What is the recommended treatment and management plan for hypertension and heart failure using Lisinopril (angiotensin-converting enzyme inhibitor)?

Lisinopril for Hypertension and Heart Failure Management

Lisinopril is a first-line medication for both hypertension and heart failure with reduced ejection fraction (HFrEF), with recommended initial doses of 10 mg daily for hypertension and 5 mg daily for heart failure, titrated to target doses of 20-40 mg for hypertension and up to 40 mg for heart failure to reduce mortality and hospitalizations. 1, 2

Dosing Recommendations

For Hypertension:

• Initial dose: 10 mg once daily 1
• Target dose: 20-40 mg once daily 1
• Maximum dose: Up to 80 mg daily (though additional benefit beyond 40 mg is limited) 1
• For patients already on diuretics: Start with 5 mg once daily 1
• Blood pressure target: <130/80 mmHg for most patients 2

For Heart Failure:

• Initial dose: 5 mg once daily (when used with diuretics and usually digitalis) 1
• For patients with hyponatremia (serum sodium <130 mEq/L): Start with 2.5 mg once daily 1
• Target dose: 20-35 mg once daily 2
• Maximum dose: Up to 40 mg once daily 1

Renal Impairment Adjustments:

• For creatinine clearance >30 mL/min: No dose adjustment needed 1
• For creatinine clearance 10-30 mL/min: Start with half the usual dose 1
• For creatinine clearance <10 mL/min or hemodialysis: Start with 2.5 mg once daily 1, 3

Treatment Algorithm for Hypertension

1. Initial Assessment:

   • Determine baseline blood pressure
   • Assess for target organ damage and cardiovascular risk factors
   • Check baseline renal function and electrolytes

2. Monotherapy Phase:

   • Start lisinopril 10 mg once daily
   • Reassess blood pressure after 2-4 weeks
   • If target BP not achieved, increase dose to 20 mg
   • Further titrate to 40 mg if needed

3. Combination Therapy Phase (if BP remains uncontrolled):

   • Add a thiazide diuretic (e.g., hydrochlorothiazide 12.5 mg) 2
   • If still not controlled, consider adding calcium channel blocker or beta-blocker

4. Monitoring:

   • Check renal function and electrolytes 1-2 weeks after initiation and after each dose increase
   • Monitor for hypotension, especially when combining with diuretics
   • Long-term monitoring every 3-6 months

Treatment Algorithm for Heart Failure

1. Initial Assessment:

   • Determine LVEF and NYHA functional class
   • Check baseline renal function, electrolytes, and blood pressure
   • Assess for signs of fluid overload

2. Initiation Phase:

   • For patients without fluid retention: Start with lisinopril 5 mg once daily 1
   • For patients with fluid retention: Start lisinopril 5 mg and diuretic concurrently 4
   • For patients with hyponatremia or hypotension: Start with 2.5 mg once daily 1

3. Titration Phase:

   • Double the dose at 2-week intervals 2
   • Aim for target dose of 20-35 mg daily or maximum tolerated dose 2
   • Monitor blood pressure, renal function, and potassium

4. Optimization Phase:

   • Add beta-blocker once stable on ACE inhibitor 2
   • Consider adding mineralocorticoid receptor antagonist for persistent symptoms 2
   • For patients who remain symptomatic, consider ARNI (sacubitril/valsartan) to replace ACE inhibitor 2

Monitoring and Management of Side Effects

Common Side Effects:

• Cough: Most common ACE inhibitor-specific side effect

  • Usually doesn't require discontinuation
  • If severe and persistent, consider switching to ARB 2

• Hypotension:

  • Asymptomatic hypotension: No change needed
  • Symptomatic hypotension: Consider reducing diuretic dose if no signs of congestion 2
  • Severe hypotension (systolic BP <90 mmHg for >1 hour): Consider dose reduction or discontinuation 1

• Renal Function Deterioration:

  • Small increases in creatinine are expected and acceptable
  • An increase up to 50% above baseline or to 3 mg/dL is acceptable 2
  • If greater increases occur, consider reducing dose or discontinuing nephrotoxic medications

• Hyperkalemia:

  • Monitor potassium levels, especially when combined with potassium-sparing diuretics
  • Discontinue potassium supplements if hyperkalemia develops

Special Considerations

• Elderly Patients: Similar efficacy as in younger patients, but may require lower starting doses 5
• Diabetic Patients: Provides additional renoprotective benefits 5
• Post-MI Patients: Reduces mortality and left ventricular dysfunction when started within 24 hours 1, 5
• Pregnancy: Contraindicated due to risk of fetal harm 2

Combination Therapy

• For Hypertension:

  • First-line combination with thiazide diuretics 2
  • Can be combined with calcium channel blockers if needed

• For Heart Failure:

  • Combination with beta-blockers is recommended for all patients with HFrEF 2
  • Addition of mineralocorticoid receptor antagonists for patients with persistent symptoms 2
  • Diuretics should be used as needed to manage fluid overload 2

Common Pitfalls to Avoid

1. Underdosing: Many patients are maintained on suboptimal doses. Always aim for target doses shown to be effective in clinical trials 4

2. Inappropriate discontinuation:

   • Don't stop therapy due to mild, asymptomatic hypotension
   • Don't discontinue due to small increases in creatinine or potassium

3. Failure to monitor:

   • Always check renal function and electrolytes after initiation and dose increases
   • Regular monitoring is essential, especially in high-risk patients

4. Drug interactions:

   • Avoid NSAIDs when possible as they may reduce efficacy and increase risk of renal dysfunction
   • Be cautious with potassium supplements and potassium-sparing diuretics

5. Failure to educate patients:

   • Patients should understand the importance of medication adherence
   • They should report symptoms like dizziness, persistent cough, or swelling