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Pharmacology · chapter 18 · Antihypertensive and Antianginal Drugs

Angiotensin-Converting Enzyme (ACE) Inhibitors

The 14 things this section of the textbook says that you are most likely to be asked about — quoted word for word, not retold. Then 6 practice questions with the reasoning.

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Key points

  1. What ACE inhibitors block

    Angiotensin-converting enzyme (ACE) inhibitors are a classification of drugs that block the body’s production of angiotensin II.

  2. What angiotensin II does to vessels

    Angiotensin II also causes vasoconstriction and inhibits the reuptake of norepinephrine, stimulating catecholamine release.

  3. First-line treatment for hypertension

    ACE inhibitors are used to treat hypertension and cardiovascular diseases by reducing the release of aldosterone as part of the first line of treatment for clients who have hypertension (Goyal et al., 2022).

  4. Weaker response to monotherapy in some

    Some clients with hypertension demonstrate a lower response to ACE inhibitor monotherapy. ACE inhibitors interfere with the renin-angiotensin-aldosterone system, which causes high blood pressure when renin levels are high.

  5. Low renin and combined therapy

    Black clients often have hypertension, but also have lower levels of renin. Therefore, concomitant therapy may be required to increase response to antihypertensive therapies.

  6. Adverse effects

    Adverse effects include angioedema, nonproductive cough, neutropenia (low neutrophils in the blood), agranulocytosis (low granulocytes in the blood), proteinuria (protein in the urine), and rash.

  7. Cough, hyperkalemia and hypotension

    Clients may develop an ACE inhibitor–associated cough (a persistent, dry, itchy cough), hyperkalemia (elevated potassium level in the blood), or hypotension (Jun et al., 2021).

  8. Pregnancy and renal impairment

    ACE inhibitors should not be taken during pregnancy. Clients with renal impairment should use them cautiously.

  9. Previous hypersensitivity

    Clients with a previous hypersensitivity reaction to an ACE inhibitor should not be prescribed this classification of drug.

  10. Monitor blood pressure, pulse and potassium

    Assess the client’s blood pressure and pulse on an ongoing basis with initial dosing and intermittently during drug therapy. Monitor serum potassium levels for hyperkalemia.

  11. Salt substitutes and hyperkalemia

    Taking ACE inhibitors with potassium-containing salt substitutes or consuming large amounts of high potassium foods increases the risk of hyperkalemia. Having a blood potassium level above 6.0 mmol/L is considered a medical emergency and can result in cardiac arrest.

  12. Side effects to report

    Report side effects such as low blood pressure, cough, heart palpitations, nausea, vomiting, fever, chills, sore throat, swelling of the eyes and lips, or difficulty breathing to their health care provider.

  13. Signs of heart attack or stroke

    Report symptoms such as chest pain, slurred speech, hemiparesis, and difficulty speaking or walking to their health care provider immediately because these may be symptoms of a heart attack or stroke.

  14. Black box warning in pregnancy

    The use of ACE inhibitors during the second and third trimesters of pregnancy has been associated with fetal and neonatal injury, including hypotension, neonatal skull hypoplasia, anuria, reversible or irreversible renal failure, and death.

Terms to know

ACE inhibitors
Angiotensin-converting enzyme (ACE) inhibitors are a classification of drugs that block the body’s production of angiotensin II.
ACE inhibitor–associated cough
Clients may develop an ACE inhibitor–associated cough (a persistent, dry, itchy cough), hyperkalemia (elevated potassium level in the blood), or hypotension (Jun et al., 2021).
Neutropenia
Adverse effects include angioedema, nonproductive cough, neutropenia (low neutrophils in the blood), agranulocytosis (low granulocytes in the blood), proteinuria (protein in the urine), and rash.
Hyperkalemia
Clients may develop an ACE inhibitor–associated cough (a persistent, dry, itchy cough), hyperkalemia (elevated potassium level in the blood), or hypotension (Jun et al., 2021).

Practice questions

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  1. A client starting lisinopril tells the nurse they cook with a salt substitute because they were told to cut down on salt. What is the nurse's best response?

    1. Take the lisinopril two hours after using the salt substitute.
    2. Avoid salt substitutes, because they are high in potassium and can raise your potassium level.
    3. Use the salt substitute only with meals that contain meat.
    4. That is a good choice because it lowers sodium intake.

    Answer: Avoid salt substitutes, because they are high in potassium and can raise your potassium level.

    Salt substitutes contain potassium, and taking an ACE inhibitor with them increases the risk of hyperkalemia. Encouraging the substitute or changing the timing does not remove that risk.

  2. A client who has taken enalapril for two weeks reports a persistent, dry, itchy cough with no fever. How should the nurse interpret this finding?

    1. It means the dose is too low.
    2. It is a sign of a bacterial chest infection.
    3. It is a known adverse effect of ACE inhibitors.
    4. It is a sign of hypokalemia.

    Answer: It is a known adverse effect of ACE inhibitors.

    A persistent, dry, itchy cough is described as ACE inhibitor–associated cough, and clients are taught it may develop. The section does not link it to infection, underdosing or low potassium.

  3. A client with hypertension who is taking an ACE inhibitor tells the nurse she has just found out she is pregnant. What is the nurse's priority action?

    1. Tell her to continue the drug and recheck her blood pressure at the next visit.
    2. Notify the health care provider, because ACE inhibitors should not be taken during pregnancy.
    3. Tell her to double her fluid intake.
    4. Teach her to take the dose at bedtime.

    Answer: Notify the health care provider, because ACE inhibitors should not be taken during pregnancy.

    ACE inhibitors should not be taken during pregnancy, and use in the second and third trimesters carries a black box warning for fetal and neonatal injury. The provider must be told; continuing the drug or changing the timing leaves the fetus exposed.

  4. A nurse is caring for a client who has just started an ACE inhibitor. Which assessments should the nurse include? Select all that apply.

    1. Serum calcium level
    2. Pulse
    3. Swelling of the eyes and lips
    4. Serum potassium level
    5. Blood pressure

    Answer: Pulse, Swelling of the eyes and lips, Serum potassium level, Blood pressure

    The nurse assesses blood pressure and pulse with initial dosing, monitors serum potassium for hyperkalemia, and watches for angioedema such as swelling of the eyes and lips. Calcium monitoring is not described for ACE inhibitors in this section.

  5. Which findings in a client's history would make the nurse question an order for an ACE inhibitor or use it only with caution? Select all that apply.

    1. History of angioedema with an ACE inhibitor
    2. Current pregnancy
    3. Well-controlled seasonal allergies
    4. Renal impairment
    5. Previous hypersensitivity reaction to an ACE inhibitor

    Answer: History of angioedema with an ACE inhibitor, Current pregnancy, Renal impairment, Previous hypersensitivity reaction to an ACE inhibitor

    Clients with previous hypersensitivity or angioedema from an ACE inhibitor should not receive the class, the drugs should not be taken in pregnancy, and renal impairment calls for caution. Seasonal allergies are not listed as a contraindication.

  6. A client taking an ACE inhibitor has a serum potassium level of 6.2 mmol/L. How should the nurse interpret this result?

    1. It is a medical emergency that can lead to cardiac arrest.
    2. It is an expected, harmless effect of the drug.
    3. It means the client needs more potassium-rich foods.
    4. It shows the drug is not working.

    Answer: It is a medical emergency that can lead to cardiac arrest.

    ACE inhibitors can cause hyperkalemia, and a potassium level above 6.0 mmol/L is a medical emergency that can result in cardiac arrest. It is not harmless, and more potassium would make it worse.

Where every quote comes from

Section 18.2 Angiotensin-Converting Enzyme (ACE) Inhibitors of Pharmacology for Nurses by Tina Barbour-Taylor, Leah Mueller (Sabato), Donna Paris, Dorie Weaver, OpenStax, 2024. Read the whole section free at openstax.org.

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