Differences

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--- cardio:raas:lisinopril [2026/02/12 22:53] – created andrew2393cns
+++ cardio:raas:lisinopril [2026/02/13 16:12] (current) – andrew2393cns
@@ Line 1: / Line 1: @@
-====== Lisinopril ======
+====== Lisinopril (Prinivil®, Zestril®) ======
-Lisinopril is a long-acting ACE inhibitor used in hypertension, heart failure, and post–myocardial infarction care.
+<WRAP right 340px>
+<WRAP infobox>
+| | {{ :cardio:raas:lisinopril_structure.svg |}} |
+^ Lisinopril |
+| Brand Names | Prinivil®, Zestril® |
+| Drug Class | [[cardio:raas:acei|ACE Inhibitor]] |
+| Primary Indications | [[cardio:hypertension:start|Hypertension]]; [[cardio:heart_failure:start|Heart Failure (HFrEF)]]; Post-MI |
+| Blood Pressure Effect | ↓ SVR |
+| Mortality Benefit | Yes (HFrEF, post-MI) |
+| Elimination | Renal |
+| Black Box Warning | Fetal Toxicity |
+| FDA Approval | 1987 |
+</WRAP>
+</WRAP>
-It is one of the most commonly prescribed ACE inhibitors.
+===== Overview =====
-Class:
+Lisinopril is a long-acting [[cardio:raas:acei|angiotensin-converting enzyme (ACE) inhibitor]] used in the treatment of [[cardio:hypertension:start|hypertension]], [[cardio:heart_failure:start|heart failure with reduced ejection fraction]], and post–myocardial infarction ventricular dysfunction.
-→ [[cardio:raas:acei|ACE Inhibitors]]
+It reduces systemic vascular resistance, decreases aldosterone-mediated sodium retention, and mitigates maladaptive neurohormonal activation. Lisinopril improves survival in HFrEF and post-MI patients and remains a cornerstone agent in cardiometabolic therapy.
+<WRAP clear></WRAP>
 ----
@@ Line 12: / Line 28: @@
 ===== Mechanism of Action =====
-• Inhibits Angiotensin-Converting Enzyme (ACE)
+**Primary Molecular Target**
-• ↓ Angiotensin II
+  * Inhibition of angiotensin-converting enzyme (ACE)
-• ↓ Aldosterone
-• ↑ Bradykinin
+**RAAS Effects**
+  * ↓ Conversion of Angiotensin I → Angiotensin II
+  * ↓ Aldosterone secretion
+  * ↓ Vasoconstriction
+**Bradykinin Effect**
+  * ↑ Bradykinin levels (due to reduced breakdown)
-Net Effects:
+**Net Physiologic Outcomes**
-• ↓ Systemic vascular resistance (afterload)
+  * ↓ Systemic vascular resistance (afterload)
-• Mild ↓ preload
+  * ↓ Sodium and water retention
-• ↓ Ventricular remodeling
+  * ↓ Ventricular remodeling
-• ↓ Blood pressure
+  * Improved cardiac output in HFrEF
 ----
@@ Line 27: / Line 49: @@
 ===== Indications =====
-==== Hypertension ====
+  * [[cardio:hypertension:start|Hypertension]]
-• First-line agent in many patients
+  * [[cardio:heart_failure:start|Heart Failure (HFrEF)]]
-• Especially beneficial in diabetes or CKD
+  * Post–myocardial infarction with LV dysfunction
-→ [[cardio:hypertension:start|Hypertension Module]]
+Renal protection:
+  * Diabetic nephropathy (albuminuria reduction)
 ----
-==== Heart Failure (HFrEF) ====
+<WRAP blackbox>
-• Mortality reduction
+===== Black Box Warning =====
-• Reduced hospitalization
-• Prevents ventricular remodeling
-Core GDMT component.
+ACE inhibitors can cause fetal toxicity when administered during pregnancy.
-→ [[cardio:heart_failure:start|Heart Failure Module]]
+Mechanism:
+  * Disruption of fetal RAAS
+  * Risk of renal failure, oligohydramnios, skull hypoplasia
+Discontinue immediately if pregnancy is detected.
+</WRAP>
 ----
-==== Post-Myocardial Infarction ====
+<WRAP contra>
-• Reduces remodeling
+===== Contraindications =====
-• Improves survival
-----
+Absolute:
+  * History of ACE inhibitor–induced angioedema
+  * Pregnancy
+  * Bilateral renal artery stenosis
-==== Diabetic Nephropathy ====
+Relative / Caution:
-• ↓ Proteinuria
+  * Hyperkalemia
-• Slows CKD progression
+  * Severe renal impairment
+  * Volume depletion
+</WRAP>
 ----
+<WRAP details>
 ===== Dosing =====
 Hypertension:
-• Start: 5–10 mg daily
+  * Initial: 10 mg daily
-• Usual range: 10–40 mg daily
+  * Typical: 20–40 mg daily
-• Max: 40 mg daily
+  * Max: 40 mg daily
 Heart Failure:
-• Start low (2.5–5 mg daily)
+  * Initial: 2.5–5 mg daily
-• Titrate to 20–40 mg daily as tolerated
+  * Titrate upward as tolerated
-Once-daily dosing.
+Renal adjustment:
+  * Required in reduced eGFR
+</WRAP>
 ----
+<WRAP details>
 ===== Pharmacokinetics =====
-• Not a prodrug
+Absorption:
-• Not hepatically metabolized
+  * Oral
-• Renally cleared
-• Half-life ~12 hours
+Bioavailability:
+  * ~25%
+Metabolism:
+  * Not metabolized
+Half-life:
+  * ~12 hours
+Elimination:
+  * Renal (unchanged)
-Dose adjustment required in renal impairment.
+</WRAP>
 ----
+<WRAP details>
 ===== Adverse Effects =====
-• Dry cough
+Common:
-• Hyperkalemia
+  * Dry cough (bradykinin-mediated)
-• Hypotension
+  * Dizziness
-• Angioedema (rare)
+  * Hypotension
-• Mild creatinine elevation
+Electrolyte:
+  * Hyperkalemia
+Serious:
+  * Angioedema
+  * Acute kidney injury (in bilateral RAS)
+</WRAP>
 ----
-===== Monitoring =====
+<WRAP details>
+===== Drug Interactions =====
-Check:
+Increased hyperkalemia risk:
-• Serum creatinine
+  * [[cardio:diuretics:mra|Potassium-Sparing Diuretics]]
-• Potassium
+  * Potassium supplements
-Recheck labs 1–2 weeks after initiation or dose change.
+Renal function risk:
+  * NSAIDs
+  * Volume depletion
-Mild creatinine rise (<30%) is expected.
+Avoid combination:
+  * ACE inhibitor + [[cardio:raas:arb|ARB]]
+  * ACE inhibitor + [[cardio:raas:direct_renin_inhibitor|Direct Renin Inhibitor]]
+</WRAP>
 ----
-===== Contraindications =====
+<WRAP monitoring>
+===== Monitoring =====
+Labs:
+  * Serum creatinine
+  * Potassium
+Vitals:
+  * Blood pressure
+Clinical:
+  * Cough
+  * Angioedema symptoms
-• Pregnancy
+</WRAP>
-• History of ACE inhibitor–induced angioedema
-• Bilateral renal artery stenosis
 ----
-===== Drug Interactions =====
+<WRAP pearls>
+===== Clinical Pearls =====
-Increased hyperkalemia risk with:
+  * Mortality benefit in HFrEF
-• [[cardio:hf:spironolactone|Spironolactone]]
+  * Renoprotective in diabetes
-• [[cardio:hf:eplerenone|Eplerenone]]
+  * Cough due to bradykinin accumulation
-• Potassium supplements
+  * First-line in many hypertension guidelines
-• ARBs
+  * Hold during acute kidney injury or dehydration
-Avoid dual ACE + ARB therapy.
+</WRAP>
 ----
-===== Clinical Pearls =====
+===== Comparison Within Class =====
+Compared to other [[cardio:raas:acei|ACE inhibitors]]:
-✔ One of the most commonly used ACE inhibitors
+  * Not a prodrug (active form)
-✔ Once-daily dosing
+  * Long duration (once-daily dosing)
-✔ Mortality benefit in HFrEF
+  * Fully renally cleared
-✔ Monitor potassium and creatinine
+  * Similar mortality benefit to enalapril in HFrEF
-✔ Switch to ARB if cough develops
 ----
-Related:
+===== Related =====
-→ [[cardio:raas:acei|ACE Inhibitors]]
+  * [[cardio:raas:acei|ACE Inhibitors]]
-→ [[cardio:raas:arb|ARBs]]
+  * [[cardio:hypertension:start|Hypertension Module]]
-→ [[cardio:hf:arni|ARNI]]
+  * [[cardio:heart_failure:start|Heart Failure Module]]
-→ [[cardio:start|Return to CV Modules]]
+  * [[cardio:intro:start|Cardiovascular Pharmacology]]