start with a low dose
* check renal function and electrolytes before starting an ACE inhibitor and review after 1–2 weeks
* encourage patients to continue ACE inhibitors during the COVID‑19 pandemic as there is no clinical evidence to support stopping treatment

Question 6

Drug class and indication

Captopril

Answer 6

ACE inhibitor
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment
* Post MI in patients with left ventricular dysfunction
* Diabetic nephropathy (type 1 diabetes)

Question 7

Drug Class and indication

Enalapril

Answer 7

ACE inhibitor
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment
* Asymptomatic left ventricular dysfunction

Question 8

Drug class and indication

Enalapril with hydrochlorothiazide

Answer 8

ACE inhibitor + Thiazide diuretic
* Hypertension

Question 9

Drug class and indication

Fosinopril

Answer 9

ACE inhibitor
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment

Question 10

Drug class and indication

Fosinopril with hydrochlorothiazide

Answer 10

ACE inhibitor + Thiazide diuretic
* Hypertension

Question 11

Drug class and indication

Lisinopril

Answer 11

ACE inhibitor
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment
* Post MI, acute treatment

Question 12

Drug class and indication

Perindopril

Answer 12

ACE inhibitor
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment
* Reduction of risk of MI or cardiac arrest in people with established coronary heart disease without heart failure

Question 13

Drug class and indication

Perindopril with amlodipine

Answer 13

ACE inhibitor + Dihydropyridine Calcium channel blocker
* Hypertension
* Stable coronary heart disease

Question 14

Drug class and indication

Perindopril with indapamide

Answer 14

ACE inhibitor + Thiazide diuretic
* Hypertension

Question 15

Drug class and indication

Quinapril

Answer 15

ACE inhibitor
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment

Question 16

Drug class and indication

Quinapril with hydrochlorothiazide

Answer 16

ACE inhibitor + Thiazide diuretic
* hypertension

Question 17

Drug class and indication

Ramipril

Answer 17

ACE inhibitor
* Hypertension
* Post MI
* Prevention of MI, stroke, cardiovascular death in patients >55 years with: cardio risk factors

Question 18

Drug class and indication

Ramipril with felodipine

Answer 18

ACE inhibitor + Dihydropyridine calcium channel blocker
* Hypertension

Question 19

Drug class and indication

Trandolapril

Answer 19

ACE inhibitor
* Hypertension
* Post MI in patients with left ventricular dysfunction

Question 20

Generic names of ACE inhibitors

Answer 20

Captopril
Enalapril
Enalapril with hydrochlorothiazide
Fosinopril
Fosinopril with hydrochlorothiazide
Lisinopril
Perindopril
Perindopril with amlodipine
Perindopril with indapamide
Quinapril
Quinapril with hydrochlorothiazide
Ramipril
Ramipril with felodipine
Trandolapril

Question 21

Drug interactions
ACE inhibitor

Answer 21

Triple threat = ACE inhibitor + NSAID + loop or thiazide diuretic
Lithium + ACE inhibitors
Loop diuretics + ACE inhibitors
NSAIDs + ACE inhibitors NSAIDs (including selective COX‑2 inhibitors) may reduce antihypertensive effect of ACE inhibitor and may increase risk of renal impairment and hyperkalaemia (risk is further increased if a thiazide or loop diuretic is also taken). Avoid combination in the elderly or if renal hypoperfusion or impairment exists; monitor BP, weight, serum creatinine and potassium concentration. Use no more than 100–150 mg aspirin daily.
sartans + ACE inhibitors
Sartans given with ACE inhibitors increase the risk of hypotension, hyperkalaemia and renal impairment without additional benefit; avoid combinations (see Treatment with an ACE inhibitor and a sartan).

Members of this class are captopril, enalapril, fosinopril, lisinopril, perindopril, quinapril, ramipril and trandolapril.

ACE inhibitors can cause potassium retention, which may lead to hyperkalaemia, especially in people with renal impairment or diabetes, or if taken with potassium supplements or with other drugs* that can also cause potassium retention. Avoid combinations if possible or monitor potassium concentration.

Note that aldosterone antagonists are used with ACE inhibitors in patients with heart failure, with routine potassium concentration monitoring.

Monitor potassium concentration if an ACE inhibitor is given with drugs* that can reduce potassium concentration, as hypokalaemia may still occur.

ACE inhibitors also reduce BP; administration with other drugs* that lower BP may result in additional hypotensive effects (which may be intended); avoid combinations or use carefully and monitor BP.