ACEi and ARBs

Question 1

What drugs have a -kiren ending?

Answer 1

Renin inhibitors

Question 2

What drugs have a -Prils ending?

Answer 2

ACE inhibitors

Question 3

What drugs have a -sartans ending?

Answer 3

ARBs (angiotensin receptor blockers)

Question 4

What are the actions of ACEi?

Answer 4

• Dec BP, reduce Ang II constrictors
• Dec BV so reduction in aldosterone
• Dec sympathetic activation
• Inc Bradykinin (prevents metabolism)
• Dec generation ROS
• Dec glomerular filtration rate
• Dec hypertension remodelling

Question 5

What does bradykinin do?

Answer 5

• stimulates dilation of blood vessels

Question 6

What is ROS why is a decrease beneficial?

Answer 6

Reactive oxygen species

- diminishes oxidative stress related injuries

Question 7

What are the major ACE inhibitors?

Answer 7

Captopril
Enalapril 
Lisinopril 
Ramipril 
Perindopril 
Trandolapril

Question 8

What is the benefit of slower onset ACEi’s and which ACE are longer onset?

Answer 8

longer = Captopril and enalapril

benefits of slower onset = longer duration so one pill daily and less rashes or taste disturbance

Question 9

What major factor will effect what is first line in patients with heart failure?

Answer 9

Whether ejection fraction is preserved or not

Question 10

What is first line in Heart failure with reduced ejection fraction?

Answer 10

ACEi and Beta blocker or aldosterone antagonist

ARB if intolerant to ACEi

Question 11

What are possible second line treatments if HF symptoms remain?

Answer 11

One of these:

• Replace ACEi with sacubitril valsartan
• add ivabradine
• add hydralazine and nitrate
• use digoxin (symptomatic relief if have a sinus rhythm)

Question 12

What is the most common side effect of ACEi?

Answer 12

Dry cough (may want to change to ARB)

Question 13

What are the adverse effects of ACEi?

Answer 13

• Acute renal failure
• Hypotension (first dose)
• Hyperkalaemia
• Teratogenicity (abnormalities in foetus)
• skin rash
• Taste disturbance

Question 14

What are the drug interactions of ACEi?

Answer 14

• with Diuretics dec Na
• potassium sparing diuretics inc risk of hyperkalaemia
• hypotensive agents inc hypotension
• NSAIDs reduce renal BF and inc risk of renal impairment

Question 15

When are ACEi contraindicated?

Answer 15

• avoid in renovascular disease
• severe aortic stenosis
• start at low does in HF

Question 16

What needs to be monitored in patients taking ACEi?

Answer 16

• Potassium if taking potassium sparing diuretic

- monitor BP and renal function in patients with HF

Question 17

In patients with heart failure without reduced ejection fraction what other treatments should be tried before medication?

Answer 17

1) first treat comorbidities e.g. hypertension, atrial fibrillation, ischaemic heart disease or diabetes
2) personalised exercise based cardiac rehabilitation
3) start on first line medication treatment

Question 18

What are the most common ARBs?

Answer 18

• Losartans
• Irbesartan
• Valsartan
• Candesartan

Question 19

What are the actions of ARBs?

Answer 19

• antagonise effects of Ang II at AT1 receptors
• have no effect on metabolism of bradykinin
• can promote AT2 receptor signalling

Question 20

How do actions of ACEi and ARBs differ?

Answer 20

• all angiotensin is stopped in ARBs as acts at receptor whereas in ACEi some Ang still made in non-ACE pathways

Question 21

When are ARBs contraindicated?

Answer 21

• similar to ACEi
• bilateral renal artery stenosis
• aortic stenosis
• pregnancy
• must monitor renal function in unilateral disease, renal impairment or atherosclerosis

Question 22

What are the adverse effects of ARBs?

Answer 22

• better tolerated than ACEi usually
• 1st dose hypotension
• acute renal failure
• hyperkalaemia
• angio-oedema

Question 23

What is the new drug class which acts similarly to ACEi/ARBs?

Answer 23

ARNIs (dual NEP enzyme/angiotensin receptor inhibitors