Today we’re going to be discussing two of probably the most prescribed medications, the ACE inhibitors ace inhibitors, and the ARB’s. Both of these groups are related but work in different ways. But first let’s talk again about high blood pressure and what we know about it so that we can understand how these medications work. We know the heart is the pump of the body, we know the heart has to contract to pump blood and fluid through the blood vessels and circulate throughout the body, and return to the heart. We also know that there is a normal range of blood pressure that’s created when the heart contracts and pushes that blood and fluid through the blood vessels. High blood pressuregenerally occurs when those blood vessels are narrowed, now that can be caused by lifestyle and can be caused by a number of different factors, but what occurs here is the workload of the heart increases and what occurs is the heart now has to contract more forcefully thereby generating greater amounts of pressure to force the same amount of fluid and blood through the heart into those narrow blood vessels. So the heart has to now contract more forcefully greater amount of workload greater amount of pressure to push the blood and fluid through those narrow blood vessels, that’s what we consider high blood pressure.
So let’s talk first about the group ACE inhibitors, A stands for angiotensin, C stands for converting, and E stands for enzyme and we have the word inhibitors after it. So it’s angiotensin converting enzyme inhibitors it’s a big word so we’re going to use substance A to represent angiotensin, so when I use substance A or say it that means angiotensin. It’ll make the explanation a lot easier to talk about and how it works. So how do the angiotensin or substance A converting enzyme inhibitors work, how do these medications reduce blood pressure. substance A is secreted by the kidney and flows throughout the body in its very inactive form, it really does nothing in its original form it’s inactive. What occurs is that there is another substance, an enzyme, what we call a converting enzyme that attaches to substance A and converts it from an inactive form to that of an active form and what that active form does it is a very strong and potent vasoconstrictor. In essence it constricts the blood vessels and therefore increases the blood pressure.
So we have a substance a circulating throughout the body that is inactive, it does really nothing, however when a substance called the converting enzyme attaches to that substance a it converts it from an inactive form to an active form, and what occurs then is that active form works on arteries and veins the blood vessels of the body to constrict them to narrow them. And in doing so puts more work on the heart to push the fluid through the heart the blood and fluid through the heart and therefore increases blood pressure.
What these medications do is they inhibit that enzyme, they inhibit that converting enzyme to attach to the inactive substance a thereby not allowing the active form of substance A to be formed, and cause vasoconstriction or a narrowing of the blood vessels. Therefore preventing or reducing high blood pressure. Other activities that causes high blood pressure with active substance A is that it retains sodium, it makes the body retain sodium. Sodium is a water magnet so both between the vasoconstriction or the narrowing or further narrowing of the blood vessels and the retention of fluid, water in particular, we get an increase in blood pressure. So it works in two different areas, one the blood vessels, and two in the kidneys because it’s not allowing sodium to be excreted or urinated out and therefore reduction in fluids. so it works in actually two areas of the body to decrease blood pressure.
Ace inhibitors are usually administered by mouth and are given once or twice a day usually taking one in the morning and one in the evening after dinner, just before bedtime so that you have the coverage throughout the day and throughout the night.
So let’s talk about some of the side effects, some of the common side effects with ace inhibitors, and before I begin I want to preface this that any side effect that’s persistent , you really need to contact your health care provider. Any persistent side effect is not something that is not normal and you need to inform the health care provider so that they can make changes either to the medication or to the dosage an with ace inhibitors. There’s an interesting side effect called a dry cough, we call it an angiotensin cough or an ACE inhibitor cough, and it’s a dry hacking type of cough that has no real reason to be there. You don’t have anything that’s causing it outside, you’re not having some type of irritant that you’re breathing into the back of your throat and stimulating a cough, it’s just there. This would be something that you would want to definitely contact your health care provider for they may want to change the medication to another medication, or a different class of medication. Fatigue dizziness these are also side effects an again fatigue and dizziness may be transient, they may not be persistent, but if you continually find yourself persistently fatigued or you find yourself having serious dizziness or a number of bouts of dizziness it’s definitely important that the you contact your health care provider. They may want to change the dosage or the medication the dosage strength for that medication to reduce that. Headaches may occur again they usually sometimes a transient but if it’s persistent that’s another side effect you want to you want to contact your health care provider. Also a loss of taste, that would be definitely something I would call my health care provider about, specially somebody who likes food like myself you don’t want to have a loss of taste.
In terms of drug interactions, taking other medications non-steroidal anti-inflammatory drugs or what we call NSAID’s now these are the ibuprofen’s of the world the Naprosyn’s of the world. You know trade names like Advil,Motrin, Aleve, so if you’re taking something for, example arthritis, and you’re constantly taking the non-steroidal anti-inflammatory drugs such as Naprosyn, or Ibuprofen those can reduce the effectiveness of ace inhibitors. Taking an occasional dose is not going to be a problem, but chronically using them that could affect the effectiveness of this high blood pressure medication.
So let’s talk about how ARB’s, angiotensin receptor blockers, work and I want you to keep in mind get a visualization of a big parking lot with cars parked in every space except one. So we have substance A angiotensin which we called substance A and this angiotensin or substance A is in an active form. We know from the previous description on ace inhibitors substance A in active form causes vasoconstriction a narrowing of the blood vessels. What the ARB’s do is they compete and fill in that one parking space that substance a angiotensin would fill in to cause a blocking of the blood vessels narrowing. So we have a parking lot with 1 space vacant and if substance A angiotensin fits into that parking space it will cause a narrowing of of the blood vessels. This medicine goes and fills that space up so it prevents substance A angiotensin from going in there and affecting that blood vessel, that’s exactly what these medications do. They also prevent fluid from building up because they allow sodium to be excreted or urinated and therefore water to be lost as well.
The side effects are basically similar to those of the ace inhibitors, again any side effect that’s persistent, any side effect that’s dramatic please contact your health care provider and let them know. If you should have any type of swelling in your throat, your tongue, difficulty in breathing and obviously any kind of chest pains that’s an immediate call to your emergency services so that you can get to the hospital and get treatment. Another point here is if you are pregnant, thinking on becoming pregnant, or breastfeeding and you have been placed on these medications you need to make sure that all your health care providers know, and discuss this with them.
ARB’s are usually taken orally and they may be taken once or twice a day depending upon how the health care provider wants to set up your medication regimen.
Examples of ACE inhibitors include:
Generic name Common brand name
- Benazepril (Lotensin)
- Captopril
- Enalapril (Vasotec)
- Fosinopril
- Lisinopril (Prinivil, Zestril)
- Moexipril
- Perindopril
- Quinapril (Accupril)
- Ramipril (Altace)
- Trandolapril
Examples of Beta Blockers
| Generic name | Common brand names |
| acebutolol | Sectral* |
| atenolol | Tenormin* |
| betaxolol | Kerlone* |
| bisoprolol fumarate | Zebeta* |
| carteolol hydrochloride | Cartrol* |
| metoprolol tartrate | Lopressor* |
| metoprolol succinate | Toprol-XL* |
| nadolol | Corgard* |
| penbutolol sulfate | Levatol* |
| pindolol* | Visken* |
| propranolol hydrochloride* | Inderal* |
| solotol hydrochloride | Betapace* |
| timolol maleate* | Blocadren* |
References & Links
- Types of blood pressure medications. American Heart Association. https://www.heart.org/en/health-topics/high-blood-pressure/changes-you-can-make-to-manage-high-blood-pressure/types-of-blood-pressure-medications. Accessed July 14, 2021.
- Argulian E, et al. Misconceptions and facts about beta-blockers. The American Journal of Medicine. 2019; doi:10.1016/j.amjmed.2019.01.039.
- Whelton PK, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71:e13.
- Mann JFE. Choice of drug therapy in primary (essential) hypertension. https://www.uptodate.com/contents/search. Accessed June 28, 2019.
- Sidawy AN, et al., eds. Atherosclerotic risk factors: Hypertension. In: Rutherford’s Vascular Surgery and Endovascular Therapy. 9th ed. Philadelphia, Pa.: Elsevier; 2019. https://www.clinicalkey.com. Accessed June 28, 2019.
- Bloch MJ, et al. Antihypertensive drugs and lipids. https://www.uptodate.com/contents/search. Accessed July 14, 2021.
- Mann JFE. Choice of drug therapy in primary (essential) hypertension. https://www.uptodate.com/contents/search. Accessed June 25, 2019.
- Types of blood pressure medications. American Heart Association. https://www.heart.org/en/health-topics/high-blood-pressure/changes-you-can-make-to-manage-high-blood-pressure/types-of-blood-pressure-medications. Accessed July 26, 2021.
- Sidawy AN, et al., eds. Atherosclerotic risk factors: Hypertension. In: Rutherford’s Vascular Surgery and Endovascular Therapy. 9th ed. Philadelphia, Pa.: Elsevier; 2019. https://www.clinicalkey.com. Accessed July 11, 2019.
- Bakris GL, et al. Calcium channel blockers. In: Hypertension: A Companion to Braunwald’s Heart Disease. 3rd ed. Philadelphia, Pa.: Elsevier Saunders; 2018. https://www.clinicalkey.com. Accessed July 19, 2019.
- Aronson JK, ed. Calcium channel blockers. In: Meyler’s Side Effects of Drugs. 16th ed. Amsterdam, Netherlands: Elsevier; 2016. https://www.clinicalkey.com. Accessed July 19, 2019.
- Block MJ, et al. Major side effects and safety of calcium channel blockers. https://www.uptodate.com/contents/search. Accessed July 19, 2019.
Sept. 16, 2021
https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/in-depth/ace-inhibitors/art-20047
https://medlineplus.gov/ency/patientinstructions/000364.htm
Data, quotes, or other informationhttps://www.ncbi.nlm.nih.gov/books/NBK430896/
Supporting points blocker.https://newsnetwork.mayoclinic.org/discussion/ace-inhibitors/