The Role of Ace Inhibitors in Hypertension
Saturday, December 27th, 2008When you need an ace up your sleeve in the treatment of hypertension, one type of drug meets that criterion - the ACE inhibitors.
Doctors say they work well - sometimes even better - than other antihypertensives, have relatively few side effects, don’t deplete the body’s supply of potassium which can be dangerous, don’t interfere with a person’s memory, work performance, or sexual function, and are useful in patients suffering from angina and congestive heart failure.
ACE is short for angiotensin converting enzyme. Angiotensin occurs naturally in the body and has two relatives. The first one is a good guy; he doesn’t cause any trouble.
The black sheep of the family is angiotensin II which raises blood pressure by constricting the arteries. This is the target of ACE inhibitors; they inhibit the action of angiotensin II, thereby normalizing blood pressure.
“I prefer ACE inhibitors because in my experience, they have the fewest side effects. For example, unlike diuretics, they don’t raise your cholesterol or make you spend the better part of your life in the bathroom emptying your bladder; unlike beta-blockers, they don’t slow you down, give you bad dreams, worsen your asthma, induce heart failure, or drive you to reading porn magazines to help restore some interest in sex,” said Dr. Isadore Rosenfeld of the New York Hospital - Memorial Sloan-Kettering Cancer Center in “The Best Treatment.”
Since their introduction in the 1980s, ACE inhibitors have moved up the ladder as first-line drugs in the treatment of hypertension. There are many reasons why doctors prefer them over other drugs.
ACE inhibitors can be used by the young and old alike. They spare men the agony of impotence while on beta-blockers or diuretics. They are equal to or superior in action to both these drugs. And in severe cases of hypertension, ACE inhibitors can safely be combined with diuretics or calcium-channel blockers. Beta-blockers also work well with ACE inhibitors but not as successful as other combinations.
“There is another good reason to start with an ACE inhibitor. If it results in a dramatic drop in pressure, then you know that renin is an important factor in the causation of your hypertension. (Renin is the blood pressure-raising hormone made by the kidneys that is blocked by the ACE inhibitor.) Excessive amounts of renin are produced when the arteries going to the kidneys are narrowed. So if you respond to an ACE inhibitor, it may be worth looking at these arteries to see if they can be dilated by balloon angioplasty,” Rosenfeld explained.
“On the other hand, when an ACE inhibitor is not effective, that more or less rules out renin and suggests instead a salt-dependent type of hypertension for which calcium antagonists or diuretics are more effective,” he added.
Not everyone, however, agrees with Rosenfeld’s recommendations. Other researchers argue that this line of thinking comes from the early experience with the ACE inhibitor captopril which has since been refuted by newer studies.
In the Journal of Hypertension, Professor John L. Reid of the Department of Materia Medica, University of Glasgow, said that people with hypertension generally respond well to ACE inhibitors regardless of their blood renin levels or the amount of sodium in the body. He said other factors - such as individual patient response - may be the reason why some individuals do not benefit from ACE inhibitors.
Regardless of how you or your doctor feels about ACE inhibitors, there are certain contraindications you should be aware of. ACE inhibitors are a no-no if you’re allergic to them or to any of their components. Their safety has not been established in pregnancy or in children. They should be avoided in patients with severe narrowing of the aortic valve in the heart, and should be used cautiously in those with kidney disease. (Next: Choosing from the four ACES of hypertension.)
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