NCLEX Review Guide: ACE Inhibitors and ARBs

ACE Inhibitors

• ACE inhibitors block the conversion of angiotensin I to angiotensin II, reducing vasoconstriction and aldosterone secretion. This leads to decreased blood pressure and reduced cardiac workload through vasodilation and decreased sodium retention.
• Common medications include lisinopril, enalapril, captopril, and ramipril - remember they typically end in "-pril".

ARBs (Angiotensin Receptor Blockers)

• ARBs directly block angiotensin II receptors, preventing vasoconstriction without affecting bradykinin metabolism. This provides similar cardiovascular benefits to ACE inhibitors but with fewer side effects.
• Common medications include losartan, valsartan, olmesartan, and telmisartan - remember they typically end in "-sartan".

Primary Indications

• Hypertension - First-line therapy, especially in patients with diabetes or chronic kidney disease
• Heart failure - Reduces mortality and hospitalizations by decreasing cardiac workload
• Post-myocardial infarction - Prevents cardiac remodeling and improves survival
• Diabetic nephropathy - Provides renal protection by reducing intraglomerular pressure

Common Side Effects

• Hyperkalemia - Monitor potassium levels regularly, especially with concurrent potassium supplements or potassium-sparing diuretics
• Hypotension - Particularly with first dose; start low and titrate slowly, especially in elderly patients
• Dry cough (ACE inhibitors only) - Occurs in 10-15% of patients due to increased bradykinin levels
• Dizziness, fatigue, and headache due to blood pressure reduction

Serious Adverse Effects

• Angioedema - Life-threatening swelling of face, lips, tongue, or throat; discontinue immediately and provide emergency care
• Acute kidney injury - Monitor creatinine and BUN, especially in patients with pre-existing renal disease
• Teratogenic effects - Contraindicated in pregnancy; can cause fetal kidney damage and oligohydramnios

Pre-Administration Assessment

1. Check baseline blood pressure, heart rate, and orthostatic vital signs
2. Review laboratory values: serum creatinine, BUN, and potassium levels
3. Assess for pregnancy status in women of childbearing age
4. Review current medications for potential interactions (especially potassium supplements, NSAIDs)

Ongoing Monitoring

• Vital signs - Monitor blood pressure and heart rate regularly; teach patients to rise slowly to prevent orthostatic hypotension
• Laboratory monitoring - Check potassium, creatinine, and BUN within 1-2 weeks of initiation and periodically thereafter
• Symptom assessment - Monitor for signs of angioedema, persistent cough, or worsening heart failure symptoms

Essential Teaching Points

• Medication adherence - Take daily as prescribed, even if feeling well; hypertension is often asymptomatic
• Safety measures - Rise slowly from sitting or lying positions to prevent dizziness and falls
• Dietary considerations - Avoid excessive potassium intake and salt substitutes containing potassium
• When to seek help - Report persistent cough, swelling of face/lips/tongue, severe dizziness, or signs of infection

• ☐ I can differentiate between ACE inhibitors (-pril) and ARBs (-sartan)
• ☐ I understand why ARBs are preferred when patients develop ACE inhibitor cough
• ☐ I know the key monitoring parameters: BP, K+, creatinine
• ☐ I can identify signs of angioedema and appropriate nursing actions
• ☐ I understand why these medications are contraindicated in pregnancy
• ☐ I can teach patients about orthostatic precautions