NCM-106 | ACE Inhibitors (Angiotensin Converting Enzyme)

PHARMACOLOGY 💊
ACE Inhibitors are cardiac medications that lower the blood pressure by inhibiting the
conversion of Angiotensin I to Angiotensin II. It is vital the nurse knows how the drug
works, side effects, the nursing considerations, and education to provide to the patient
etc.

Name: ACE: Angiotensin-Converting Enzyme Inhibitors

Medications end in PRIL

Examples: Captopril, Lisinopril, Ramipril, Quinapril, Benazepril

-They inhibit the RAAS (renin-angiotensin aldosterone system).

Goal of the RAAS? To manage our blood pressure by activating a substance that
naturally occurs in our body called Angiotensin II.

How is this work?

Low blood pressure occurs -> Kidneys release RENIN into circulation -> causes
ANGIOTENSINOGEN (a protein created and released by the liver) to produce
ANGIOTENSIN I -> then a substance called ANGIOTENSIN-CONVERTING ENZYME
(ACE) converts Angiotensin I to -> ANGIOTENSIN II

ACE Inhibitors prevent the conversion of Angiotensin I to Angiotensin II (which is an

active vasoconstrictor).

ACE: converts Angiotensin I to Angiotensin II and it inactivates bradykinin by breaking it

down (note: inhibiting ACE will increase the amount of bradykinin)

● Bradykinin: is an inflammatory substance that dilates vessels but increased

amounts of it are thought to lead to the dry, persistent cough experienced
with ACEI. If this is experienced and can’t be tolerated by the patient, the
physician may switch the patient to an angiotensin II receptor blocker
(ARB).

Angiotensin II:

● Causes major vasoconstriction of the vessels (increases Systemic Vascular

Resistance SVR and blood pressure)

● Trigger the release of ALDOSTERONE

● Causes the kidneys to keep water and sodium but excrete potassium.
Since ACE Inhibitors block the role of angiotensin II, it will cause the opposite effects:

● Dilates vessels (decrease SVR and blood pressure)

● Causes kidneys to excrete water and sodium (has somewhat of a diuretic

effect) but KEEPS potassium (risk for hyperkalemia)

Used for?
● Heart failure (systolic dysfunction): this is when the left ventricle can’t pump
blood forward out of the heart very well. This will cause the blood to
backflow into the lungs, increase the workload on the ventricle which will
enlarge it, and decrease cardiac output.

● These medications will decrease afterload (the resistance the

ventricle must overcome to pump blood out and forward). ACEI
will lower the systemic vascular resistance and make it easier
for the heart to squeeze blood forward. Also, they will decrease
preload (the amount the ventricles stretch once they’re filled
with blood at the ending of the filling phase (diastole).

● Hypertension

● After a myocardial infarction: these medications will help limit the damaging
effects on the heart muscle caused by the damage of the infarct.

Responsibilities of a Nurse?
● Assess blood pressure and pulse routinely (watching for hypotension, especially
if the patient is taking diuretics or other cardiac medications).

Monitor labs:

● Potassium level (hyperkalemia….normal potassium 3.5-5): hyperkalemia

can cause EKGchanges like: Tall peaked T waves

● Renal failure: Elevated BUN and Creatinine and low urinary output <30 cc/hr

○ Normal BUN: 5-20

○ Normal Serum creatinine: 0.6–1.2 mg/dL

Watch for Angioedema: This is swelling deep in the skin (dermis and subcutaneous
tissue)…..it’s very dangerous!
 ● Signs and symptoms: swelling on the face (mouth, eyes, tongue, lips,
dyspnea, swelling of extremities)….can occur in any person but most
commonly occurs in African American patients.

Assess how the patient is tolerating the medication? Is the patient having a dry,
persistent cough that they can’t tolerate? Some patients can tolerate it. They should
NEVER just quit taking the medication because rebound hypertension can occur, but
the patient should talk with the MD about switching to another medication like an ARB
(angiotensin II receptor blocker).

● Also, for patients who are taking an ACEI for heart failure the nurse would
need to further investigate that the persistent cough isn’t exacerbation of
heart failure. When this occurs fluid builds up in the lungs because the
heart is too weak to pump it forward. Signs and symptoms of this include:
crackles during auscultation, decrease in oxygen saturation,difficulty
breathing on excretion etc.

Side effects?
Persistent dry cough, dizziness (change positions slowly), hypotension, high potassium
level, angioedema (life threatening)

Education for Patients?

● Check blood pressure and pulse regularly (daily the best)… always record
it and bring readings to check-up with the doctor.

● Avoid salt substitutes with potassium. If also taking potassium-sparing

diuretics like Spironolactone, avoid consuming foods high in potassium
like…potatoes, pork, oranges, tomatoes, avocados, spinach, bananas.

● Dry persistent cough can occur…if bothersome notify MD…don’t just stop
taking it due to rebound hypertension!!

● Don’t skip doses or abruptly quit taking (some patients may quit taking due
to irritating cough)….this will lead to rebound hypertension.

● Missed dose? take when remembered that same day ... .if
remembered not until the next dose take that day’s scheduled
dose but never double doses due to risk of severe
hypotension.

● Report immediately: if experiencing any type of swelling of face or mouth,

difficulty breathing…this could be angioedema.