At What DBP Should Lisinopril Be Held?
There is no specific diastolic blood pressure threshold at which lisinopril must be held based on current hypertension guidelines. However, clinical judgment should guide holding lisinopril when DBP falls below 70 mmHg, particularly if the patient develops symptomatic hypotension, as this represents the lower boundary where cardiovascular benefit diminishes and potential harm may occur.
Evidence-Based DBP Thresholds
Target DBP Ranges from Guidelines
The 2024 ESC guidelines recommend a DBP target of <80 mmHg for all hypertensive patients, independent of risk level and comorbidities 1.
When DBP is not at target (≥80 mmHg) but systolic BP is controlled (120-129 mmHg), intensifying treatment to achieve DBP of 70-79 mmHg may be considered to reduce cardiovascular risk 1.
The 2017 ACC/AHA guidelines recommend a combined BP treatment goal of <130/80 mmHg for adults with confirmed hypertension, with the DBP goal being <80 mmHg 1.
The J-Curve Phenomenon and Lower DBP Limits
Post-hoc analyses suggest that progressive reduction in cardiovascular events occurs with DBP lowering down to 75 mmHg, though additional benefit at these low values becomes small 1.
A J-curve phenomenon is unlikely to occur down to DBP values of 75 mmHg except perhaps in patients with advanced atherosclerotic disease 1.
The 2012 European guidelines recommend targeting DBP to values within the range of 80-85 mmHg, and possibly close to lower values in this range, for all hypertensive patients 1.
Clinical Decision Algorithm for Holding Lisinopril
Hold or Reduce Lisinopril When:
DBP consistently falls below 70 mmHg, especially if accompanied by symptoms of hypotension (dizziness, lightheadedness, syncope, falls) 1.
Symptomatic orthostatic hypotension develops at any DBP level, as this indicates inadequate cerebral perfusion regardless of the absolute number 1.
DBP is below 75 mmHg in patients with advanced atherosclerotic disease, where the J-curve phenomenon may apply and further lowering could compromise coronary perfusion 1.
Monitor Closely When:
DBP is in the 70-79 mmHg range, as this represents the lower therapeutic target where benefit is maintained but further reduction may not provide additional cardiovascular protection 1.
Elderly patients (≥65 years) have DBP <80 mmHg, as they may be more susceptible to hypotension-related adverse events including falls and syncope 1.
Important Clinical Caveats
Populations Requiring More Conservative Approach
Patients aged ≥85 years should have more lenient BP targets (systolic <140 mmHg), suggesting that aggressive DBP lowering should also be avoided in this population 1.
Moderate-to-severely frail patients at any age may require more lenient BP targets (<140/90 mmHg), indicating that lower DBP thresholds for holding medication should be higher in this group 1.
Patients with symptomatic orthostatic hypotension should have treatment adjusted regardless of absolute DBP values, as symptoms take precedence over numbers 1.
Monitoring Strategy
The antihypertensive effect of lisinopril begins within 2 hours, peaks around 6 hours, and lasts for at least 24 hours, so DBP should be assessed at trough (before next dose) to determine if holding is necessary 2.
Steady state is achieved in 2-3 days with lisinopril, meaning that DBP changes after dose adjustments should be reassessed within this timeframe 2.
Practical Threshold Recommendation
Hold lisinopril when DBP is <70 mmHg on repeated measurements, or when DBP is <75 mmHg with concurrent symptoms of hypotension or in patients with advanced coronary artery disease. This approach balances the evidence showing cardiovascular benefit down to 75 mmHg 1 with the 2024 ESC recommendation that DBP of 70-79 mmHg may be considered as a lower target 1, while avoiding potential harm from excessive DBP lowering below 70 mmHg where evidence of benefit is lacking.