What is the recommended starting dose of Angiotensin-Converting Enzyme (ACE) inhibitor or Angiotensin Receptor Blocker (ARB) for a patient with a blood pressure of 117/85 mmHg?

Starting ACE Inhibitor or ARB Dosage for Blood Pressure 117/85 mmHg

Direct Answer

You should not start an ACE inhibitor or ARB at this blood pressure of 117/85 mmHg, as this patient does not have hypertension and does not meet criteria for pharmacological blood pressure treatment unless they have specific high-risk conditions. 1

Blood Pressure Classification

• A blood pressure of 117/85 mmHg falls into the "elevated blood pressure" category (systolic 120-139 mmHg or diastolic 70-89 mmHg), not hypertension (≥140/90 mmHg). 1
• Hypertension requiring immediate pharmacological treatment is defined as BP ≥140/90 mmHg for most patients. 1

When to Consider Treatment at This Blood Pressure

Pharmacological treatment at BP 117/85 mmHg is only recommended if:

• The patient has sufficiently high cardiovascular disease (CVD) risk (≥10% over 10 years) AND confirmed BP ≥130/80 mmHg after 3 months of lifestyle intervention. 1
• The patient has compelling indications such as chronic kidney disease with proteinuria, diabetes with diabetic kidney disease, or heart failure with reduced ejection fraction. 1

Initial Management Approach

• First-line approach: Implement lifestyle modifications including dietary sodium restriction, weight management if overweight, regular physical activity, and limiting alcohol consumption. 1
• Monitoring: Reassess blood pressure after 3 months of lifestyle intervention to determine if pharmacological treatment becomes necessary. 1
• Risk stratification: Calculate 10-year CVD risk to determine if earlier pharmacological intervention is warranted. 1

If Treatment Is Indicated (Based on Compelling Indications)

For Chronic Kidney Disease with Diabetes:

• ACE Inhibitor starting doses: Lisinopril 10 mg daily, Enalapril 5 mg daily, or Ramipril 1.25-2.5 mg daily. 1
• ARB starting doses: Losartan 25-50 mg daily, Valsartan 80 mg daily, or Irbesartan 150 mg daily. 1
• Goal is to uptitrate to higher end of dose range when tolerated (e.g., Lisinopril 20-40 mg daily, Losartan 50-100 mg daily). 1

For Heart Failure with Reduced Ejection Fraction:

• ACE Inhibitor starting doses: Lisinopril 2.5-5 mg daily, Enalapril 2.5 mg twice daily, or Captopril 6.25 mg three times daily. 1
• Start at lower doses and titrate upward gradually based on tolerance. 1

Critical Monitoring Parameters

• Before initiating treatment: Check serum creatinine, potassium, and assess for bilateral renal artery stenosis. 1
• After initiation: Recheck renal function and potassium within 1-2 weeks, particularly in patients with preexisting kidney disease or diabetes. 1
• Blood pressure target: If treatment is started, aim for systolic BP 120-129 mmHg if well tolerated. 1

Important Caveats

• Starting antihypertensive medication at BP 117/85 mmHg without compelling indications exposes the patient to unnecessary medication side effects (cough with ACE inhibitors, hyperkalemia, acute kidney injury) without proven benefit. 1
• The patient should be counseled that their current blood pressure is in a healthy range and does not require medication unless specific high-risk conditions are present. 1
• If the patient has isolated systolic hypertension concerns or white-coat hypertension, confirm diagnosis with home blood pressure monitoring or 24-hour ambulatory monitoring before initiating treatment. 1