What are the blood pressure parameters to hold losartan (angiotensin II receptor antagonist) due to hypotension?

Blood Pressure Hold Parameters for Losartan

Losartan should generally be held if systolic blood pressure falls below 90 mmHg or if the patient develops symptomatic hypotension (dizziness, lightheadedness, syncope), though asymptomatic low blood pressure alone in stable patients does not necessarily require medication discontinuation. 1

Evidence-Based Hold Parameters

Absolute Hold Criteria

• Systolic BP <80-90 mmHg with symptoms warrants immediate hold of losartan 1
• Symptomatic orthostatic hypotension (significant drop with position change causing dizziness, near-syncope) requires medication reassessment 1, 2
• Signs of end-organ hypoperfusion (altered mental status, oliguria, cool extremities) mandate immediate discontinuation 1

Context-Dependent Considerations

In Heart Failure Patients:

• The 2025 Heart Failure Association guidelines emphasize that asymptomatic low BP in clinically stable patients on optimal therapy is unlikely caused by losartan and should prompt evaluation for other causes rather than automatic medication discontinuation 1
• Target BP in heart failure should be maintained >120/70 mmHg but <130/80 mmHg, with holds considered below this range if symptomatic 1

In General Hypertension:

• The 2020 ISH guidelines recommend treatment targets of <130/80 mmHg (or <140/80 mmHg in elderly patients) 1
• This implies holding parameters would reasonably be systolic <100 mmHg or symptomatic hypotension at any level 1

Clinical Algorithm for Hold Decisions

Step 1: Confirm Low Blood Pressure

• Verify BP reading with repeat measurement 1
• Check for orthostatic changes (measure supine and standing BP) 1, 2
• Assess if reading represents true hypotension versus measurement error

Step 2: Assess Symptom Severity

Symptomatic hypotension indicators: 1

• Dizziness or lightheadedness (especially with position changes)
• Fatigue or weakness beyond baseline
• Syncope or near-syncope
• Confusion or altered mentation
• Chest pain or dyspnea

If asymptomatic: Patient education and reassurance may be sufficient without medication adjustment, particularly in stable heart failure patients 1

Step 3: Identify Contributing Factors

Before holding losartan, evaluate for: 1

• Overdiuresis (most common reversible cause)
• Concurrent antihypertensive medications (alpha-blockers for BPH, other vasodilators)
• Volume depletion (vomiting, diarrhea, poor oral intake)
• Cardiac causes (worsening heart failure, valvular disease, arrhythmias)
• Medication interactions or recent dose escalations

Step 4: Management Strategy

If BP 80-100 mmHg systolic with symptoms:

• Hold losartan temporarily 1
• Address reversible causes (reduce diuretics if overdiuresed, discontinue non-essential antihypertensives)
• Restart at lower dose (25 mg) once BP stabilizes above 100 mmHg systolic 1

If BP <80 mmHg systolic:

• Hold losartan immediately 1
• Evaluate for acute causes requiring intervention
• Consider IV fluids if volume depleted
• Restart only after BP consistently >90-100 mmHg and underlying cause addressed

Special Populations

Elderly Patients (≥85 years) and Frail Patients

• More conservative hold parameters may be appropriate 1
• Consider holding if systolic BP <100 mmHg even if asymptomatic, given higher risk of falls and complications 1
• The 2024 ESC guidelines suggest that in frail patients, achieving target BP may not be possible, and the "as low as reasonably achievable" (ALARA) principle should guide therapy 1

Patients with Chronic Kidney Disease

• Monitor more closely as RAS inhibitors like losartan are first-line but require careful BP monitoring 1
• Hold parameters remain similar, but also monitor renal function and electrolytes 1

Common Pitfalls to Avoid

1. Don't automatically discontinue losartan for asymptomatic low BP in stable patients - this is a critical error, especially in heart failure where the medication provides mortality benefit 1

2. Don't ignore orthostatic measurements - standing BP may be significantly lower than seated readings, and orthostatic hypotension is the more clinically relevant parameter 1, 2

3. Don't hold losartan without addressing diuretic overuse first - excessive diuresis is often the culprit and should be corrected before discontinuing beneficial RAS blockade 1

4. Don't use rigid numerical cutoffs alone - clinical context (symptoms, comorbidities, overall stability) matters more than a single BP reading 1

5. Avoid permanent discontinuation when temporary hold is appropriate - losartan provides significant cardiovascular and renal protection; restart at lower dose once BP stabilizes 1, 3

Practical Hold Parameters Summary

Recommended hold thresholds:

• Systolic BP <90 mmHg with symptoms → Hold temporarily 1
• Systolic BP <80 mmHg regardless of symptoms → Hold immediately 1
• Symptomatic orthostatic hypotension → Hold and reassess 1, 2
• Asymptomatic BP 90-100 mmHg in stable patient → Continue with close monitoring, patient education 1

Restart criteria:

• Systolic BP consistently >100 mmHg
• Resolution of symptoms
• Correction of contributing factors
• Consider restarting at 25 mg daily and titrating slowly 1