Comparing ACE Inhibitors and ARBs

Hey everyone, it's Sarah with RegisteredNurseRN.com and today we're going to compare some medications. We're going to look at ACE inhibitors and ARBs. And as always, whenever you get done watching this YouTube video, you can access the free quizzes that will test you on these two medications. So let's get started. In our previous lectures, we went in depth over ACE inhibitors and ARBs, but now let's do a quick review so we can see the similarities and the differences. So when you take an exam, you can easily differentiate between these two medications. So we have ACE inhibitors. ACE stands for angiotensin converting enzyme. ARB stands for angiotensin 2 receptor blockers. Now these medications affect RAS. They do it in different ways, however, they both achieve the same results. Now, what is RAS? Well, RAS is the renin-angiotensin-aldosterone system. But what does this system do? Well, it manages our blood pressure, specifically whenever it drops. And the whole goal of RAS is to get angiotensin II on board because it is a major active vasoconstrictor. And if we can vasoconstrictor. strict among other things we can increase our blood pressure we increase blood pressure we maintain tissue perfusion so what happens with RAS is that whenever the blood pressure drops the kidneys themselves and the kidneys will sense this and they will release renin when renin goes into the circulation it is going to stimulate a substance that is in the liver called angiotensinogen and angiotensinogen is going to turn into angiotensin 1. Well, we got to get to angiotensin 2. So to do that, ACE will help us out. That is angiotensin converting enzyme. It's going to convert angiotensin 1 into angiotensin 2. So we're there. We have this major vasoconstrictor present, but it has to bind to some receptors because then we can get things going. So one type of receptor that this angiotensin 2 is going to bind to is called an angiotensin 2 receptor. receptor site type 1. And whenever angiotensin 2 binds with those type 1 receptors, it is going to lead to the results we need. It's going to cause vasoconstriction of our smooth vessels. So when we constrict vessels, that is going to clamp down and that is going to help increase blood pressure, increase our systemic vascular resistance. In addition, we are going to trigger the release of a substance. called aldosterone by the adrenal cortex. And the whole reason for this is to help increase blood volume. Because if we can increase blood volume, we constrict our vessels, we are definitely going to increase blood pressure and maintain tissue perfusion. And to do this, this aldosterone will cause the kidneys to keep sodium in water but excrete potassium. Now let's look at how these two medications affect RAS. Because remember, they do it. in different ways but they achieve the same results and really what they're targeting is this angiotensin 2 so let's look at ACE inhibitors what ACE inhibitors are going to do is they are going to inhibit ACE hence their name so they inhibit this part of RAS they prevent angiotensin 1 from turning into angiotensin 2 so we don't have angiotensin 2 being able to do its job now ARBs what it's going to do is it's going to inactivate the angiotensin 2 receptor sites type 1 so we will have the conversion of angiotensin 1 to angiotensin 2 you have ACE doing its job but what we're going to prevent is this angiotensin 2 being able to bind with these type 1 receptors so you don't get the effects of angiotensin 2 so as you can see they're both affecting angiotensin 2 ACE inhibitors is just preventing this ACE. ARBs, it's preventing the activation of these receptor sites. Either way, they are affecting how angiotensin 2 works. Therefore, with both of these medications, what they're going to achieve is that they're going to cause vasodilation instead of vasoconstriction. So that's going to decrease systemic vascular resistance and decrease the blood pressure and it's going to make it a little bit easier on the heart to pump. And here in a moment when we talk about what these drugs are used. for it you'll see why they're beneficial on some patients in addition they're both going to decrease that secretion of aldosterone which again was to help increase our blood volume so instead of keeping sodium and water we're going to excrete it but they will cause the kidneys to keep potassium so we really have to watch out for hyperkalemia in these patients who take these drugs now Now some other things you want to remember to help you differentiate between them is how their generic name ends. What does it specifically end with? With ACE inhibitors, the generics are going to end with pril, like lisinopril. With ARBs, the generics will end with pril. in with sartin, like low sartin. So when you're looking at the meds and you're trying to determine is this an ACE or an ARB, look at the ending of those generic names. It'll really help you. And another thing I want to point out is with ACE inhibitors, some patients, not all, can develop this persistent, nagging, dry cough. And the reason for that is because of how this ACE inhibitor is influencing this ACE enzyme that is converting angiotensin. 1 into angiotensin 2. Over here with ARBs, a dry persistent nagging cough is not likely. A lot of times if a patient does develop this dry persistent cough with an ACE, the physician may put them on an ARB because that will help clear that up. The reason for that is because ACE normally will inactivate a substance called bradykinin. Bradykinin is an inflammatory substance and what it will do is it will break it down so it will inactivate. But if we're blocking this by throwing on an ACE inhibitor, we're not going to be inactivating this bradykinin. So it can increase and it can cause this coughing. Another thing with ACE inhibitors that you want to watch out for as the nurse is something that can happen called angioedema. This is where you have swelling of the deep tissues and it can present of swelling of the face, the tongue, the lips, and it can cause difficulty breathing. If that happens, that's a medical emergency. It's less likely to happen with an ARB, so there's a low chance of it happening, but you always just want to monitor for that as well. Now let's wrap up this review and let's talk about what these medications are used for and look at our nursing interventions and our patient education together. So what are ACE and ARBs used to treat? Well, we've already learned that they help lower the blood pressure. So they're great in helping patients who have hypertension, managing the blood pressure, that blood pressure, keeping it low. In addition, patients who have heart failure, this is where that heart muscle is damaged and it can't really pump, so it's not really maintaining cardiac output. Plus blood can backflow, go into the lungs, lead to pulmonary edema. And how ACE and ARBs will work is that they can help decrease the afterload and the preload on the heart, making it easier to pump and get blood out to maintain cardiac output. In addition, ACE and ARBs can be used after a patient has a myocardial infarction. Cardio Infarction. Again, just helping the heart pump easier after it's been damaged. And these medications can help decrease the progression of diabetic nephropathy in those patients who have type 2 diabetes. Now what is diabetic nephropathy? Well this is kidney disease caused by diabetes and whenever a patient has kidney disease those little nephrons in the kidneys are affected because that's a functional unit of the kidney that that doesn't work. And they really lose the ability to filter the blood very well. So protein will start to leak into the urine. Well, if you have high blood pressure, you're increasing the amount of protein that's going into the urine. Well, if we throw an ACE and ARB on, that can help lower the blood pressure, which will decrease the amount of protein that's going into the urine, hence slowing down our kidney disease. So these medications have like that renal protective mechanism. Now, what are some patient education? Education and things you want to watch out for as the nurse. Well, we've learned that this meant these medications can increase the potassium Level with the way that it affects aldosterone Because aldosterone is not really going to be released. So now the kidneys are going to start keeping Potassium so there's a risk for hyperkalemia Therefore you want to monitor the potassium levels, but you want to tell the patient to avoid consuming a diet really high in potassium So watch those salt substitutes that have potassium and those foods that are high in potassium like spinach, avocados, bananas, etc. because that can increase our potassium levels. In addition, you want to talk to the patient about how to prevent a condition called rebound hypertension. This is where the blood pressure will get so high it'll be hard to actually bring the blood pressure down and this tends to happen when a patient just abruptly quits taking their ACE or their ARB. So educate the patient about the importance. and never just quit taking. the medication because sometimes patient let's say they're started on ace inhibitor they develop that dry nagging persistent cough it's driving them crazy and it's driving everyone else around them crazy because they keep coughing so they may just quit taking the medication but Instead of doing that, they need to talk to their doctor and their doctor can switch them to something else where they won't have that dry cough. So just let them know that that can happen if they just abruptly quit taking it. In addition, they need to make sure they're monitoring their blood pressure. at home. They need to get a device. They need to write down the recordings of what their blood pressure is. Daily doing this is best because we want to make sure that these medications are, in fact, managing their blood pressure or are they still hypertensive or is it too much? They're hypotensive. So definitely communicate that to them and lifestyle changes that they need to do. If they're taking these medications to help lower the blood pressure, let them know that antihypertensive medications are not a cure for high blood pressure. They need to manage their diet by eating healthy, exercising, or quit smoking if they're smoking to help with that as well. So we want to monitor the potassium level as we discussed over here because of hyperkalemia, but we also want to look at the liver enzymes, making sure the liver is not being affected, and renal function. Because in some patients who are dependent on the RAS because let's say they have severe heart failure, with severe heart failure their cardiac output isn't that great so they depend on this RAS to maintain cardiac output for them so if we give them an ACE and an ARB which affects RAS that's really going to cause some kidney issues so we want to be making sure we monitor the BUN the creatinine what's the renal out their urinary output is it at least 30 cc's an hour are they having any abnormal swelling going on in their body where they're retaining fluid and lastly you want to talk to the patient about this cough that can happen with these ACE inhibitors and if they can't tolerate it, what should they do? And remember, they can be switched to ARBs, which doesn't have that dry, persistent cough. Now, one thing you really want to watch out for if you're working with patients who have heart failure and they're on an ACE inhibitor, let's say that all of a sudden they get this cough. Well, you want to further investigate this cough. You don't want to just write it off. Oh, it's that cough that you get with ACE inhibitors because with heart failure, they... their heart will be weak the blood will back up into the lungs where they'll get pulmonary edema so they'll start getting a cough but this cough will be like a wet cough you'll hear crackles if you listen to their lungs they'll have difficulty breathing with just any movement like moving from the bedside chair to the bed they get really winded so you want to make sure that is this just that cough that you get with ACE inhibitors which is dry it's not going to be have crackles or wet or is this heart failure exacerbation? So make sure you look at that. In addition, educate the patient about this angioedema. That's more likely to happen with the ACE inhibitors, but it can happen with ARBs. It's less likely. It's rare too, but educate them about the swelling of the face, the mouth, the lips, difficulty breathing, and let them know that it's a medical emergency and that they should seek attention immediately. Okay, so that wraps up this review over ACE inhibitors versus ARBs. Thank you so much for watching. Don't forget to take the free quiz and to subscribe to our channel for more videos.

So let's get started. In our previous lectures, we went in depth over ACE inhibitors and ARBs, but now let's do a quick review so we can see the similarities and the differences. So when you take an exam, you can easily differentiate between these two medications.

So we have ACE inhibitors. ACE stands for angiotensin converting enzyme. ARB stands for angiotensin 2 receptor blockers. Now these medications affect RAS. They do it in different ways, however, they both achieve the same results.

Now, what is RAS? Well, RAS is the renin-angiotensin-aldosterone system. But what does this system do? Well, it manages our blood pressure, specifically whenever it drops. And the whole goal of RAS is to get angiotensin II on board because it is a major active vasoconstrictor.

And if we can vasoconstrictor. strict among other things we can increase our blood pressure we increase blood pressure we maintain tissue perfusion so what happens with RAS is that whenever the blood pressure drops the kidneys themselves and the kidneys will sense this and they will release renin when renin goes into the circulation it is going to stimulate a substance that is in the liver called angiotensinogen and angiotensinogen is going to turn into angiotensin 1. Well, we got to get to angiotensin 2. So to do that, ACE will help us out. That is angiotensin converting enzyme. It's going to convert angiotensin 1 into angiotensin 2. So we're there.

We have this major vasoconstrictor present, but it has to bind to some receptors because then we can get things going. So one type of receptor that this angiotensin 2 is going to bind to is called an angiotensin 2 receptor. receptor site type 1. And whenever angiotensin 2 binds with those type 1 receptors, it is going to lead to the results we need.

It's going to cause vasoconstriction of our smooth vessels. So when we constrict vessels, that is going to clamp down and that is going to help increase blood pressure, increase our systemic vascular resistance. In addition, we are going to trigger the release of a substance. called aldosterone by the adrenal cortex. And the whole reason for this is to help increase blood volume.

Because if we can increase blood volume, we constrict our vessels, we are definitely going to increase blood pressure and maintain tissue perfusion. And to do this, this aldosterone will cause the kidneys to keep sodium in water but excrete potassium. Now let's look at how these two medications affect RAS.

Because remember, they do it. in different ways but they achieve the same results and really what they're targeting is this angiotensin 2 so let's look at ACE inhibitors what ACE inhibitors are going to do is they are going to inhibit ACE hence their name so they inhibit this part of RAS they prevent angiotensin 1 from turning into angiotensin 2 so we don't have angiotensin 2 being able to do its job now ARBs what it's going to do is it's going to inactivate the angiotensin 2 receptor sites type 1 so we will have the conversion of angiotensin 1 to angiotensin 2 you have ACE doing its job but what we're going to prevent is this angiotensin 2 being able to bind with these type 1 receptors so you don't get the effects of angiotensin 2 so as you can see they're both affecting angiotensin 2 ACE inhibitors is just preventing this ACE. ARBs, it's preventing the activation of these receptor sites. Either way, they are affecting how angiotensin 2 works.

Therefore, with both of these medications, what they're going to achieve is that they're going to cause vasodilation instead of vasoconstriction. So that's going to decrease systemic vascular resistance and decrease the blood pressure and it's going to make it a little bit easier on the heart to pump. And here in a moment when we talk about what these drugs are used. for it you'll see why they're beneficial on some patients in addition they're both going to decrease that secretion of aldosterone which again was to help increase our blood volume so instead of keeping sodium and water we're going to excrete it but they will cause the kidneys to keep potassium so we really have to watch out for hyperkalemia in these patients who take these drugs now Now some other things you want to remember to help you differentiate between them is how their generic name ends.

What does it specifically end with? With ACE inhibitors, the generics are going to end with pril, like lisinopril. With ARBs, the generics will end with pril. in with sartin, like low sartin.

So when you're looking at the meds and you're trying to determine is this an ACE or an ARB, look at the ending of those generic names. It'll really help you. And another thing I want to point out is with ACE inhibitors, some patients, not all, can develop this persistent, nagging, dry cough.

And the reason for that is because of how this ACE inhibitor is influencing this ACE enzyme that is converting angiotensin. 1 into angiotensin 2. Over here with ARBs, a dry persistent nagging cough is not likely. A lot of times if a patient does develop this dry persistent cough with an ACE, the physician may put them on an ARB because that will help clear that up.

The reason for that is because ACE normally will inactivate a substance called bradykinin. Bradykinin is an inflammatory substance and what it will do is it will break it down so it will inactivate. But if we're blocking this by throwing on an ACE inhibitor, we're not going to be inactivating this bradykinin.

So it can increase and it can cause this coughing. Another thing with ACE inhibitors that you want to watch out for as the nurse is something that can happen called angioedema. This is where you have swelling of the deep tissues and it can present of swelling of the face, the tongue, the lips, and it can cause difficulty breathing.

If that happens, that's a medical emergency. It's less likely to happen with an ARB, so there's a low chance of it happening, but you always just want to monitor for that as well. Now let's wrap up this review and let's talk about what these medications are used for and look at our nursing interventions and our patient education together.

So what are ACE and ARBs used to treat? Well, we've already learned that they help lower the blood pressure. So they're great in helping patients who have hypertension, managing the blood pressure, that blood pressure, keeping it low.

In addition, patients who have heart failure, this is where that heart muscle is damaged and it can't really pump, so it's not really maintaining cardiac output. Plus blood can backflow, go into the lungs, lead to pulmonary edema. And how ACE and ARBs will work is that they can help decrease the afterload and the preload on the heart, making it easier to pump and get blood out to maintain cardiac output. In addition, ACE and ARBs can be used after a patient has a myocardial infarction.

Cardio Infarction. Again, just helping the heart pump easier after it's been damaged. And these medications can help decrease the progression of diabetic nephropathy in those patients who have type 2 diabetes.

Now what is diabetic nephropathy? Well this is kidney disease caused by diabetes and whenever a patient has kidney disease those little nephrons in the kidneys are affected because that's a functional unit of the kidney that that doesn't work. And they really lose the ability to filter the blood very well.

So protein will start to leak into the urine. Well, if you have high blood pressure, you're increasing the amount of protein that's going into the urine. Well, if we throw an ACE and ARB on, that can help lower the blood pressure, which will decrease the amount of protein that's going into the urine, hence slowing down our kidney disease.

So these medications have like that renal protective mechanism. Now, what are some patient education? Education and things you want to watch out for as the nurse. Well, we've learned that this meant these medications can increase the potassium Level with the way that it affects aldosterone Because aldosterone is not really going to be released.

So now the kidneys are going to start keeping Potassium so there's a risk for hyperkalemia Therefore you want to monitor the potassium levels, but you want to tell the patient to avoid consuming a diet really high in potassium So watch those salt substitutes that have potassium and those foods that are high in potassium like spinach, avocados, bananas, etc. because that can increase our potassium levels. In addition, you want to talk to the patient about how to prevent a condition called rebound hypertension. This is where the blood pressure will get so high it'll be hard to actually bring the blood pressure down and this tends to happen when a patient just abruptly quits taking their ACE or their ARB.

So educate the patient about the importance. and never just quit taking. the medication because sometimes patient let's say they're started on ace inhibitor they develop that dry nagging persistent cough it's driving them crazy and it's driving everyone else around them crazy because they keep coughing so they may just quit taking the medication but Instead of doing that, they need to talk to their doctor and their doctor can switch them to something else where they won't have that dry cough.

So just let them know that that can happen if they just abruptly quit taking it. In addition, they need to make sure they're monitoring their blood pressure. at home. They need to get a device.

They need to write down the recordings of what their blood pressure is. Daily doing this is best because we want to make sure that these medications are, in fact, managing their blood pressure or are they still hypertensive or is it too much? They're hypotensive. So definitely communicate that to them and lifestyle changes that they need to do.

If they're taking these medications to help lower the blood pressure, let them know that antihypertensive medications are not a cure for high blood pressure. They need to manage their diet by eating healthy, exercising, or quit smoking if they're smoking to help with that as well. So we want to monitor the potassium level as we discussed over here because of hyperkalemia, but we also want to look at the liver enzymes, making sure the liver is not being affected, and renal function.

Because in some patients who are dependent on the RAS because let's say they have severe heart failure, with severe heart failure their cardiac output isn't that great so they depend on this RAS to maintain cardiac output for them so if we give them an ACE and an ARB which affects RAS that's really going to cause some kidney issues so we want to be making sure we monitor the BUN the creatinine what's the renal out their urinary output is it at least 30 cc's an hour are they having any abnormal swelling going on in their body where they're retaining fluid and lastly you want to talk to the patient about this cough that can happen with these ACE inhibitors and if they can't tolerate it, what should they do? And remember, they can be switched to ARBs, which doesn't have that dry, persistent cough. Now, one thing you really want to watch out for if you're working with patients who have heart failure and they're on an ACE inhibitor, let's say that all of a sudden they get this cough.

Well, you want to further investigate this cough. You don't want to just write it off. Oh, it's that cough that you get with ACE inhibitors because with heart failure, they...

their heart will be weak the blood will back up into the lungs where they'll get pulmonary edema so they'll start getting a cough but this cough will be like a wet cough you'll hear crackles if you listen to their lungs they'll have difficulty breathing with just any movement like moving from the bedside chair to the bed they get really winded so you want to make sure that is this just that cough that you get with ACE inhibitors which is dry it's not going to be have crackles or wet or is this heart failure exacerbation? So make sure you look at that. In addition, educate the patient about this angioedema. That's more likely to happen with the ACE inhibitors, but it can happen with ARBs. It's less likely.

It's rare too, but educate them about the swelling of the face, the mouth, the lips, difficulty breathing, and let them know that it's a medical emergency and that they should seek attention immediately. Okay, so that wraps up this review over ACE inhibitors versus ARBs. Thank you so much for watching. Don't forget to take the free quiz and to subscribe to our channel for more videos.

Transcript for:Comparing ACE Inhibitors and ARBs

Transcript for:
Comparing ACE Inhibitors and ARBs