What is the recommended treatment and dosage for high blood pressure and heart failure using Lisinopril (Angiotensin-Converting Enzyme inhibitor)?

Lisinopril for Hypertension and Heart Failure

For heart failure, start lisinopril at 2.5 mg daily and titrate aggressively to the target dose of 30-35 mg once daily, as higher doses significantly reduce mortality and hospitalizations compared to low doses. 1

Heart Failure Dosing

The ATLAS trial definitively demonstrated that high-dose lisinopril (32.5-35 mg daily) reduces hospitalizations by 24% and the combined endpoint of death or hospitalization by 12% compared to low doses (2.5-5 mg daily). 1, 2

Initiation Protocol

• Start at 2.5 mg once daily in all heart failure patients, or in those with hyponatremia (serum sodium <130 mEq/L) 3, 4
• Start at 5 mg once daily if not hyponatremic and hemodynamically stable 4
• Titrate upward at intervals of not less than 2 weeks based on tolerance 1
• Target dose: 30-35 mg once daily - this is the evidence-based goal that improves outcomes 1, 2
• Maximum dose: 40 mg once daily 4

Critical Monitoring During Titration

• Check serum potassium and creatinine after 5-7 days of starting or any dose change, then recheck every 5-7 days until stable 3, 1
• Monitor blood pressure, renal function, and electrolytes 1-2 weeks after each dose increment, at 3 months, then every 6 months 3, 1
• An increase in creatinine up to 50% above baseline, or to 3 mg/dL (whichever is greater), is acceptable and should not prompt discontinuation 1

Common Pitfall

Most clinicians fail to titrate to target doses - staying at low doses (2.5-5 mg) denies patients the proven mortality and morbidity benefits of higher doses 1. The ATLAS trial clearly showed that higher doses are both more effective and similarly tolerated 2.

Hypertension Dosing

Initial Therapy

• Start at 10 mg once daily in adults not taking diuretics 4
• Start at 5 mg once daily if already on diuretics 4
• Usual maintenance range: 20-40 mg once daily 4
• Doses up to 80 mg have been used but provide no additional benefit 4

Pediatric Dosing (≥6 years old)

• Start at 0.07 mg/kg once daily (maximum 5 mg) 4
• Maximum: 0.61 mg/kg once daily (not to exceed 40 mg) 4
• Only use if GFR >30 mL/min/1.73m² 4

Post-Myocardial Infarction

In hemodynamically stable patients within 24 hours of MI onset: 4

• Give 5 mg orally initially
• 5 mg after 24 hours
• 10 mg after 48 hours
• Then 10 mg once daily for at least 6 weeks 4

If systolic BP is 100-120 mmHg during first 3 days: start at 2.5 mg 4

If hypotension develops (SBP ≤100 mmHg): reduce to 5 mg daily maintenance, with temporary reductions to 2.5 mg as needed 4

If prolonged hypotension (SBP <90 mmHg for >1 hour): discontinue lisinopril 4

Renal Impairment Dosing

• CrCl >30 mL/min: No adjustment needed 4
• CrCl 10-30 mL/min: Start at half the usual dose (hypertension: 5 mg; heart failure: 2.5 mg; post-MI: 2.5 mg), titrate to maximum 40 mg daily 4
• CrCl <10 mL/min or hemodialysis: Start at 2.5 mg once daily 4

Essential Precautions

Avoid These Medications

• NSAIDs and COX-2 inhibitors - worsen renal function and reduce ACE inhibitor efficacy 3, 1
• Potassium-sparing diuretics during initiation unless specifically needed for persistent hypokalemia 3, 1

Pre-Treatment Optimization

• Review and potentially reduce diuretic doses 24 hours before starting to avoid excessive hypotension 3
• Avoid excessive diuresis before ACE inhibitor initiation 3

Timing Consideration

• Consider evening dosing when supine to minimize hypotension risk, though evidence in heart failure is limited 3
• If morning dosing, supervise for several hours with blood pressure monitoring in high-risk patients 3

Combination Therapy

ACE inhibitors should always be combined with diuretics and beta-blockers (if tolerated) in heart failure patients 3

For hypertension, if blood pressure remains uncontrolled on lisinopril alone, add a low-dose thiazide diuretic (e.g., hydrochlorothiazide 12.5 mg) 4

Tolerability Note

ACE inhibitor-induced cough rarely requires discontinuation - only switch to an angiotensin receptor blocker if cough is proven ACE inhibitor-related through withdrawal and rechallenge 1. Hypotension after the initial dose does not preclude careful subsequent titration 4.