Should lisinopril be given with hypotension?

Lisinopril Should Be Held When Blood Pressure is 100/66 mmHg

Lisinopril should be held when blood pressure is 100/66 mmHg due to the risk of hypotension, which could lead to decreased organ perfusion and adverse outcomes. 1, 2

Rationale for Holding Lisinopril

• Hypotension (systolic BP <90 mmHg or significantly below baseline) is a clear contraindication to ACE inhibitor administration as stated in multiple guidelines 1, 2
• The FDA drug label specifically lists hypotension as a contraindication for lisinopril use 2
• The patient's current blood pressure of 100/66 mmHg is already at the lower end of normal range, and administering lisinopril would likely cause further reduction in blood pressure 2, 3
• Even in acute myocardial infarction settings where lisinopril is beneficial, the drug label recommends dose reduction or discontinuation if systolic BP falls below 100 mmHg 2

Clinical Decision Algorithm

1. Assess current BP and symptoms:

   • BP 100/66 mmHg - already borderline low
   • Check for symptoms of hypoperfusion (dizziness, lightheadedness, confusion) 1, 3

2. Consider the risks of administering lisinopril:

   • Further BP reduction could lead to inadequate organ perfusion 2, 3
   • Risk of symptomatic hypotension increases with lower baseline BP 1, 3
   • First-dose hypotension can be particularly pronounced 3, 4

3. Decision point:

   • Hold lisinopril when systolic BP <100 mmHg or if patient is symptomatic 2
   • Resume lisinopril only when BP has stabilized at higher levels 1, 2

Special Considerations

• If the patient has heart failure or post-MI status, the benefits of ACE inhibitor therapy must be weighed against the risks of hypotension 1, 2
• In acute MI patients, lisinopril should be held if systolic BP <100 mmHg for more than 1 hour 2
• For patients with heart failure, the appearance of hypotension after initial dosing doesn't preclude subsequent careful dose titration after effective management of the hypotension 2

Management After Holding Lisinopril

• Monitor BP frequently until it stabilizes 1
• Assess volume status and consider IV fluids if hypovolemia is contributing to hypotension 1
• When BP improves (systolic consistently >100 mmHg), consider restarting at a lower dose (2.5-5 mg) 2
• Consider alternative causes of hypotension if BP remains low despite holding antihypertensive medications 1

Common Pitfalls to Avoid

• Continuing ACE inhibitors despite hypotension can lead to renal dysfunction, syncope, and inadequate organ perfusion 2, 5
• Failure to recognize drug interactions that may potentiate hypotensive effects of lisinopril 6
• Overlooking volume depletion as a contributing factor to hypotension in patients on ACE inhibitors 2, 3
• Assuming that all patients require daily antihypertensive medications regardless of current BP readings 1

Remember that the primary goal of antihypertensive therapy is to reduce cardiovascular risk while maintaining adequate organ perfusion. Temporarily holding lisinopril when BP is low is consistent with this goal and supported by clinical guidelines 1, 2.