Can captopril (angiotensin-converting enzyme inhibitor) be given to a patient with hypotension?

Captopril Should Not Be Given with Blood Pressure of 81/67

Captopril should not be administered to a patient with a blood pressure of 81/67 mmHg due to the risk of symptomatic hypotension, which is a contraindication to ACE inhibitor therapy. 1

Contraindications to ACE Inhibitors

• ACE inhibitors, including captopril, are contraindicated in patients with symptomatic hypotension (systolic blood pressure less than 80 mm Hg) 1
• A blood pressure of 81/67 mmHg is considered hypotension and represents a significant risk for further blood pressure reduction with ACE inhibitor administration 1
• Patients with pre-existing hypotension who receive ACE inhibitors are at immediate risk of cardiogenic shock and should first receive other forms of treatment until stability has been achieved 1

Risks of Administering Captopril in Hypotensive Patients

• First-dose hypotension is a significant concern with captopril, with studies showing blood pressure nadirs occurring approximately 59 minutes after administration 2
• In hypotensive patients, captopril can cause a further reduction in blood pressure by 15-16% on average, which could be dangerous in an already hypotensive patient 2
• Acute renal failure can develop following hypotension induced by the first dose of captopril, particularly in elderly patients with heart failure 3
• The FDA label for captopril specifically warns about the risk of hypotensive effects, especially in patients who may be volume-depleted 4

Management Recommendations

• For patients with heart failure and hypotension, stabilize blood pressure before initiating ACE inhibitor therapy 1
• If ACE inhibitor therapy is essential after blood pressure stabilization, consider using very low initial doses (6.25 mg of captopril) under close medical supervision 4, 5
• Monitor blood pressure frequently during the first hour after administration, as this is when the maximum hypotensive effect typically occurs 2, 6
• Ensure adequate hydration status before considering ACE inhibitor therapy in hypotensive patients 4

Alternative Approaches

• For patients with heart failure who cannot tolerate ACE inhibitors due to hypotension, consider isosorbide dinitrate and hydralazine as alternative therapies once blood pressure has stabilized 1
• If an ACE inhibitor is absolutely necessary for a patient with heart failure, wait until blood pressure has normalized with other treatments before initiating therapy 1
• For patients with acute myocardial infarction and hypotension, delay ACE inhibitor therapy until hemodynamic stability is achieved 1

Common Pitfalls to Avoid

• Never administer captopril to patients with symptomatic hypotension without first stabilizing their blood pressure 1
• Avoid initiating ACE inhibitor therapy in patients at immediate risk of cardiogenic shock 1
• Do not combine ACE inhibitors with ARBs or aldosterone antagonists in hypotensive patients due to increased risk of adverse effects 7, 8
• Recognize that elderly patients and those on diuretics are at particularly high risk for hypotension with ACE inhibitors 3, 5