What is a good parameter to hold blood pressure medications, such as Angiotensin-Converting Enzyme (ACE) inhibitors or alpha blockers, in patients with hypotension?

Parameters for Holding Blood Pressure Medications in Hypotension

Blood pressure medications should be held when systolic blood pressure is below 90 mmHg or if the patient is experiencing symptomatic hypotension. 1

General Parameters for Holding Antihypertensive Medications

• For most antihypertensive medications, hold if systolic blood pressure is less than 90 mmHg or diastolic blood pressure is less than 60 mmHg 1
• For ACE inhibitors specifically, hold if systolic blood pressure is less than 100 mmHg 2
• For alpha blockers, hold if systolic blood pressure is less than 100 mmHg due to their vasodilatory effects and risk of orthostatic hypotension 1, 3
• In perioperative settings, beta blockers should be held if heart rate is less than 50 bpm or systolic blood pressure is less than 100 mmHg 1

Medication-Specific Considerations

ACE Inhibitors/ARBs

• Hold if systolic blood pressure is less than 100 mmHg 2
• For patients with acute myocardial infarction receiving lisinopril, hold if systolic blood pressure is less than 100 mmHg 2
• First-dose hypotension is a particular concern with ACE inhibitors, especially in patients with heart failure, severe hypertension on multiple medications, renovascular hypertension, or elderly patients 4

Alpha Blockers

• Hold if systolic blood pressure is less than 100 mmHg 1, 3
• Use with caution in elderly patients due to increased risk of orthostatic hypotension 3
• Consider administering at bedtime to minimize orthostatic hypotension risk 3

Beta Blockers

• Hold if heart rate is less than 50 bpm or systolic blood pressure is less than 100 mmHg 1
• In perioperative settings, bradycardia (heart rate <50 bpm) and hypotension (systolic BP <100 mmHg) are significant concerns that warrant holding the medication 1

Special Patient Populations

Elderly Patients

• Consider holding medications at higher blood pressure thresholds (e.g., SBP <110-120 mmHg) due to increased risk of falls and orthostatic hypotension 1, 3
• Monitor closely for orthostatic changes in blood pressure 3

Heart Failure Patients

• For patients with heart failure, blood pressure should be maintained above 120/70 mmHg 1
• If systolic blood pressure falls below 100 mmHg, consider holding ACE inhibitors or ARBs 2

Acute Stroke Patients

• In acute ischemic stroke, maintain blood pressure below 220/120 mmHg unless thrombolytic therapy is planned 1
• For patients receiving thrombolysis, maintain blood pressure below 185/110 mmHg 1
• In hemorrhagic stroke, maintain systolic blood pressure between 130-180 mmHg 1

Monitoring and Restarting Medications

• After holding medications for hypotension, monitor blood pressure every 1-2 hours until stable 1
• Consider volume status assessment before restarting medications, as hypovolemia may contribute to hypotension 1
• When restarting ACE inhibitors after hypotensive episodes, begin at a very low dose to prevent sudden decreases in blood pressure 1
• For alpha blockers, restart at lower doses (e.g., doxazosin 1 mg) when blood pressure has stabilized 3

Common Pitfalls and Caveats

• Abrupt discontinuation of beta blockers can lead to rebound hypertension and tachycardia; if possible, taper rather than abruptly discontinue 1
• When holding antihypertensives due to hypotension, investigate underlying causes such as sepsis, hypovolemia, or anemia 1
• Patients on multiple antihypertensive medications are at higher risk for hypotension; consider holding one medication at a time rather than all simultaneously 5
• In patients with resistant hypertension who require multiple medications including alpha blockers, careful monitoring of blood pressure is essential when holding medications 3

Remember that these parameters serve as general guidelines, and clinical judgment should be exercised based on individual patient circumstances and comorbidities.