Should Lisinopril Be Held for Low Heart Rate?
No, lisinopril (an ACE inhibitor) should not be held for bradycardia because ACE inhibitors do not directly cause low heart rate—they do not have negative chronotropic effects. 1
Key Pharmacologic Principle
Lisinopril does not affect heart rate or cardiovascular reflexes 1. Unlike beta-blockers or calcium channel blockers, ACE inhibitors work by:
- Inhibiting angiotensin-converting enzyme activity
- Reducing plasma angiotensin II and aldosterone
- Increasing plasma renin activity
- Not affecting sinus node automaticity or atrioventricular conduction 1
When Bradycardia Occurs in Patients on Lisinopril
If a patient on lisinopril develops symptomatic bradycardia, the approach should focus on identifying the actual cause 2:
Evaluate for Reversible Causes (Class I Recommendation)
- Medications that actually cause bradycardia: beta-blockers, calcium channel blockers, digoxin, antiarrhythmic drugs 2
- Electrolyte abnormalities (hypokalemia, severe acidosis)
- Hypothyroidism 2
- Acute myocardial infarction
- Metabolic abnormalities 2
Review Other Heart Rate-Slowing Drugs
If bradycardia is symptomatic (heart rate <50 bpm with worsening symptoms), the guideline-recommended approach is to 2:
- Review and adjust beta-blockers (halve dose or stop if severe deterioration)
- Review need for digoxin, amiodarone, or diltiazem 2
- Arrange ECG to exclude heart block 2
Acute Management of Symptomatic Bradycardia
If the patient has symptomatic bradycardia with hemodynamic compromise, treatment options include 2:
- Atropine 0.5-1 mg IV (Class IIa recommendation) 2
- Beta-agonists (dopamine, isoproterenol, epinephrine) if atropine fails 2
- Temporary pacing for persistent hemodynamically unstable bradycardia refractory to medical therapy 2
None of these interventions involve holding lisinopril.
Important Clinical Context
When ACE Inhibitors Should Be Continued
Lisinopril provides significant mortality and morbidity benefits in heart failure patients, even those with atrial fibrillation 3. High doses (32.5-35 mg daily) reduce:
- Death or hospitalization by 12% (p=0.002)
- Heart failure hospitalizations by 24% (p=0.002) 4
The One Exception: Drug Interaction
The only documented case linking lisinopril to bradycardia involved concomitant tizanidine therapy, where the combination caused severe hypotension and bradycardia 5. This was an interaction effect, not a direct effect of lisinopril alone.
Common Pitfall to Avoid
Do not discontinue beneficial ACE inhibitor therapy when bradycardia occurs. Instead:
- Identify the true culprit medication (beta-blocker, calcium channel blocker, digoxin) 2
- Adjust or discontinue the actual bradycardia-causing agent 2
- Continue lisinopril for its proven cardiovascular benefits 6, 4
Asymptomatic bradycardia in physiologically normal individuals (athletes, during sleep) requires no intervention and certainly no medication adjustments 2.