Angiotensin-converting enzyme (ACE) inhibitors: Nursing pharmacology

Angiotensin converting enzyme inhibitors, or ACE inhibitors for short, are a group of medications that help decrease blood pressure and are typically used to treat hypertension or heart failure, but they can be also administered to clients who have recently had a myocardial infarction.Now, ACE inhibitors usually end in “-pril”, and include enalapril, lisinopril, ramipril, benazepril, and captopril.

Most of these medications are taken orally, but there’s one ACE inhibitor called enalaprilat that can be administered intravenously for hypertension or severe heart failure when oral treatment isn’t practical.

However, it’s not recommended for acute heart failure or myocardial infarction.Alright, ACE inhibitors work by inhibiting the action of an enzyme called angiotensin-converting enzyme, or ACE for short, preventing it from converting angiotensin I into its active form angiotensin II.

Angiotensin II causes blood vessels to constrict, which increases the blood pressure. In addition, it stimulates the adrenal glands to release aldosterone, which increases reabsorption of sodium and water in the kidneys.

This results in increased blood volume, which also contributes to increased blood pressure. So once ACE inhibitors are administered, there’s less angiotensin II in the bloodstream, which decreases vasoconstriction, as well as decreased aldosterone release by the adrenals, leading to natriuresis, or excretion of sodium along with water by the kidneys.

In this way, ACE inhibitors effectively lower the blood pressure. Now, the most common side effects of ACE inhibitors are mild and nonspecific, such as a headache, dizziness, and fatigue.

However, many clients also complain of a constant, dry, irritating cough. That’s because normally, ACE also breaks down bradykinin, so when the client takes ACE inhibitors, bradykinins accumulate, and they’re thought to induce the cough reflex.

In fact, this is a common reason for quitting ACE inhibitors and switching to another medication. Less frequently, bradykinin accumulation may lead to increased capillary permeability, which results in fluid accumulation and swelling of the eyes, lips, tongue, pharynx, and glottis; this is called angioedema, and can be life threatening.

Other side effects of ACE inhibitors include tachycardia, as well as hypotension, which tends to occur with the first few doses.

Finally, ACE inhibitors decrease potassium excretion in the urine, and this could lead to hyperkalemia, so it’s important for clients who are taking ACE inhibitors to avoid taking potassium supplements and salt substitutes that contain potassium.As far as contraindications go, ACE inhibitors should be avoided in clients who also take potassium sparing diuretics like spironolactone, or have another underlying cause of hyperkalemia.

Also, ACE inhibitors should be given with caution in those with renal insufficiency. Lastly, as a boxed warning, ACE inhibitors and other medications with a similar mechanism of action are contraindicated during pregnancy, since they may cause fetal injury.

Alright, if your client is prescribed an ACE inhibitor, perform a baseline assessment, including vital signs, ECG, CBC, urinalysis, sodium, potassium, creatinine, and BUN.

For female clients of childbearing age, obtain a negative pregnancy test, and advise them to let their healthcare provider know if they plan to become pregnant.

If the medication is prescribed for heart failure, assess your client’s weight, lung sounds, and for the presence of edema or dyspnea.

Next, be sure to explain why the medication is prescribed and describe common side effects your client should watch for.

Let them know that hypotension can often occur with the first few doses, so instruct your client to be mindful of any feeling of dizziness or weakness, and to make position changes slowly until they adjust to their medication.

Be sure to explain that angioedema is a less common but serious side effect that can occur within the first week of treatment, and that they should seek immediate medical attention if they notice swelling of their eyes, lips, or tongue.

And, let your client know that ACE inhibitors sometimes cause a dry, nonproductive cough which usually resolves after a few days; if the cough persists or interferes with sleep, instruct them to contact their healthcare provider.

Also teach your client to avoid potassium supplements and salt substitutes that contain potassium while taking an ACE inhibitor; and advise them that taking NSAIDs while they are taking an ACE inhibitor can reduce the antihypertensive effect of their medication.

If your client is prescribed either enalapril, lisinopril, ramipril, or benazepril, let them know that they can take their medication without regard to meals.On the other hand, if your client is prescribed captopril, teach them to take the medication on an empty stomach, or 1 hour before or 2 hours after a meal.Now, to assist your client with their blood pressure management, stress the importance of lifestyle modifications that can help control their blood pressure, such as weight loss, smoking cessation, decreased alcohol intake, increased physical activity, and following a low sodium diet.

Teach your client how to take their blood pressure at home, and explain blood pressure readings that warrant the need to seek medical attention.

And finally, ensure your client understands not to abruptly stop taking their medication, because of the risk of rebound hypertension.Throughout ACE inhibitor therapy, periodically monitor your client’s blood pressure, as well as laboratory results, including CBC, BUN, creatinine and potassium.

If you are administering an ACE inhibitor to a client in an acute care setting, closely monitor for signs of angioedema and have 1:1000 epinephrine readily available in case this occurs.

Also be alert for other side effects such as hyperkalemia, and institute fall precautions. If your client is receiving IV enalaprilat, closely monitor their blood pressure until it has stabilized.As you care for a client receiving an ACE inhibitor, evaluate for the therapeutic responses such as normalization of your client's blood pressure and a decrease in the symptoms of heart failure.

Alright, as a quick recap…ACE inhibitors help lower blood pressure and are used to treat clients with hypertension, heart failure, and who have recently recovered from a myocardial infarction.

ACE inhibitors work by preventing the conversion of angiotensin I to angiotensin II which leads to decreased vasoconstriction and decreased sodium and water retention.

Common side effects include headache, dizziness, fatigue, dry cough, tachycardia, hypotension, and hyperkalemia, and a less frequent but life threatening side effect is angioedema.

ACE inhibitors are contraindicated during pregnancy and in clients who are at risk of hyperkalemia, like those taking a potassium sparing diuretic.

Nursing considerations include client education, safe administration, and monitoring the client’s response to treatment.