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Pharmacology · chapter 19 · Heart Failure Drugs

Drugs Affecting the Renin-Angiotensin-Aldosterone System

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. Why angiotensin II strains the failing heart

    Two of these effects that are important in heart failure are constriction of arterioles and sodium and water retention of the kidneys. Vasoconstriction causes increased afterload, and sodium and water retention cause increased preload.

  2. ACE inhibitor adverse effects

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

  3. ACE inhibitor cough and hyperkalemia

    Clients may develop an ACE inhibitor–associated cough (a persistent, dry, itchy cough). Hyperkalemia (elevated potassium level in the blood) may develop.

  4. Pregnancy and renal impairment

    ACE inhibitors cause fetal toxicity and should be immediately discontinued if pregnancy occurs. Clients with renal impairment should use cautiously.

  5. 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.

  6. ARBs: fewer side effects than ACE inhibitors

    The effect of ARBs is similar to that of ACE inhibitors; however, the side effects are lessened. This means that the potential for angioedema is decreased.

  7. ARBs and mood disturbances

    Clients with a history of mood disturbances or who are at risk for mood disturbances should be monitored closely for suicidal ideation.

  8. What an ARNI is

    It is a combination of an ARB and a new type of medication, a neprilysin inhibitor. There currently is only one medication in the ARNI class: sacubitril/valsartan (Entresto).

  9. Why blocking neprilysin helps

    Neprilysin is an enzyme that breaks down BNP. The inhibition of neprilysin means that BNP can stay in the body’s circulatory system longer.

  10. Only one of ACE inhibitor, ARB or ARNI

    Clients should not take ACE inhibitors, ARBs, or ARNIs at the same time. Clients should be prescribed only one of these classifications of medication at a time.

  11. How MRAs work

    Aldosterone antagonists block the receptor so that aldosterone can’t bind there. The end result is increased sodium and water excretion into the urine, and potassium reabsorption.

  12. MRAs: kidney disease and other drugs

    Because MRAs cause potassium retention, they should not be used by clients who have kidney disease. MRAs must be used carefully with other medications, such as ACE inhibitors and ARBs, that may cause hyperkalemia.

  13. MRAs: monitor electrolytes

    The client should have their serum electrolytes monitored regularly while taking MRAs. If hyperkalemia occurs, the drug may have to be discontinued.

  14. Black box: fetal toxicity

    Fetal toxicity can occur when taking ACE inhibitors during the second and third trimesters of pregnancy or when taking ARBs or ARNIs during pregnancy.

Terms to know

Angiotensin-converting enzyme (ACE) inhibitors
Angiotensin-converting enzyme (ACE) inhibitors are a classification of drugs that block the body’s production of angiotensin II.
Angiotensin II receptor blockers (ARBs)
Angiotensin II receptor blockers (ARBs) are a classification of drugs that bind to and inhibit angiotensin II type I receptors.
angiotensin receptor/neprilysin inhibitors (ARNIs)
Recently, a new classification of heart failure medication was developed, angiotensin receptor/neprilysin inhibitors (ARNIs).
Mineralocorticoid receptor antagonists (MRAs)
Mineralocorticoid receptor antagonists (MRAs) (also known as aldosterone antagonists) are often categorized as diuretics because they ultimately do cause diuresis.

Practice questions

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  1. A client with heart failure who takes lisinopril mentions using a potassium-based salt substitute to cut down on sodium. What is the nurse's main concern?

    1. Hypoglycemia
    2. Hyperkalemia
    3. Worsening cough
    4. Hyponatremia from too little salt

    Answer: Hyperkalemia

    Taking ACE inhibitors with potassium-containing salt substitutes increases the risk of hyperkalemia, and a potassium level above 6.0 mmol/L is a medical emergency. The other problems are not linked to salt substitutes in the section.

  2. A client who started enalapril two weeks ago reports a persistent, dry, itchy cough with no fever. What does the nurse recognise?

    1. A sign of fetal toxicity
    2. A sign of hyperkalemia
    3. A sign that the dose is too low
    4. An ACE inhibitor–associated cough

    Answer: An ACE inhibitor–associated cough

    Clients may develop an ACE inhibitor–associated cough, described as persistent, dry, and itchy, and clients are taught to report it. Hyperkalemia and fetal toxicity are separate adverse effects that do not present as cough.

  3. A client admitted with heart failure has a home medication list that includes lisinopril. A new order is written for sacubitril/valsartan. What should the nurse do?

    1. Give sacubitril/valsartan only at bedtime.
    2. Hold the lisinopril for one dose only.
    3. Question the order, because ACE inhibitors and ARNIs should not be taken at the same time.
    4. Give both drugs as ordered.

    Answer: Question the order, because ACE inhibitors and ARNIs should not be taken at the same time.

    Clients should not take ACE inhibitors, ARBs, or ARNIs at the same time, so the nurse reviews all medications and clarifies the order. Giving both, changing timing, or holding one dose does not resolve the duplication.

  4. A nurse is teaching a client who is starting spironolactone for heart failure. Which instructions should the nurse include? Select all that apply.

    1. Take a daily potassium supplement.
    2. Report breast enlargement or tenderness.
    3. Avoid foods high in potassium and salt substitutes.
    4. Tell your provider if you also take an ACE inhibitor or ARB.
    5. Report dizziness or fainting.

    Answer: Report breast enlargement or tenderness., Avoid foods high in potassium and salt substitutes., Tell your provider if you also take an ACE inhibitor or ARB., Report dizziness or fainting.

    MRAs cause potassium retention, so clients avoid high-potassium foods and salt substitutes and tell the provider about ACE inhibitors, ARBs, or other potassium-sparing drugs; gynecomastia and low blood pressure symptoms are reported. A potassium supplement would add to the risk of hyperkalemia.

  5. A client with heart failure and a history of depression is started on losartan. Which actions should the nurse take? Select all that apply.

    1. Teach the client that a dry cough is the most common side effect.
    2. Monitor closely for suicidal ideation.
    3. Monitor for changes in liver and renal function.
    4. Monitor blood pressure as prescribed.
    5. Monitor for electrolyte imbalances.

    Answer: Monitor closely for suicidal ideation., Monitor for changes in liver and renal function., Monitor blood pressure as prescribed., Monitor for electrolyte imbalances.

    For ARBs, the nurse monitors blood pressure, electrolytes, and liver and renal function, and clients with a history of mood disturbances are monitored closely for suicidal ideation. Unlike ACE inhibitors, ARBs have no side effect of cough.

  6. A client taking valsartan for heart failure tells the nurse she is planning to become pregnant. What should the nurse tell her?

    1. Stop the drug only in the third trimester.
    2. Switch to a potassium salt substitute during pregnancy.
    3. ARBs are safe throughout pregnancy.
    4. Notify your provider, because ARBs cause fetal toxicity and should not be taken during pregnancy.

    Answer: Notify your provider, because ARBs cause fetal toxicity and should not be taken during pregnancy.

    ARBs cause fetal toxicity and should not be taken during pregnancy, and clients notify the provider if planning pregnancy. The black box warning covers ARBs during pregnancy, not only one trimester.

Where every quote comes from

Section 19.2 Drugs Affecting the Renin-Angiotensin-Aldosterone System 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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