Perioperative Management of Lisinopril to Prevent Hypotension

Introduction to Perioperative Hypotension Risk

• The American College of Cardiology and American Heart Association recommend transient discontinuation of ACE inhibitors before non-cardiac surgery to reduce significant perioperative hemodynamic fluctuations 2, 1
• The European Society of Cardiology notes that perioperative use of ACE inhibitors carries a risk of severe hypotension under anesthesia, and hypotension is less frequent when ACE inhibitors are discontinued the day before surgery 1

Evidence-Based Management Guidelines

• The American Heart Association recommends omitting ACE inhibitors on the day of surgery to reduce significant perioperative hemodynamic fluctuations 3
• The European Society of Cardiology states that it is recommended to continue ACE inhibitors during non-cardiac surgery in stable patients with left ventricular systolic dysfunction (Class I recommendation) 1

Special Population Management

• The European Society of Cardiology recommends continuing ACE inhibitors in patients with left ventricular systolic dysfunction in stable clinical condition 1, 3
• The American Heart Association recommends continuing ACE inhibitors in cardiac-stable patients with left ventricular systolic dysfunction scheduled for high-risk surgery 3

Practical Management Recommendations

• Stop lisinopril 24 hours before surgery for patients with hypertension without heart failure 1, 2, 3
• Continue lisinopril through the perioperative period for patients with heart failure with preserved function 1, 3
• Implement intensive hemodynamic monitoring for patients with heart failure 1
• Avoid hypovolemia and correct electrolyte abnormalities preoperatively 4

Critical Pitfalls to Avoid

• Never abruptly discontinue ACE inhibitors in heart failure patients, as this can precipitate acute decompensation 1
• Do not assume 24-hour discontinuation is always sufficient, as individual patient factors can prolong the hypotensive risk 1