Blood Pressure Monitoring and Check-up Frequency
Patients started on an angiotensin-converting enzyme (ACE) inhibitor should return for a follow-up appointment monthly until blood pressure control is met.1,2 The 2017 American College of Cardiology (ACC) and American Heart Association (AHA) hypertension guidelines found strong evidence to support the recommendation of promoting other strategies to improve control of blood pressure in patients on antihypertensive therapy to include the use of home blood pressure monitoring, team-based care, and telehealth strategies [Strong Recommendation (Level A)].2 The evidence in these studies demonstrated the benefits of a combination of home blood pressure monitoring, telehealth, and team-based (e.g., nurse case manager, pharmacist, doctor) care over just office-based follow-up.3-7 At the follow-up check-up, the doctor will measure blood pressure and assess for adverse effects.1,2 Patients with more severe hypertension (≥160 systolic blood pressure or ≥100 diastolic blood pressure) or complicating comorbid conditions, such as heart failure (HF), diabetes, or chronic kidney disease (CKD), need more frequent visits.2 Serum potassium and creatinine should be tested at least once or twice a year.1 Once the blood pressure goal is met and stable, visits can be at three- to six-month intervals.
Renal Function Monitoring Details
Periodic renal function monitoring is recommended for patients taking ACE inhibitors.8-18 Drugs that inhibit the renin-angiotensin system (RAS), such as ACE inhibitors, can cause changes in renal function including acute renal failure. Patients whose renal function may depend on the activity of the RAS include those with renal artery stenosis, CKD, severe HF, or volume depletion. They may be at higher risk of developing oliguria, progressive azotemia, or acute renal failure when taking an ACE inhibitor. Doctors should consider withholding or discontinuing treatment in patients who develop a clinically significant decrease in renal function on an ACE inhibitor.
The 2014 Eighth Joint National Committee (JNC8) guidelines recommend that adults with CKD should include an ACE inhibitor or an angiotensin receptor blocker (ARB) as part of their antihypertensive treatment to improve kidney outcomes [Moderate recommendation (Grade B)].19 The 2017 ACC/AHA Hypertension Guidelines recommend that adults with CKD should include an ACE inhibitor as part of their antihypertensive treatment to improve kidney outcomes [Moderate recommendation (Level B-R)].2 Since use of an ACE inhibitor will commonly increase serum creatinine and may produce other metabolic effects such as hyperkalemia, people with CKD require monitoring of electrolyte and serum creatinine levels.19
Serum Potassium Monitoring Details
Manufacturers recommend monitoring serum potassium periodically in patients receiving an ACE inhibitor.8-10,12-18,20-22 Drugs that inhibit the RAS can cause hyperkalemia.8-18,20-23 Patients at risk of developing hyperkalemia include those:
- with renal insufficiency
- with diabetes mellitus
- who also use potassium-sparing diuretics, potassium supplements, and/or potassium-containing salt substitutes
A 2010 meta-analysis reviewed 39 studies for the effects on serum potassium levels of ACE inhibitors, ARBs, aldosterone receptor antagonists, and direct renin inhibitors, alone and in combination, in patients with hypertension, HF, or CKD.24 In patients on ACE inhibitor monotherapy with hypertension and no risk factor for hyperkalemia, the incidence of hyperkalemia was very low (≤2%). Patients with risk factors, such as HF or CKD, had a higher incidence of hyperkalemia (5% to 10%).
A 2003 meta-analysis of 354 randomized double-blind placebo-controlled trials of hypertension treatment with thiazides, beta blockers, ARBs, calcium channel blockers, and ACE inhibitors looked at the rate of side effects at the standard dose.23 The study found potassium increased by 4%, or 0.16-mmol/L, with ACE inhibitors (95% confidence interval [0.08 – 0.23-mmol/L], 15 trials, 20 treatment arms).
A 1998 study of 1,818 outpatients using ACE inhibitors found 194 (11%) developed hyperkalemia (defined as a potassium level higher than 5.1-mmol/L).25 The study concluded that while mild hyperkalemia was common, subsequent severe hyperkalemia was uncommon in patients younger than 70 years with normal renal function.
Hypotension rarely occurs in patients with uncomplicated hypertension treated with ACE inhibitors alone, but patients may report lightheadedness, especially in the first few days of treatment.8-18,20-22
Manufacturers recommend that patients at risk of excessive hypotension be started on an ACE inhibitor under medical supervision and followed for the first two weeks of treatment or whenever the dose of the ACE inhibitor and/or diuretic is increased.8-18,20-22 Patients at risk of excessive hypotension include those who:
- have HF with systolic blood pressure below 100 mm Hg
- have ischemic heart disease
- have cerebrovascular disease
- have hyponatremia
- are on high dose diuretic therapy
- are undergoing renal dialysis
- have severe volume- and/or salt-depletion.
Examples of patients at risk for volume and/or salt-depletion include those who8-18,20-22:
- take water pills (diuretics)
- are on a low-salt diet
- take other medicines that affect your blood pressure
- get sick with vomiting or diarrhea
- do not drink enough fluids
- Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003; 42 (6): 1206-1252.
- Whelton PK, Carey RM, Aronow WS, 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: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension 2017.
- Margolis KL, Asche SE, Bergdall AR, et al. Effect of home blood pressure telemonitoring and pharmacist management on blood pressure control: a cluster randomized clinical trial. JAMA 2013; 310 (1): 46-56.
- Bosworth HB, Powers BJ, Olsen MK, et al. Home blood pressure management and improved blood pressure control: results from a randomized controlled trial. Arch Intern Med 2011; 171 (13): 1173-1180.
- Brennan T, Spettell C, Villagra V, et al. Disease management to promote blood pressure control among African Americans. Popul Health Manag 2010; 13 (2): 65-72.
- Bosworth HB, Olsen MK, Grubber JM, et al. Two self-management interventions to improve hypertension control: a randomized trial. Ann Intern Med 2009; 151 (10): 687-695.
- Green BB, Cook AJ, Ralston JD, et al. Effectiveness of home blood pressure monitoring, Web communication, and pharmacist care on hypertension control: a randomized controlled trial. JAMA 2008; 299 (24): 2857-2867.
- Altace [package insert]. New York, NY: Pfizer Laboratories; 2017.
- Accupril [package insert]. New York, NY: Parke Davis, Pfizer; 2017.
- Trandolapril [package insert]. Laurelton, NY: Epic Pharma, LLC; 2017.
- Angiotensin-converting enzyme inhibitors. Drug Facts and Comparisons [online database]. Wolters Kluwer Health, Inc; 2017. Accessed Oct 8, 2017.
- Prinivil [package insert]. Whitehouse Station, NJ: Merck Sharp & Dohme Corp.; 2016.
- Moexipril hydrochloride [package insert]. Teva Pharmaceuticals USA Inc; 2016.
- Fosinopril sodium [package insert]. Miami, FL: Ciplo USA Inc; 2015.
- Vasotec [package insert]. Bridgewater, NJ: Valeant Pharmaceuticals North America LLC; 2015.
- Lotensin [package insert]. Parsippany, NJ: Validus Pharmaceuticals LLC; 2014.
- Capoten [package insert]. Spring Valley, NY: Par Pharmaceutical Companies, Inc.; 2012.
- Aceon [package insert]. North Chicago, IL: Abbot Laboratories; 2011.
- James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults. JAMA 2014; 311 (5): 507-520.
- Sica DA. Angiotensin-converting enzyme inhibitors side effects--physiologic and non-physiologic considerations. J Clin Hypertens (Greenwich) 2004; 6 (7): 410-416.
- Warner NJ, Rush JE. Safety profiles of the angiotensin-converting enzyme inhibitors. Drugs 1988; 35 Suppl 5: 89-97.
- Izzo JL, Jr., Weir MR. Angiotensin-converting enzyme inhibitors. J Clin Hypertens (Greenwich) 2011; 13 (9): 667-675.
- Law M, Wald N, Morris J. Lowering blood pressure to prevent myocardial infarction and stroke: a new preventive strategy. Health Technol Assess 2003; 7 (31): 1-94.
- Weir MR, Rolfe M. Potassium homeostasis and renin-angiotensin-aldosterone system inhibitors. Clin J Am Soc Nephrol 2010; 5 (3): 531-548.
- Reardon LC, Macpherson DS. Hyperkalemia in outpatients using angiotensin-converting enzyme inhibitors. How much should we worry? Arch Intern Med 1998; 158 (1): 26-32.