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Learning Objectives Discuss the reason for using ACE Inhibitors and the mechanism by which they work. Identify three common adverse effects of using ACE Inhibitors. Identify three considerations for educating a patient on the use of ACE Inhibitors
ACE Inhibitors ACE Inhibitors are medications that belong in the class of medications known as antihypertensive medications. ACE Inhibitors work on the Renin-Angiotensin- Aldosterone System
Renin-Angiotensin-Aldosterone System A system which works to increase blood pressure when the pressure within the kidneys drops. As a result of low blood pressure and/or oxygenation in the nephron, renin is released from the juxtaglomerular cells. Renin travels to the liver via the cardiovascular system and combines with angiotensinogen to form angiotensin I. Angiotensin I travels through the cardiovascular system and arrives at the lungs where it is changed into Angiotensin II. The alveoli use Angiotensin Converting Enzyme also known as kinase II to cause this conversion. (Karch, 2012, pg. 671)
Renin-Angiotensin-Aldosterone System cont. Angiotensin II is a powerful vasoconstrictor which causes a rise in peripheral resistance and increases pressure. Angiotensin II works to increase the release of aldosterone from the adrenal glands. Aldosterone causes renal retention of sodium and water, which further increases blood pressure by increasing volume. (Karch, 2012, pg. 671)
Mechanism of Action for ACE Inhibitors ACE Inhibitors work in the lungs to inhibit Angiotensin Converting Enzyme from turning Angiotensin I into Angiotensin II. These medications cause an increase of bradykinin, which inhibits kinase II, another name for Angiotensin Converting Enzyme. (Lehne, 2007, pg. 464) Blood Pressure is decreased due to a decrease in blood volume, peripheral resistance, and cardiac load. ACE Inhibitors, inhibit vasoconstriction and release of aldosterone which inhibits the retention of sodium and water.
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 mortality caused by hypertension.” (Lehne, ,2007, pg. 465)
Indications For Use cont. Heart Failure By decreasing arteriolar tone region blood flow to the heart improves. By decreasing afterload, cardiac output increases. Venous dilation increases causing a decrease in pulmonary congestion and peripheral edema. Dilates the vessels of the kidneys increasing renal flow and helps to excrete sodium and water. This helps to decrease edema and blood volume. Prevents pathologic changes in the heart that result from reducing the angiotensin II levels in the heart. (Lehne, 2007, pg. 465)
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 it should be considered for permanent use. Nephropathy Slows renal disease of diabetic or nondiabetic origins Decreases glomerular filtration pressure.
Indications For Use cont. Type 2 Diabetes Decreases morbidity in high risk patients. Increased levels of angiotensin II have a correlation to type 2 diabetes. ACE inhibitors increase kinin levels, which increase production of prostaglandins and nitric oxide. Prostaglandins and nitric oxide improve muscular sensitivity to insulin. (Solski & Longyhore, 2008, pg. 936) May preserve pancreatic function and prevent onset of diabetes especially with people who have hypertension.
Adverse Effects First-Dose Hypotension Usually occurs with initial dose. Worse in patients with severe hypertension, or are on diuretics, or are sodium or volume depleted. Cough “Persistent, dry, irritating, nonproductive cough can develop with all ACE inhibitors.” (Lehne, 2007, pg. 466) Due to rise in bradykinin which occurs due to inhibition of kinase II. Occurs in 5-10% of patients and is more common in women and the elderly.
Adverse Effects cont. Hyperkalemia Potassium levels rise due to the inhibition of aldosterone, which causes potassium to be retained by the kidneys. Renal Failure Can cause renal insufficiency in people who have bilateral renal artery stenosis, because dropping the pressure in the renal arteries in these patients can cause glomerular filtration to fail. Fetal Injury In the second and third trimesters a fetus can experience hypotension, hyperkalemia, skull hypoplasia, renal failure, and death.
Drug Interactions Antihypertensive agents Can cause an increased effect of medications especially with diuretics. Potassium increasing medications Cause an increased risk of hyperkalemia due to the suppression of aldosterone. Lithium Increases to risk of lithium toxicity. Allopurinol Increases hypersensitivity to medication NSAIDS Reduce antihypertensive effects of medication.
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 our blood pressure Excessive sweating Diarrhea Vomiting Dehydration
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.
Test Questions1. Which of these patients would most likely be treated with an ACE inhibitor? a) A 38-year old women who has become hypertensive in the last trimester of her pregnancy. b) A 78-year old man who just had a heart attack and is in renal failure. c) A 60-year old man who is a diabetic and suffers from hypertension. d) A 72-year old female with a history of hypertenstion who comes to the ER in septic shock.
Test Questions2. Which statement by a patient taking ACE inhibitors demonstrates the patient’s understanding of the medication? a) “I don’t 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.”
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
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.
References Karch, A. (2011). Focus on nursing pharmacology (5th ed.). Philadephia, PA: Wolters Kluwer | Lippincott Williams & Wilkins. Lehne, R. (2007). Pharmacology for nursing care (6th ed.). St. Louis, MO: Saunders|Elsevier. Solski, L. V. & Longyhore. (2008). Prevention of type 2 diabetes mellitus with angiotensin-converting- enzyme inhibitors. American Journal of Health- System Pharmacy, 65(10): 935-40. Waterfield, J. (2008). ACE inhibitors: use, action, and prescribing rationale. Nurse Prescribing, 6(3): 110-4.