From the Guidelines
Lisinopril-HCTZ is a suitable treatment option for diastolic heart failure, as it combines an ACE inhibitor (lisinopril) with a thiazide diuretic (hydrochlorothiazide) to address both afterload reduction and fluid retention. The typical starting dose is 10-12.5 mg once daily (10 mg lisinopril with 12.5 mg hydrochlorothiazide), which can be titrated up to 20-25 mg daily if needed and tolerated 1. This combination medication helps manage diastolic heart failure by addressing two key issues: the lisinopril component reduces afterload, blocks harmful neurohormonal activation, and prevents cardiac remodeling, while the hydrochlorothiazide component helps control fluid retention and blood pressure.
Key benefits of using Lisinopril-HCTZ in diastolic heart failure include:
- Reduced afterload and improved cardiac output
- Decreased fluid retention and blood pressure
- Prevention of cardiac remodeling
- Improved symptoms and quality of life
When starting this medication, it is essential to monitor:
- Blood pressure
- Kidney function
- Electrolytes (particularly potassium)
Common side effects of Lisinopril-HCTZ include:
- Dry cough
- Dizziness
- Electrolyte disturbances
Patients should be advised to:
- Take the medication at the same time each day
- Report significant drops in blood pressure or dizziness
- Understand that the full therapeutic effect may take several weeks
This medication should be used as part of a comprehensive treatment plan that includes:
- Sodium restriction
- Regular physical activity
- Management of comorbidities like hypertension and diabetes 1.
From the FDA Drug Label
In two placebo controlled, 12-week clinical studies compared the addition of lisinopril up to 20 mg daily to digitalis and diuretics alone. The combination of lisinopril, digitalis and diuretics reduced the following signs and symptoms of heart failure: edema, rales, paroxysmal nocturnal dyspnea and jugular venous distention In one of the studies, the combination of lisinopril, digitalis and diuretics reduced orthopnea, presence of third heart sound and the number of patients classified as NYHA Class III and IV; and improved exercise tolerance.
Lisinopril can be used for the treatment of diastolic congestive heart failure (CHF), as it has been shown to reduce signs and symptoms of heart failure when combined with digitalis and diuretics. The recommended dose is up to 20 mg daily. However, it is essential to note that the primary studies mentioned in the label focused on systolic heart failure.
- The use of lisinopril in diastolic CHF is not directly addressed in the provided label.
- Hydrochlorothiazide (HCTZ) is mentioned as a comparator in the studies for hypertension, but not specifically in the context of diastolic CHF treatment with lisinopril. 2
From the Research
Lisinopril HCTZ for Diastolic CHF
- Lisinopril is an orally active, nonsulfhydryl angiotensin-converting-enzyme (ACE) inhibitor that is effective in lowering blood pressure in all grades of essential hypertension 3.
- The addition of hydrochlorothiazide (HCTZ) to lisinopril enhances its antihypertensive effect, and lisinopril also attenuates hypokalaemia induced by thiazide diuretics 3, 4.
- In patients with congestive heart failure, lisinopril improves indices of cardiac function and produces greater benefit than captopril in one controlled study 4.
- High doses of lisinopril (32.5 to 35mg, administered once daily) demonstrate clinically important advantages over low doses (2.5 to 5mg, administered once daily) of the drug in the treatment of congestive heart failure, including a reduced risk of major clinical events and hospitalisations for heart failure 5.
- Lisinopril is generally well tolerated by patients with heart failure, with the most common adverse events being dizziness, headache, hypotension, and diarrhoea 5.
- The appropriate treatment of diastolic HF has yet to be determined, but beta-blockade is effective in the prevention of HF in the post-MI period and as first-line agents in the treatment of young/middle-aged hypertension 6.
- Lisinopril has been evaluated for the treatment of congestive heart failure and has been found to significantly improve exercise duration, left ventricular ejection fraction (LVEF), and the clinical signs and symptoms of CHF when compared with placebo 7.