Can you take lisinopril (angiotensin-converting enzyme inhibitor) before brain surgery?

Management of Lisinopril Before Brain Surgery

Lisinopril should be discontinued 24 hours before brain surgery to reduce the risk of intraoperative hypotension. 1

Rationale for Discontinuation

ACE inhibitors like lisinopril can cause significant hemodynamic complications during surgery:

• Perioperative use of ACE inhibitors carries a risk of severe hypotension under anesthesia, particularly following induction and when combined with beta-blockers 1
• Recent evidence from a large cohort study demonstrates that patients who stopped their ACE inhibitors 24 hours before noncardiac surgery were less likely to suffer from all-cause death, stroke, or myocardial injury and experienced less intraoperative hypotension than those continuing these medications until surgery 1
• The response to vasopressors may be impaired in patients taking ACE inhibitors during surgery, making management of hypotension more challenging 1

Guidelines Support

Multiple professional guidelines support this recommendation:

• The American College of Cardiology/American Heart Association (ACC/AHA) 2017 guideline states: "In patients with hypertension undergoing major surgery, discontinuation of ACE inhibitors or ARBs perioperatively may be considered" (Class IIb recommendation, Level B-NR evidence) 1
• The European Society of Cardiology (ESC) guidelines similarly suggest: "Transient discontinuation of ACE inhibitors before non-cardiac surgery in hypertensive patients should be considered" 1

Special Considerations

When to Resume Medication

• ACE inhibitors should be resumed after surgery as soon as volume status is stable 1
• Close monitoring is required when restarting the medication

Exception for Patients with LV Dysfunction

• For patients with left ventricular systolic dysfunction who are in stable clinical condition, it may be reasonable to continue ACE inhibitors during the perioperative period under close monitoring 1
• The ESC guidelines recommend: "ACE inhibitors be continued during non-cardiac surgery in stable patients with LV systolic dysfunction" 1

Potential Complications of Continuing Lisinopril

1. Severe hypotension during anesthesia induction 1, 2
2. Reduced effectiveness of vasopressors to treat hypotension 1
3. Increased risk of hemodynamic instability 2
4. Potential for acute kidney injury in the setting of perioperative hypotension 2

Practical Management Algorithm

1. For patients taking lisinopril for hypertension:

   • Discontinue lisinopril 24 hours before brain surgery 1
   • Monitor blood pressure closely before surgery
   • Resume lisinopril postoperatively once hemodynamic stability is achieved

2. For patients taking lisinopril for heart failure with LV dysfunction:

   • Consider continuing lisinopril under close monitoring 1
   • Have vasopressors readily available during anesthesia induction
   • Monitor blood pressure and renal function closely

Common Pitfalls to Avoid

• Abrupt discontinuation of other antihypertensives: Unlike ACE inhibitors, beta-blockers and clonidine should NOT be discontinued abruptly before surgery due to risk of rebound hypertension and withdrawal syndromes 1
• Starting beta-blockers immediately before surgery: This practice should be avoided as it can increase mortality 1
• Inadequate blood pressure monitoring: Close monitoring is essential during the perioperative period, especially if continuing lisinopril in patients with LV dysfunction

In conclusion, the evidence strongly supports discontinuing lisinopril 24 hours before brain surgery for patients taking it for hypertension, while carefully considering continuation only in those with stable LV dysfunction under close monitoring.