Angiotensin Converting Enzyme (ACE) Inhibitors
Mechanism of Action
↓ angiotensin converting enzyme activity = ↓ conversion of angiotensin I to angiotensin II =
↓ aldosterone production =
↓ sodium and fluid retention
↓ potassium excretion, possibly leading to increased potassium levels
↓ vasoconstriction = ↓ peripheral vascular resistance = ↓ after-load = ↑ cardiac output
Indications for Use
Hypertension
Not recommended as a first line agent in patients without chronic kidney disease, diabetes, heart failure, or history of STEMI (see below)
Heuristic: Start as a first line agent in patients who also qualify for statin therapy
Start lisinopril 10 mg daily
Titrate by 10 mg every 4 weeks to maximum dose of 40 mg daily
Stop titrating once goal blood pressure is reached
Proteinuric Chronic Kidney Disease (Diabetic and Non-Diabetic)
Reduces progression of renal disease
Start ACE in patients with
Urine protein excretion > 1000 mg/day
Estimate 24-hour urine protein using urine protein:urine creatinine ratio
Urine protein/urine creatinine ≈ grams of protein excreted per day
Diabetes mellitus type 1 or 2 and urine microalbumin:urine creatinine ratio greater than 30 mg/g/day
Recommended agent/dose: Enalapril 10 mg daily
Heart Failure with Reduced Ejection Fraction
Improve symptoms and reduce mortality in patients with LVEF < 40 %
Start lisinopril 10 mg daily; increase dose by 10 mg every 2 weeks to goal of 40 mg daily
Following ST-Elevation Myocardial Infarction
Decrease risk of heart failure s/p STEMI
Start lisinopril 5 mg daily within 24 hours of event provided that patient is stable
Increase dose by 10 mg per day while in the hospital
Titrate to goal of 40 mg daily; maintain or decrease dose if hypotension develops
Continue for at least 6 weeks after event
Adverse Effects
First-dose hypotension
Bradykinin-mediated
Persistent, dry, irritating, and non-productive cough
Angioedema
Fetal injury