Angiotensin Converting Enzyme Inhibitors

ACE Inhibitors for Hypertension

Presented by Jin Kim RN

Autonomic nervous system The Autonomic nervous system (ANS)

Controls the cardiovascular system Transmits parasympathetic and sympathetic messages to the

heart Parasympathetic –slows heart rate Sympathetic –increases heart rate

Extrinsic and Intrinsic Reflexes Extrinsic and Intrinsic reflexes

Extrinsic reflexes- blood pressure responds from outside of the cardiac system, such as pain, temperature

Intrinsic reflexes- baroreceptor and chemoreceptor responds to stimulus from inside the cardiac system

Cardiac Output Arterial tone Blood volume

Renin Angiotensin System (RAS) Renin

Enzyme stored in the kidneys Released when blood pressure is low

Renin converts into angiotensinogen When it enters into the circulatory system

Angiotensinogen then becomes angiotensin I Angiotensin I converts to angiotensin II

When it enters into the pulmonary system

Angiotensin II stimulates the release of aldosterone from the adrenal glands

Aldosterone causes water and sodium retention Increasing blood volume

Increasing blood pressurePhoto courtesty by blobs.org

Hypertension Hypertension (HTN)

Defined as blood pressure (BP) which is higher than normal

Two types Primary (Essential) Hypertension Secondary Hypertension

Photo courtesy Rockwell Nutrition Blog

Blood Pressure Ranges Normal BP

Systolic pressure < 120 mm Hg Diastolic pressure < 80 mm Hg

Pre-hypertension Systolic pressure between 120-139 mm Hg Diastolic pressure between 80-89 mm Hg

Hypertension Systolic pressure persistently > 140 mm Hg Diastolic pressure persistently > 100 mm Hg

List of ACE Inhibitors Benazepril (Lotensin) Captopril (Capoten) Cilazapril (Inhibace) Enalapril (Vasotec, Epaned) Fosinopril (Monopril) Lisinopril (Prinivil, Zestril) Moexipril (Univasc) Perindopril (Aceon, Coversyl) Quinapril (Accupril) Ramipril (Altace) Trandolapril (Mavik)

Lisinopril Drug class

Angiotensin Converting Enzyme (ACE) Inhibitors

Indications for use Hypertension Heart Failure

Mechanism of Action Blocks angiotensin I from converting into angiotensin

II (a vasoconstrictor) Prevents degrading of bradykinin and vasodilatory

prostaglandins Increases plasma renin and decreases aldosterone

levels

Lisinopril- Goals

Therapeutic effect/goals Vasodilation Decreased blood pressure Increased survival for heart failure patients Decrease in heart failure symptoms

Lisinopril-Pregnancy Category Pregnancy risk category

Crosses into the placenta, can enter into breast milk Pregnancy risk category- D Can be fetal demise or injure the fetus

Immediately stop taking and contact health care provider if pregnant

Enters into the breast milk Do not give breast milk while on Lisinporil

Lisinopril – Side Effects and Adverse Reactions Common Side Effects

Dizziness Cough Hypotension

Life Threatening Angioedema

Welts or swelling around eyes, lips, throat, or other part of the body

Other Side Effects Fatigue Headache Weakness GI Symptoms Rashes Hypoglycemia for those

with diabetes Hyperkalemia Decreased in taste

Contraindications Use with caution in

Renal impairment Hypovolemia Hyponatremia On diuretics

Less effective for black patients

Geriatric patients should take a lower dosage

Not recommended for children under 6 years old

Nursing Management Monitor Vital Signs

Blood pressure and Pulse Before, during, after 1 hour of medication administration

Monitor for hypoglycemia in patients with diabetes

Monitor labs tests Electrolytes (Potassium) Kidney and liver functions

Evaluate outcomes and side effects

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Research and Evidence ACE Inhibitor efficacy

92 trials conducted All ACE inhibitors are effective Taking over the maximum suggested dosing

does not decrease BP more than the maximum dosage

50-60% in BP reduction at the starting dose which is recommended

Randomized controlled tests suggests that Lisinopril is effective at any dose from 1/16 of a maximum dose to a maximum dose. At the 1/16th dose only SBP was lowered. Fosinopril at 1/16th dose lowers SBP & DBP

Studies indicate that there is no decrease in mortality rate for those who used ACE inhibitors vs. Angiotensin receptor blockers (ARBs)

Patient Education

Take medication as prescribed and at the same time every day

Take missed doses as soon as remembered, unless it is close to the time for the next dose

Never take a higher or lower dose without consulting the doctor

Do not discontinue this medication without consulting the doctor

If pregnancy occurs, do not take next dose and contact the doctor right away

Do not use salt substitutes without consulting the doctor Photo courtesy HealthiNation.com

Patient Education cont.

Be cautious of orthostatic hypotension

Do not drive or operate heavy machinery until, effects of medication on individual is established- as it may cause dizziness

Do not add alternative medications such as herbal or vitamins without consulting the doctor

Be sure attend follow up appointments to ensure therapeutic effects

Instruct/demonstrate on how to take BP and Pulse (take around same time each day) write down the results and bring to appointments

Encourage a healthy lifestyle

Alternative Therapies for Hypertension Herbal Therapies

Garlic- placebo studies indicate efficacy

Celery- evidence (P<0.05) in reduction of BP

Indian plantago- preliminary clinical research shows reduced BP (-8 mm Hg SBP, -2 mm Hg DBP)

Tomato extract- study showed significant decrease in BP (-10 mm Hg SBP, -5 mm Hg DBP) Supplements

Alternative Therapies Cont. Maritime pine- being studied, reports suggests it inhibits ACE

Rauwolfia- used in the Hindu population, and causes hypotension

Cacao- clinical research shows decrease in BP (-5 mm Hg SBP, -3 mm Hg DBP)

Photo courtesy by zokiva.com

Alternative Therapies cont. Coenzyme Q 10

Compared to a placebo, did not lower blood pressure (according to the Cochrane library)

Omega-3 Fatty Acids Epidemiological and clinical studies- slight decrease in BP especially SBP

Acupuncture Significant reductions in BP, both SBP and DBP- treatment span 1 month 2X/week

Patients did not change their lifestyle, diet, or exercise

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Thank You!

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References Blood pressure lowering efficacy of angiotensin converting enzyme (ACE) inhibitors for primary hypertension.

(208, October 8). Retrieved February 12, 2017, from https://www.ncbi.nlm.nih.gov/pubmed/18843651 Cochrane. (n.d.). Retrieved February 12, 2017, from http://www.cochrane.org/CD007435/HTN_coenzyme-q10-

high-blood-pressure Complementary and Alternative Treatments for High Blood Pressure. (n.d.). Retrieved February 12, 2017, from

http://www.webmd.com/hypertension-high-blood-pressure/guide/hypertension-complementary-alternative-treatments#2

Heran, B. S. (2009). Blood pressure lowering efficacy of angiotensin converting enzyme (ACE) inhibitors for primary hypertension. Cochrane Database Of Systematic Reviews, (4), doi:10.1002/14651858.CD003823.pub2

Marsh, C. D., & Rizzo, C. M. (2017). Hypertension. Magill’S Medical Guide (Online Edition) Porth, C. (2015). Essentials of Pathophysiology Concepts of Altered Health States (4th ed.). Philadelphia, PA:

Lippincott Williams & Wilkins. Omega-3 fatty acids and blood pressure. (2012, June 12). Retrieved February 12, 2017, from

https://www.ncbi.nlm.nih.gov/pubmed/22591893 Tabassum, N., & Ahmad, F. (2011). Role of natural herbs in the treatment of hypertension. Retrieved February

16, 2017, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3210006/ The effect of acupuncture on high blood pressure of patients using antihypertensive drugs. (2013). Retrieved

February 12, 2017, from https://www.ncbi.nlm.nih.gov/pubmed/23724695 Vallerand, A. H., Deglin, J. H., & Sanoski, C. A. (2017). Davis's drug guide for nurses. Philadelphia: F.A. Davis

Company.