When is it appropriate to hold lisinopril (Angiotensin-Converting Enzyme (ACE) inhibitor) for systolic blood pressure (SBP) management in patients at risk for hypotension?

When to Hold Lisinopril Based on Systolic Blood Pressure

Hold lisinopril when systolic blood pressure is less than 90 mmHg for more than 1 hour, or consider holding when SBP is less than 100 mmHg in acute myocardial infarction patients. 1

Critical Blood Pressure Thresholds for Holding Lisinopril

Absolute Contraindications (Must Hold)

• Systolic BP < 90 mmHg for more than 1 hour: Lisinopril must be withdrawn in patients with prolonged hypotension, particularly in the acute MI setting where this represents a clear safety threshold. 1

• Systolic BP < 80 mmHg: ACE inhibitors should be used with extreme caution in patients with very low systemic blood pressures, as they are at immediate risk of cardiogenic shock and should not have ACE inhibitor therapy initiated until hemodynamic stability is achieved. 2

Relative Contraindications (Consider Holding or Dose Reduction)

• Systolic BP < 100 mmHg in acute MI patients: The FDA label specifies that if hypotension occurs (SBP ≤ 100 mmHg) in acute MI patients, a reduced daily maintenance dose of 5 mg may be given with temporary reductions to 2.5 mg if needed. 1

• Systolic BP 100-120 mmHg in acute MI patients: Initiate therapy with a reduced dose of 2.5 mg rather than the standard 5 mg dose during the first 3 days after infarction. 1

• Systolic BP < 120 mmHg in post-MI patients: The GISSI-3 trial protocol used 2.5 mg starting doses for patients with baseline systolic blood pressure less than 120 mmHg. 1

Clinical Context-Specific Guidelines

Heart Failure Patients

• Starting dose considerations: Patients with heart failure and hyponatremia (serum sodium < 130 mEq/L) should start at 2.5 mg once daily rather than the standard 5 mg dose. 1

• Hypotension management: The appearance of hypotension after the initial dose does not preclude subsequent careful dose titration, following effective management of the hypotension. 1

• Diuretic adjustment: Ensure appropriate diuretic dosing to help minimize hypovolemia, which may contribute to hypotension. 1

Hypertensive Emergency/Urgency Settings

• Avoid initiation in hypertensive emergency: ACE inhibitors should not be initiated in hypotensive patients who are at immediate risk of cardiogenic shock; such patients should first receive other forms of treatment and then be re-evaluated for ACE inhibition once stability has been achieved. 2

• Hypertensive urgency management: For patients presenting with severe BP elevation (>180/120 mmHg) without target organ damage, oral ACE inhibitors like captopril are preferred first-line agents, but lisinopril is not specifically recommended in this acute setting. 3, 4

Monitoring and Dose Adjustment Algorithm

Step 1: Assess Pre-Dose Blood Pressure

• Measure BP before each dose administration
• If SBP < 90 mmHg for > 1 hour → Hold dose and notify provider 1
• If SBP 90-100 mmHg → Consider dose reduction to 2.5-5 mg 1
• If SBP 100-120 mmHg in acute MI → Use reduced starting dose (2.5 mg) 1

Step 2: Evaluate Clinical Context

• Acute MI patients: More stringent BP thresholds apply (hold if SBP < 100 mmHg with symptoms) 1
• Heart failure patients: Assess volume status and diuretic adequacy before holding 1
• Renal impairment: Patients with creatinine clearance < 30 mL/min should receive reduced initial doses (2.5 mg), making them more susceptible to hypotension 1

Step 3: Assess for Symptomatic Hypotension

• Dizziness, lightheadedness, syncope, or orthostatic symptoms warrant holding the dose regardless of absolute BP number 2
• Orthostatic hypotension (≥20 mmHg systolic or ≥10 mmHg diastolic drop on standing) is a relative contraindication 2

Common Pitfalls and How to Avoid Them

Pitfall 1: Ignoring Volume Status

• Avoid: Holding lisinopril solely based on BP without assessing volume depletion from excessive diuresis 1
• Solution: Adjust diuretic dose first; fluid depletion can potentiate adverse effects of ACE inhibitors 2

Pitfall 2: Permanent Discontinuation After Single Hypotensive Episode

• Avoid: Permanently stopping lisinopril after one episode of hypotension 1
• Solution: The appearance of hypotension after initial dose does not preclude subsequent careful dose titration following effective hypotension management 1

Pitfall 3: Not Reducing Dose in High-Risk Populations

• Avoid: Using standard 5-10 mg starting doses in acute MI patients with SBP < 120 mmHg 1
• Solution: Start with 2.5 mg in acute MI patients with low-normal BP (100-120 mmHg) 1

Pitfall 4: Overlooking Renal Function

• Avoid: Standard dosing in patients with creatinine clearance < 30 mL/min 1
• Solution: Initial dose should be 2.5 mg once daily in patients with severe renal impairment or on hemodialysis 1

Special Populations Requiring Lower Thresholds

Elderly Patients (≥85 years)

• More lenient BP targets (e.g., < 140 mmHg systolic) should be considered, as intensive BP lowering may not generalize to this population 2
• Increased risk of orthostatic hypotension and falls requires careful BP monitoring in multiple positions 2

Patients with Moderate-to-Severe Frailty

• Personalized and more lenient BP targets should be considered, with consideration to defer BP-lowering treatment until BP > 140/90 mmHg 2

Patients with Pre-Treatment Symptomatic Orthostatic Hypotension

• BP-lowering drug treatment should be deferred until BP is > 140/90 mmHg 2
• These patients are less likely to obtain sufficient net benefit from intensive BP-lowering therapy 2