Indications
- Congestive Heart Failure (CHF) (see Congestive Heart Failure, [[Congestive Heart Failure]])
- Hypertension (see Hypertension, [[Hypertension]])
Clinical Aspects
- Decrease renal dysfunction, need for HD or CRT, and mortality rate in type 1 DM + nephropathy
- Decrease proteinuria and mortality in blacks with modest CRI due to hypertensive nephrosclerosis
- If >20% increase in Cr with use of ACE-I -> highly suggestive of renal artery stenosis
- Lesser decreases in Cr are commonly seen and usually resolve spontaneously
- With high-grade unilateral or bilateral renal artery stenosis, >20% increase in Cr with use ACE-I has 100% sensitivity/70% specificity for detection
Agents
- Captopril (Capoten) (see Captopril, [[Captopril]])
- Enalapril (Vasotec, Enalaprilat) (see Enalapril, [[Enalapril]])
- Fosinopril (Monopril) (see Fosinopril, [[Fosinopril]])
- Lisinopril (Zestril) (see Lisinopril, [[Lisinopril]])
- Moexipril (Univasc) (see Moexipril, [[Moexipril]])
- Perindopril (Coversyl, Coversum, Preterax, Aceon) (see Perindopril, [[Perindopril]])
- Quinapril (Accupril) (see Quinapril, [[Quinapril]])
- Ramipril (Altace) (see Ramipril, [[Ramipril]])
- Trandolapril (Mavik) (see Trandolapril, [[Trandolapril]])
Pharmacology
- Angiotensin Converting Enzyme (ACE) Inhibition
- Antihypertensive Effect
Adverse Effects
Allergic Adverse Effects
Anaphylaxis (see Anaphylaxis, [[Anaphylaxis]])
- Epidemiology: xxx
- Treatment: see see Anaphylaxis, [[Anaphylaxis]]
Angioedema (see Angioedema)
- Epidemiology
- Occurs in 0.1-0.2% of treated patients
- Physiology
- Mediated by bradykinins
- Possibly mediated by autoantibodies and complement activation
- Clinical
- Time of Onset: onset can occur from hours-months after starting ACE-Inhibitor
- However, most cases within hrs-1 week after starting ACE-Inhibitor
- Lingual Edema (see Lingual Edema, [[Lingual Edema]])
- Facial Edema (see Facial Edema, [[Facial Edema]])
- Time of Onset: onset can occur from hours-months after starting ACE-Inhibitor
- Treatment
- Airway Protection: as required
- Antihistamines (see H1-Histamine Receptor Antagonists, [[H1-Histamine Receptor Antagonists]])
- Diphenhydramine (Benadryl) (see Diphenhydramine, [[Diphenhydramine]]): 25-50 mg IV PRN
- Epinephrine (see Epinephrine, [[Epinephrine]])
- Corticosteroids (see Corticosteroids, [[Corticosteroids]])
- Icatibant (Firazyr) (see Icatibant, [[Icatibant]])
- Withdrawal of ACE-Inhibitor: rechallenge is contraindicated
Endocrinologic Manifestations
- Hypoaldosteronism (see Hypoaldosteronism, [[Hypoaldosteronism]])
Gastrointestinal Adverse Effects
- Elevation of Hepatic Transaminases with Hepatocellular Injury (see Drug-Induced Hepatotoxicity, [[Drug-Induced Hepatotoxicity]])
Pulmonary Adverse Effects
Cough (see Cough, [[Cough]])
- Epidemiology: occurs in 5-20% of treated patients
- Physiology: likely related to accumulation of kinins and substance P (which are usually degraded by ACE and other endopeptidases)
- Clinical: dry cough with onset typically wihtin the first few weeks of therapy (although some cases do not present with cough until months later)
- Treatment: 50% of cases with cough ultimately need to have ACE-I discontinued -> cough usually stops within 4 days of discontinuation of ACE-I
- Rechallenge with ACE-I is not recommended, as cough will usually recur
- However, since ARB’s have much lower incidence of cough, one of these may be substituted
Drug-Induced Pulmonary Eosinophilia (see Drug-Induced Pulmonary Eosinophilia, [[Drug-Induced Pulmonary Eosinophilia]])
- Associated Agents
- Captopril (see Captopril, [[Captopril]])
- Fosinopril (see Fosinopril, [[Fosinopril]])
- Perindopril
Exacerbation of Bronchospasm (see Obstructive Lung Disease, [[Obstructive Lung Disease]])
- Epidemiology: very rare
Renal Adverse Effects
- Hyperkalemia (see Hyperkalemia, [[Hyperkalemia]]): due to drug-induced hypoaldosteronism (see above)
References
- xxx