ACE inhibitors, angiotensin receptor blockers and sacubitril-valsartan
How ACE inhibitors, ARBs and neprilysin inhibition change angiotensin II, bradykinin and natriuretic peptides, why creatinine rises and potassium climbs, the bradykinin basis of cough and angioedema, the 36-hour washout, fetotoxicity, and the trial numbers that are examined.
Tier 2Medical sciences concept
Written with AI assistance and fact-checked against the sources below. For exam study, not clinical decisions. How notes are made
At a glance
- ACE inhibitors block conversion of angiotensin I to angiotensin II and the breakdown of bradykinin. ARBs block the AT1 receptor and leave bradykinin alone. Sacubitril-valsartan adds neprilysin inhibition, raising natriuretic peptides.
- All three lower angiotensin II action, so all raise renin, lower aldosterone, dilate the efferent arteriole and raise potassium.
- Paper 1 tests the expected creatinine rise, bradykinin side effects, the 36-hour washout, BNP versus NT-proBNP, fetotoxicity and dual blockade harm.
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Sources
- Therapeutic Guidelines: CardiovascularAU/NZTherapeutic Guidelines Ltd, current eTG edition (version not verified)
- National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand Guidelines for the prevention, detection, and management of heart failure in Australia 2018AU/NZHeart Lung Circ 2018;27:1123-1208, 2018
- Køber L, Adamo M et al. 2026 ESC Guidelines for the management of heart failure. Eur Heart J 2026European Society of Cardiology, 2026
- McMurray JJV, Packer M, Desai AS et al. Angiotensin-neprilysin inhibition versus enalapril in heart failure (PARADIGM-HF). N Engl J Med 2014;371:993-1004N Engl J Med, 2014
- ONTARGET Investigators. Telmisartan, ramipril, or both in patients at high risk for vascular events. N Engl J Med 2008;358:1547-59N Engl J Med, 2008
- Fried LF, Emanuele N, Zhang JH et al. Combined angiotensin inhibition for the treatment of diabetic nephropathy (VA NEPHRON-D). N Engl J Med 2013;369:1892-903N Engl J Med, 2013
- KDIGO 2024 clinical practice guideline for the evaluation and management of chronic kidney diseaseKidney International 2024;105(4S):S117-S314, 2024
- Sinert R, Levy P, Bernstein JA et al. Randomized trial of icatibant for angiotensin-converting enzyme inhibitor-induced upper airway angioedema. J Allergy Clin Immunol Pract 2017;5:1402-9J Allergy Clin Immunol Pract, 2017
- Straka BT, Ramirez CE, Byrd JB et al. Effect of bradykinin receptor antagonism on ACE inhibitor-associated angioedema. J Allergy Clin Immunol 2017;140(1):242-8J Allergy Clin Immunol, 2017
- Last updated
- 14 November 2026
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