What is the recommended usage and dosage of Angiotensin-Converting Enzyme (ACE) inhibitors for patients with hypertension?

ACE Inhibitors for Hypertension Management

ACE inhibitors are recommended as first-line therapy for hypertension, with treatment initiated at low doses and gradually titrated to target doses that have demonstrated cardiovascular event reduction in clinical trials. 1

Dosing Recommendations

• Initial therapy should begin with low doses, followed by gradual dose increments if well tolerated 1:

  • Lisinopril: Start with 10 mg once daily (5 mg if on diuretics), titrate to 20-40 mg daily 2
  • Captopril: Start with 6.25 mg three times daily, titrate to 50 mg three times daily 1
  • Enalapril: Start with 2.5 mg twice daily, titrate to 10-20 mg twice daily 1
  • Ramipril: Start with 1.25-2.5 mg once daily, titrate to 10 mg once daily 1

• For patients with blood pressure ≥160/100 mmHg, consider initial therapy with two antihypertensive medications, such as an ACE inhibitor plus a thiazide diuretic 1, 3

• Maximum doses should target those shown to reduce cardiovascular events in clinical trials, though intermediate doses may be used if target doses aren't tolerated 1

Patient Selection

• ACE inhibitors are particularly beneficial for patients with:

  • Heart failure with reduced ejection fraction (HFrEF) 1
  • Coronary artery disease 1
  • Diabetes mellitus 1
  • Chronic kidney disease, especially with albuminuria 1

• Use ACE inhibitors with caution in patients with:

  • Very low systolic blood pressure (<80 mm Hg) 1
  • Markedly increased serum creatinine (>3 mg/dL) 1
  • Bilateral renal artery stenosis 1
  • Elevated serum potassium (>5.0 mEq/L) 1

• ACE inhibitors are contraindicated in:

  • Patients with history of angioedema 1
  • Pregnancy or women planning to become pregnant 1

Monitoring

• Assess renal function and serum potassium within 1-2 weeks of initiation and periodically thereafter 1
• More frequent monitoring is recommended for patients with:
  • Preexisting hypotension 1
  • Hyponatremia 1
  • Diabetes mellitus 1
  • Azotemia 1
  • Patients taking potassium supplements 1

Important Clinical Considerations

• There are no significant differences among ACE inhibitors in their effects on symptoms or survival 1

• ACE inhibitors should not be combined with ARBs or direct renin inhibitors due to increased risk of adverse events (hyperkalemia, syncope, acute kidney injury) 1

• Abrupt withdrawal of ACE inhibitors should be avoided as it can lead to clinical deterioration 1

• Common adverse effects include:

  • Cough (most common) 4
  • Skin rash 4
  • Hypotension, especially in volume-depleted patients 1, 4
  • Hyperkalemia 4

• For patients who develop intolerable cough with ACE inhibitors, an ARB may be substituted as an alternative 1, 5

• In patients with diabetes and hypertension, ACE inhibitors are recommended as first-line therapy, particularly in those with albuminuria 1, 5

• For patients with chronic kidney disease (stage 3 or higher or stage 1-2 with albuminuria), ACE inhibitors are reasonable to slow kidney disease progression 1