hi everyone, ACE inhibitors explained in an easy mannner..Students can overcome the hurdles in understanding the complexity of this mechanism.

1. ANGIOTENSIN–
CONVERTING ENZYME
(ACE) INHIBITORS
Mr.THIRIVIKKIRAMAN.Z
Asst.Professor
Indirani College of Nursing

2. Angiotensin – Converting Enzyme (ACE)
Inhibitors
• The ACE inhibitors are important drugs for treating
Hypertension, Heart Failure Diabetic Nephropathy &
Myocardial Infarction (MI)
• Beneficial effects results largely from suppressing
formation of Angiotensin-II

3. Mechanism of Action
1) Reducing levels of Angiotensin-II(through inhibition of ACE)
ACE inhibitors can dilate Blood Vessels (Primarily Arterioles & to lesser
extent the veins)
Reduce Blood Volume (Through effects on the Kidney)
Prevent or reverse Angiotensin II-mediated pathologic changes in the
Heart & Blood Vessels

4. 2) Increasing levels of Bradykinin (through
Inhibition of Kinase II )
Elevation of Bradykinin levels promotes Vasodilation
Bradykinin promotes Vasodilation by stimulating
production of Prostaglandins and Nitirc Oxide)

5. Adverse Effects
• Like beneficial effects, certain Adverse effects result from
inhibiting ACE/KINASE II.
• Inhibition of ACE can cause :
 Hypotension
 Hyperkalemia
 Renal Failure
 Fetal Injury
• Inhibition of KINASE II, with resultant accumulation of
Bradykinin, can cause Cough & Angioedema.

6. Pharmacokinetics
• All ACE inhibitors are administered orally , except Enalapril which
is given IV
• Except Captopril & Moexipril, all oral ACE inhibitors can be
administered with food.
• Except Captopril, all ACE inhibitors have prolonged half-lives,& can
be administered just once or twice a day.
• Captopril is administered 2 or 3 times a day.
• All ACE inhibitors are excreted by the KIDNEYS.As a result, nearly all
can accumulate to dangerous levels in patients with Kidney
disease, & hence dosages must be reduced in these patients.

7. Generic Name
BENAZEPRIL
CAPTOPRIL
ENALAPRIL
FOSINOPRIL
ENALAPRILAT
Trade Name
Lotensin
Capoten
Vasotec
Monopril
Vasotec I.V
Indications
Hypertension
Hypertension
Heart Failure
LVD after MI
Diabetic
Nephropathy
Hypertension
Heart Failure
Asymptomatic
LVD
Hypertension
Heart failure
Hypertension
Starting Dose
10 mg once/day
25 mg bid or tid
2.5 mg tid
12.5 mg tid
25 mg tid
5 mg once/day
2.5 mg bid
2.5 mg bid
10 mg once/day
10 mg once
/day
1.25 mg every
6hr
Maintenance
Dose
20-40 mg/day
25-50 mg bid,tid
50-100 mg tid
50 mg tid
25 mg tid
10-40 mg/day
10-20 mg bid
10mg bid
20-40mg/day
20-40mg/day

8. LISINOPRIL
MOEXIPRIL
QUINAPRIL
RAMIPRIL
TRANDOPRIL
Prinivil, Zestril
Univasc
Accupril
Altace
Mavik
Hypertension
Heart Failure
Acute MI
Hypertension
Hypertension
Heart Failure
Hypertension
Heart failure
Prevention of
MI, stroke,&
death in people
at high risk for
CVD
Hypertension
Heart Failure
after MI
LVD after MI
10 mg once/day
5 mg once/day
5 mg once/day
7.5mg once/day
10-20mg/day
5mg bid
2.5 mg once/day
2.5 mg bid
2.5 mg/day for 1
week
1 mg once/day
1 mg once/day
1 mg once/day
20-40mgonce/d
20-40mgonce/d
10mgonce/day
7.5-30 mg/day
in 1 or 2 doses.
20-80mg/day
20-40mg bid
2.5-20mg/day
5mg bid
5mg once/day
for 3 weeks.
2-4mg once/day
4mg once/day
4mg once/day

9. THERAPEUTIC USES
ACE inhibitors produce Therapeutic effects in:
 HYPERTENSION
 HEART FAILURE
 MYOCARDIAL INFARCTION
 DIABETIC & NONDABETIC NEPHROPATHY
 PREVENTION OF MI
 DEATH IN HIGH CARDIOVASCULAR RISK
PATIENTS

10. ADVERSE EFFECTS
• ACE inhibitors are generally well tolerated.
• Some adverse effects (e.g., First Dose Hypotension,
Hyperkalemia) are due to reduction in Angiotensin II
• Whereas others (Cough, Angioedema) are due to
elevation of Bradykinin.

11. • First-Dose Hypotension
• Cough
• Hyperkalemia
• Renal failure
• Fetal Injury
• Angioedema
• Dysgeusia & Rash
• Neutropenia

12. Nursing Implications
ACE INHIBITORS
 Benazepril
 Captopril
 Enalapril
 Enalaprilat
 Fosinopril
 Lisinopril
 Moexipril
 Perindopril
 Quinapril

13. • Therapeutic goal
 Reduction of Blood Pressure in patients with Hypertension (all
ACE inhibitors)
 Hemodynamic improvement in patients with Heartfailure
(Captopril,Enalapril,Fosinopril,Lisinopril,Moexipril,Quinapril)
 Slowed progression of Diabetic Nephropathy (Captopril)
 Reduction of Mortality following acute MI (Lisnopril)
 Treatment of Heart Failure After MI (Ramipril,
Transdolapril)
 Reduction of risk of MI,Stroke or Death from Cardiovascular
causes in patients at high risk (Ramipril)

14. BASELINE DATA
 Determine Blood Pressure & obtain a White Blood Cell Count &
differential.
IDENTIFYING HIGH-RISK PATIENTS
 ACE inhibitors are contraindicated during the Second & Third
trimesters of pregnancy
 Patients with Bilateral Renal Artery Stenosis OR history of
Hypersensitivity reactions (especially Angioedema) to ACE
inhibitors.
 Exercise Caution in patients with salt or volume depletion, Renal
Impairment or Collagen disease, those taking Potassium
supplements, potasium-sparing diuretics or Lithium

15. ROUTES
Oral : All ACE inhibitors (except enalarilat)
Intravenous : Enalaprilat.
Dosage & Administration
 Begin therapy with low doses & then gradually increase the
dosage.
 Instruct patients to administer captopril & Moexipril at least 1
hour before Meals.
 All the other oral ACE inhibitors can be administered with
food.

16. Monitor Therapeutic Effects
 Monitor Blood Pressure closely for 2 hours after the first
dose and periodically thereafter.
 Obtain a White Blood Cell count & Differential count eevery
2 weeks for the first 3 months of therapy & periodically
thereafter.
 HYPERTENSION - Monitor for reduced Blood Pressure
140/90mm Hg.
 HEART FAILURE - monitor for lessening f signs &
symptoms (e.g., Dyspnea, Cyanosis, jugular vein distension,
Edema),Diabetic Nephropathy- monitor for Proteinuria.

17. MINIMIZING ADVERSE EFFECTS
First-Dose Hypotension – Severe Hypotension occur with the
first dose. Minimize Hypotension by
1) Withdrawing Diuretics 1 week before initiating ACE
inhibitors
2) Using low initial doses
3) Monitor Blood pressure for 2 hours following the first dose.
4) Instruct patients to lie down if Hypotension develops.
5) Infuse Normal saline to restore Pressure.

18. COUGH
 Warn patients about the possibility of Persistent, dry,
irritating, Non productive cough. It ma be necessary to
discontinue the ACE inhibitor.
HYPERKALEMIA
 ACE inhibitors may increase potassium levels.
 Instruct patients to avoid Potassium supplements and
Potassium-containing salt substitutes unless prescribed by
physician.
 Potassium – sparing diuretics must also be avoided.

19. Fetal Injury
 Warn pregnant women that ACE inhibiotrs taken during the
Second & Third trimesters of pregnancy can cause fetal injury
(Hypotension, Hyperkalemia, Skull Hypoplasia, Anuria, Reversible
& Irreversible renal failure, Death)
 If the patient becomes pregnant, withdraw ACE inhibitors as soon
as possible, reassure women ACE inhibitors do not represent the
risk during first trimester.
 Closely monitor infants who have been exposed to ACE inhibitors
during the second or third trimester for Hypotension, Oliguria &
Hyperkalemia.

20. Angioedema
 This rare & potentially fatal reaction is characterized by giant
wheals edema of the tongue, glottis & Pharynx.
 If Angioedema occurs, discontinue the ACE inhibitor and
never use it again.
 Treat severe reactions with subcutaneous epinephrine.
Renal Failure
 Renal failure is a risk for patients with bilateral renal artery
stenosis or stenosis in the artery of a single kidney.ACE
inhibitors are contraindicated to this people

21. Neutropenia (Mainly with Captopril)
 Neutropenia poses a high risk of infection.
 Inform patient about daily signs of infection(Fever, Sore
throat, Mouth sores) & instruct them to notify physicians if
these occur.
 Obtain WBC & Differential count every 2 weeks during the
first 3 months of therapy & periodically thereafter
 If neutropenia develops withdraw the drug immediately –(It
should get normalized approximately of 2 weeks).
 Neutropenia is most likely in patients with renal impairment
& collagen vascular disease.

22. Rash & Dysgeusia ( Mainly with Captopril)
 Minimize these reactions by avoiding high doses.
 Instruct patients to notify the physician if rash or
dysgeusia persist.
 If dysgeusia results in Anorexia & Weight loss,withdraw
the drug.
 Rash & Dysgeusia resolve with cessation of treatment.

23. THANK YOU…..