Should You Increase Lisinopril in This Patient with Uncontrolled Blood Pressure?
Yes, increase lisinopril from 20 mg to 40 mg daily as the first step, before adjusting other medications, because ACE inhibitor optimization is the cornerstone of guideline-directed medical therapy in systolic heart failure and provides both blood pressure control and mortality benefit. 1, 2
Why Lisinopril Should Be Increased First
ACE inhibitors are the foundation of heart failure therapy and must be titrated to target doses proven to reduce cardiovascular mortality and hospitalizations. The current dose of lisinopril 20 mg daily is below the target range of 20–40 mg daily established in major heart failure trials. 3, 4 In the ATLAS trial, higher doses of ACE inhibitors (32.5–35 mg daily) demonstrated a 12% lower risk of death or hospitalization compared to low doses (2.5–5 mg daily), with 24% fewer heart failure hospitalizations. 4
In patients with both heart failure and hypertension following CABG, ACE inhibitors provide dual benefit: blood pressure reduction and cardioprotective effects. Lisinopril produces smooth, gradual blood pressure reductions of 11–15% in systolic and 13–17% in diastolic pressure when given once daily as monotherapy. 5, 6 The antihypertensive effect begins within 2 hours, peaks around 6 hours, and lasts at least 24 hours. 5
The 2016 ESC guidelines explicitly recommend ACE inhibitors as Step 1 therapy for hypertension in heart failure with reduced ejection fraction (Class I, Level A). 1 The 2018 ACC/AHA guidelines similarly prioritize ACE inhibitor titration to achieve systolic blood pressure <130 mmHg in this population. 1
Why Not Adjust Other Medications First
Amlodipine 5 mg daily is already at a reasonable dose and should only be increased after ACE inhibitor optimization. The ESC guidelines designate amlodipine as Step 3 therapy—to be added only when hypertension persists despite ACE inhibitor, beta-blocker, mineralocorticoid receptor antagonist, and diuretic therapy. 1 While amlodipine is safe in systolic heart failure and can be used for blood pressure control, it does not provide the mortality benefit that ACE inhibitors offer. 7
Furosemide 20 mg daily is a low dose appropriate for mild fluid retention, and increasing it would not address the underlying blood pressure issue. Diuretics are recommended for symptom control in heart failure but are less effective than ACE inhibitors for blood pressure reduction in this population. 1 The 2013 ACC/AHA guidelines state that thiazide diuretics are more effective than loop diuretics for blood pressure control, but loop diuretics should be used when volume control is needed. 1
Amiodarone 100 mg daily is for arrhythmia management and has no role in blood pressure control. This medication should not be adjusted for hypertension management. 1
Practical Titration Strategy
Increase lisinopril from 20 mg to 30 mg daily initially, then to 40 mg daily after 1–2 weeks if tolerated. 2 The FDA label for lisinopril indicates that doses up to 80 mg daily have been used in hypertension trials, though 20–40 mg daily is the typical target range for heart failure. 3
Monitor blood pressure, renal function (creatinine/eGFR), and serum potassium 1–2 weeks after each dose increase. 1, 2 A rise in serum creatinine up to 25–30% from baseline (or an absolute value <2.5 mg/dL) is acceptable and should not prompt discontinuation. 2 If creatinine rises beyond these thresholds, reduce the ACE inhibitor dose rather than stopping it entirely. 2
Target blood pressure is <130/80 mmHg, but consideration should be given to lowering it further to <120/80 mmHg in heart failure patients. 1 In the COPERNICUS trial, carvedilol demonstrated benefits in patients with mean baseline blood pressure of 123/76 mmHg, suggesting that lower systolic pressures (around 120 mmHg) may be desirable. 1
Critical Monitoring Parameters
Check the following within 1–2 weeks after increasing lisinopril: 2
- Blood pressure (target <130/80 mmHg)
- Serum creatinine and eGFR (accept up to 30% rise)
- Serum potassium (target 4.0–5.0 mEq/L)
- Sodium and magnesium levels
Continue monitoring at 3 months, then every 6 months thereafter. 2 More frequent monitoring is needed if the patient has chronic kidney disease, diabetes, or is on medications affecting potassium homeostasis. 2
When to Consider Adding or Adjusting Other Medications
If blood pressure remains uncontrolled after lisinopril is optimized to 40 mg daily, then increase amlodipine from 5 mg to 10 mg daily. 1 The ESC guidelines recommend amlodipine or hydralazine as Step 3 therapy when hypertension persists despite ACE inhibitor, beta-blocker, MRA, and diuretic therapy. 1
Consider adding a mineralocorticoid receptor antagonist (spironolactone 12.5–25 mg daily) if the patient has NYHA class III–IV symptoms, provided baseline potassium is <5.0 mmol/L and creatinine is <2.5 mg/dL. 1, 2 This provides both blood pressure reduction and mortality benefit in heart failure. 1
If a thiazide diuretic is needed for additional blood pressure control, switch from furosemide to a thiazide or add a thiazide to the loop diuretic (sequential nephron blockade). 1 However, this should only be done after ACE inhibitor optimization and with close monitoring of electrolytes and renal function. 1
Common Pitfalls to Avoid
Do not withhold or reduce ACE inhibitors solely because of modest blood pressure reductions or mild creatinine elevation. The mortality benefit of ACE inhibitors persists even with moderate renal impairment and lower blood pressures. 2 Asymptomatic low blood pressure generally does not require medication adjustment. 2
Do not add potassium-sparing diuretics during ACE inhibitor initiation or titration to prevent hyperkalemia. 2 If spironolactone is added later, monitor potassium and creatinine 4–6 days after initiation, then every 5–7 days until values stabilize. 1, 2
Avoid NSAIDs entirely, as they promote sodium retention, worsen renal function, and blunt diuretic efficacy. 1, 2 NSAIDs also dramatically increase hyperkalemia risk when combined with ACE inhibitors. 2
Do not use non-dihydropyridine calcium channel blockers (diltiazem, verapamil) in systolic heart failure, as they have negative inotropic effects and worsen outcomes. 1 Amlodipine and felodipine are the only calcium channel blockers considered safe in heart failure with reduced ejection fraction. 1