From the Guidelines
Lisinopril should typically be continued up to and including the day of surgery, unless specifically directed otherwise by the anesthesiologist or surgeon, as recommended by the 2017 ACC/AHA guideline 1. For most routine surgeries, there is no need to stop this blood pressure medication beforehand, as maintaining blood pressure control during the perioperative period is important. However, in certain situations, such as procedures with anticipated significant blood loss or hemodynamic instability, your doctor might recommend holding the morning dose on the day of surgery. If you're having major vascular surgery or procedures where hypotension is a particular concern, your physician might suggest stopping lisinopril 24-48 hours before surgery, as supported by the 2009 ESC Guidelines 1. This recommendation stems from lisinopril's mechanism as an ACE inhibitor, which can potentially interact with anesthesia medications and cause exaggerated hypotension during surgery. Additionally, ACE inhibitors may affect kidney function during periods of reduced blood flow, which can occur during surgery. Always discuss your medications with your surgical team during your preoperative evaluation, as they will make individualized recommendations based on your specific health conditions, the type of surgery, and your overall cardiovascular risk, as emphasized by the 2014 ACC/AHA guideline 1. Some key points to consider include:
- The potential risk of severe hypotension under anesthesia when taking ACE inhibitors, particularly with concomitant beta-blocker use 1.
- The importance of maintaining continuity of ACE inhibitors in the setting of treatment for heart failure or hypertension, as supported by the 2014 ACC/AHA guideline 1.
- The need for individualized recommendations based on the patient's specific health conditions, type of surgery, and overall cardiovascular risk, as recommended by the 2017 ACC/AHA guideline 1.
From the Research
Discontinuation of Lisinopril Prior to Surgery
- There is no clear recommendation on when to discontinue Lisinopril, an Angiotensin-Converting Enzyme (ACE) inhibitor, prior to surgery 2, 3.
- A systematic review of outcomes associated with withholding or continuing ACE inhibitors and Angiotensin Receptor Blockers (ARBs) before noncardiac surgery found that withholding ACE-I/ARB therapy was not associated with a difference in mortality or major cardiac events, but was associated with significantly less intraoperative hypotension 3.
- The decision to continue or stop antihypertensive medications, including ACE inhibitors, should be made on a case-by-case basis, taking into account the individual patient's medical history and the type of surgery being performed 2.
- Some studies suggest that ACE inhibitors, including Lisinopril, can be continued up to the day of surgery, but this decision should be made in consultation with the patient's healthcare team 2, 3.
- The pharmacokinetics of Lisinopril, including its elimination half-life of 12.6 hours, may be relevant to the decision of when to discontinue the medication prior to surgery 4.