Maximum Dosage of Enalapril for LVH with Severe Hypertension
The maximum dosage of enalapril for patients with left ventricular hypertrophy (LVH) and severe hypertension is 20 mg twice daily (40 mg total daily dose), according to established clinical guidelines. 1
Dosing Guidelines
Enalapril dosing for patients with LVH and severe hypertension follows a structured approach:
Initial Dosing
- Starting dose: 2.5 mg twice daily
- For patients currently on diuretics: Consider discontinuing diuretic 2-3 days before starting enalapril to reduce risk of first-dose hypotension 2
- If diuretic cannot be discontinued: Start with 2.5 mg under medical supervision for at least 2 hours 2
Titration Schedule
- Increase dose gradually every 2-4 weeks based on blood pressure response and tolerability 1
- Typical titration: 2.5 mg → 5 mg → 10 mg → 20 mg (per dose)
- Monitor renal function and serum electrolytes 1-2 weeks after each dose increase 1
Maximum Dosage
- Maximum daily dose: 40 mg (20 mg twice daily) 1, 2
- Mean effective dose in clinical trials: 16.6 mg daily 1
Monitoring Parameters
When using enalapril for LVH with severe hypertension, monitor:
- Blood pressure: Initially and with each dose change
- Renal function: Before starting, 1-2 weeks after initiation, and periodically thereafter
- Serum potassium: Before starting and with each dose adjustment
- LV mass regression: By echocardiography to assess treatment efficacy 3, 4
Special Considerations
Renal Impairment
- Normal renal function: Standard dosing
- Mild impairment (CrCl >30 to ≤80 mL/min): Standard dosing
- Moderate to severe impairment (CrCl ≤30 mL/min): Reduce initial dose to 2.5 mg daily 2
Potential Adverse Effects
- Hypotension: Particularly with first dose; more common in volume-depleted patients
- Hyperkalemia: Monitor potassium levels, especially if combined with potassium-sparing diuretics
- Cough: Occurs in up to 20% of patients; may require switching to ARB if severe
- Angioedema: Rare but serious; requires immediate discontinuation
- Worsening renal function: Monitor creatinine; acceptable increase up to 50% from baseline 1
Evidence for Efficacy in LVH
Several studies have demonstrated that enalapril effectively reduces LVH in hypertensive patients:
- Doses of 20-40 mg daily have been shown to significantly reduce left ventricular mass index (LVMI) 3
- Long-term enalapril therapy (20-40 mg daily) has demonstrated regression of LVH without impairing LV function 3
- In one study, enalapril reduced LVMI by 12.4% over 10 months 4
- Another long-term study showed enalapril (dose not specified) reduced LVMI by 39% over 7 years 5
Clinical Pearl
While 40 mg daily is the maximum recommended dose, some patients may achieve adequate blood pressure control and LVH regression with lower maintenance doses. One study found that after achieving normalization of blood pressure and LV structure with standard doses, smaller doses (as low as 5 mg daily) were sufficient to maintain these cardiovascular improvements 5.