Could lisinopril (Angiotensin-Converting Enzyme Inhibitor) and spironolactone (Mineralocorticoid Receptor Antagonist) be causing hypotension and falls in an 81-year-old female with Heart Failure with mid-range Ejection Fraction (HFmrEF)?

Lisinopril and Spironolactone Can Cause Symptomatic Hypotension Leading to Falls in Elderly HFmrEF Patients

Both lisinopril and spironolactone are likely causing symptomatic hypotension leading to falls in this 81-year-old female with HFmrEF, and dose reduction or discontinuation of one or both medications should be considered.

Mechanism of Falls in This Patient

The combination of an ACE inhibitor (lisinopril) and mineralocorticoid receptor antagonist (spironolactone) can cause significant hypotension, especially in elderly patients. This occurs through:

1. Vasodilation effects: Lisinopril causes arterial and venous dilation by blocking angiotensin II formation
2. Volume depletion: Both medications can reduce intravascular volume
3. Age-related factors: Elderly patients have:
   • Reduced baroreceptor sensitivity
   • Altered pharmacokinetics
   • Increased risk of orthostatic hypotension

Evidence-Based Management Approach

Step 1: Assess for Symptomatic Hypotension

• Check for symptoms of dizziness, light-headedness, confusion
• Measure blood pressure in both supine and standing positions
• Look for signs of dehydration or volume depletion

Step 2: Medication Adjustment

Based on European guidelines for heart failure management 1:

1. If symptomatic hypotension is confirmed:

   • Consider reducing diuretic dose if no signs of congestion
   • Reconsider need for other vasodilators (nitrates, calcium channel blockers)
   • Reduce or temporarily discontinue one of the medications

2. If falls continue despite initial adjustments:

   • Consider halving the dose of lisinopril (to 10mg)
   • Or reduce spironolactone to 12.5mg daily

Step 3: Monitoring and Follow-up

• Monitor renal function and electrolytes (particularly potassium)
• Reassess symptoms and blood pressure within 1-2 weeks
• Adjust medications based on clinical response

Special Considerations for Elderly Patients

The 2017 ACC/AHA Hypertension Guidelines 1 note that elderly patients (>80 years) require special attention:

• They were often excluded from major clinical trials
• They have increased sensitivity to volume depletion
• They have higher risk of falls and injury from hypotension
• They may present with neurogenic orthostatic hypotension

Medication-Specific Concerns

Lisinopril

The FDA label for lisinopril 2 specifically warns about:

• Hypotension risk in heart failure patients
• Increased risk in elderly patients
• Symptoms include dizziness and light-headedness
• Risk factors include age >80, volume depletion, and concomitant medications

Spironolactone

Guidelines 1 highlight concerns with spironolactone:

• Can cause significant hypotension, especially when combined with ACE inhibitors
• Post-RALES study data showed increased hyperkalemia and early mortality in elderly "real-world" patients (mean age 78 years) 1
• Limited evidence for benefit in HFmrEF specifically

Evidence for HFmrEF Population

A 2019 study 3 specifically examining spironolactone in HFmrEF patients found:

• Benefit in reducing death and HF hospitalization
• No difference between 25mg and 50mg doses
• However, this study did not specifically address elderly patients or fall risk

Important Caveats

1. Do not stop beta-blockers abruptly if the patient is on them, as this carries risk of rebound ischemia 4

2. Avoid complete discontinuation if possible - dose reduction may be sufficient

3. Consider patient's overall heart failure status - if symptoms are well-controlled, medication reduction is more reasonable

4. Monitor for hyperkalemia when using this drug combination, especially in elderly patients with potential renal impairment

By carefully adjusting these medications while monitoring for symptomatic improvement, falls can likely be prevented while maintaining heart failure treatment benefits.