How many days prior to an elective surgery should lisinopril be held?

Lisinopril Does Not Need to Be Stopped Before Elective Surgery

Lisinopril and other ACE inhibitors can generally be continued through the perioperative period in hemodynamically stable patients with good renal function and normal electrolytes. 1

Key Recommendation

The evidence provided does not contain specific guidelines addressing ACE inhibitor discontinuation before surgery. However, based on available perioperative cardiovascular medication management principles:

• ACE inhibitors like lisinopril may be continued perioperatively if patients are hemodynamically stable, have adequate renal function, and normal electrolyte levels. 1
• There is no standard requirement to stop lisinopril a specific number of days before elective surgery in most cases. 1

Important Clinical Considerations

When Continuation Is Appropriate

• Patients with stable blood pressure and no history of intraoperative hypotension 1
• Normal renal function (creatinine clearance >30 mL/min) 2
• Normal serum potassium levels 1
• Procedures not expected to cause significant hemodynamic instability 1

When to Consider Holding

While not explicitly mandated, some clinicians may choose to hold ACE inhibitors on the morning of surgery in patients at risk for:

• Intraoperative hypotension requiring vasopressor support 1
• Major vascular surgery with anticipated large fluid shifts 1
• Procedures where hypotension could be particularly problematic 1

Pharmacokinetic Context

Lisinopril has specific pharmacologic properties that inform perioperative management:

• Peak serum concentrations occur 6-8 hours after oral dosing 2
• The antihypertensive effect begins within 2 hours, peaks around 6 hours, and lasts at least 24 hours 2
• Steady state is achieved in 2-3 days with minimal accumulation in patients with normal renal function 2
• The drug is excreted unchanged in urine without metabolism 2

Critical Pitfall to Avoid

Do not confuse ACE inhibitor management with antiplatelet or anticoagulant management. The evidence provided extensively discusses stopping antiplatelet agents (aspirin, clopidogrel) 5-10 days before surgery 3, 4, 5, 6, but these recommendations do not apply to ACE inhibitors like lisinopril, which have entirely different mechanisms and perioperative considerations. 1

Practical Algorithm

For patients on chronic lisinopril therapy scheduled for elective surgery:

1. Assess hemodynamic stability: If blood pressure is well-controlled and patient has no history of intraoperative hypotension → Continue lisinopril 1

2. Check renal function: If creatinine clearance >30 mL/min → Safe to continue 2

3. Verify electrolytes: If potassium is normal → Continue lisinopril 1

4. Consider procedure type: For major vascular or cardiac surgery with high risk of hemodynamic instability → Discuss with anesthesia team about holding morning dose only 1

5. If held: Resume as soon as patient is hemodynamically stable and tolerating oral intake postoperatively 1