Can I restart perindopril (angiotensin-converting enzyme inhibitor) in a patient with hypertension who was previously on perindopril and now has uncontrolled blood pressure after it was withheld?

Restarting Perindopril After Withholding

Yes, you can and should restart perindopril in this patient with uncontrolled hypertension who was previously on this medication, provided the patient is neurologically stable and at least 24 hours have passed since any acute event that prompted withholding. 1

When to Restart Perindopril

Restart perindopril if:

• The patient has established blood pressure ≥140/90 mmHg 1
• The patient is neurologically stable (if withheld due to stroke/TIA) 1
• At least 24 hours have passed since an acute ischemic stroke (if applicable) 1
• No specific contraindication exists (e.g., hyperkalemia, acute kidney injury, angioedema history) 2

The 2017 ACC/AHA guidelines explicitly state that starting or restarting antihypertensive therapy during hospitalization in patients with BP >140/90 mmHg who are neurologically stable is safe and reasonable to improve long-term BP control (Class IIa recommendation). 1

Dosing Strategy for Restarting

Start with the patient's previous maintenance dose if:

• Blood pressure is 140-180/90-110 mmHg 2
• No acute complications occurred during the withholding period 2
• Renal function is stable (creatinine clearance >30 mL/min) 2

Use a lower initial dose (2-4 mg daily) if:

• The patient is elderly (>70 years) and was off medication for an extended period 2
• Blood pressure is markedly elevated (>180/110 mmHg) to avoid precipitous drops 1
• The patient is on concurrent diuretic therapy 2
• Renal impairment exists (creatinine clearance 30-60 mL/min; maximum 8 mg/day) 2

Context-Specific Considerations

If Withheld Due to Acute Stroke/TIA:

• Wait 24-48 hours after the acute event before restarting 1
• Restart when blood pressure is ≥140/90 mmHg and patient is neurologically stable 1
• ACE inhibitors (including perindopril) are specifically recommended for secondary stroke prevention 1
• Target blood pressure <130/80 mmHg may be reasonable for long-term management 1

If Withheld Due to Hypotension or Acute Illness:

• Ensure hemodynamic stability before restarting 1
• Verify adequate volume status 1
• Check renal function and electrolytes, particularly potassium 2

If Withheld for Surgical Procedures:

• Restart as soon as oral intake is tolerated 1
• No specific waiting period required if blood pressure is elevated 1

Monitoring After Restart

Monitor closely for the first 2 weeks after restarting perindopril: 2

• Check blood pressure within 2-4 weeks of restart 3, 4
• Monitor serum potassium and creatinine within 1-2 weeks 4, 2
• Watch for symptomatic hypotension, especially after the first dose 2
• Assess for cough (most common side effect, though <2% discontinue) 5

Common Pitfalls to Avoid

Do not delay restarting unnecessarily: The evidence shows that withholding antihypertensive therapy beyond 24-48 hours in stable patients leads to worse long-term outcomes 1

**Do not restart during acute stroke (<24 hours):** Unless blood pressure is extremely elevated (>220/120 mmHg), early aggressive BP lowering may worsen cerebral perfusion 1

Do not forget to adjust for renal function: Perindopril accumulates significantly when creatinine clearance drops below 30 mL/min; maximum dose should be 8 mg/day with lesser degrees of impairment 2

Do not restart without checking potassium: ACE inhibitors can cause hyperkalemia, particularly in patients with renal impairment or those on other potassium-sparing agents 2

Additional Therapy if Needed

If blood pressure remains uncontrolled on perindopril alone: 4

• Add a thiazide diuretic (e.g., indapamide) as second-line therapy 1, 4
• Consider adding a calcium channel blocker (e.g., amlodipine) 4, 6
• The combination of perindopril plus indapamide has proven efficacy in reducing recurrent stroke risk by 43% 1