====== Lisinopril (Prinivil®, Zestril®) ======<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>===== Overview =====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.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>----===== Mechanism of Action =====**Primary Molecular Target**  * Inhibition of angiotensin-converting enzyme (ACE)**RAAS Effects**  * ↓ Conversion of Angiotensin I → Angiotensin II  * ↓ Aldosterone secretion  * ↓ Vasoconstriction**Bradykinin Effect**  * ↑ Bradykinin levels (due to reduced breakdown)**Net Physiologic Outcomes**  * ↓ Systemic vascular resistance (afterload)  * ↓ Sodium and water retention  * ↓ Ventricular remodeling  * Improved cardiac output in HFrEF----===== Indications =====  * [[cardio:hypertension:start|Hypertension]]  * [[cardio:heart_failure:start|Heart Failure (HFrEF)]]  * Post–myocardial infarction with LV dysfunctionRenal protection:  * Diabetic nephropathy (albuminuria reduction)----<WRAP blackbox>===== Black Box Warning =====ACE inhibitors can cause fetal toxicity when administered during pregnancy.Mechanism:  * Disruption of fetal RAAS  * Risk of renal failure, oligohydramnios, skull hypoplasiaDiscontinue immediately if pregnancy is detected.</WRAP>----<WRAP contra>===== Contraindications =====Absolute:  * History of ACE inhibitor–induced angioedema  * Pregnancy  * Bilateral renal artery stenosisRelative / Caution:  * Hyperkalemia  * Severe renal impairment  * Volume depletion</WRAP>----<WRAP details>===== Dosing =====Hypertension:  * Initial: 10 mg daily  * Typical: 20–40 mg daily  * Max: 40 mg dailyHeart Failure:  * Initial: 2.5–5 mg daily  * Titrate upward as toleratedRenal adjustment:  * Required in reduced eGFR</WRAP>----<WRAP details>===== Pharmacokinetics =====Absorption:  * OralBioavailability:  * ~25%Metabolism:  * Not metabolizedHalf-life:  * ~12 hoursElimination:  * Renal (unchanged)</WRAP>----<WRAP details>===== Adverse Effects =====Common:  * Dry cough (bradykinin-mediated)  * Dizziness  * HypotensionElectrolyte:  * HyperkalemiaSerious:  * Angioedema  * Acute kidney injury (in bilateral RAS)</WRAP>----<WRAP details>===== Drug Interactions =====Increased hyperkalemia risk:  * [[cardio:diuretics:mra|Potassium-Sparing Diuretics]]  * Potassium supplementsRenal function risk:  * NSAIDs  * Volume depletionAvoid combination:  * ACE inhibitor + [[cardio:raas:arb|ARB]]  * ACE inhibitor + [[cardio:raas:direct_renin_inhibitor|Direct Renin Inhibitor]]</WRAP>----<WRAP monitoring>===== Monitoring =====Labs:  * Serum creatinine  * PotassiumVitals:  * Blood pressureClinical:  * Cough  * Angioedema symptoms</WRAP>----<WRAP pearls>===== Clinical Pearls =====  * Mortality benefit in HFrEF  * Renoprotective in diabetes  * Cough due to bradykinin accumulation  * First-line in many hypertension guidelines  * Hold during acute kidney injury or dehydration</WRAP>----===== Comparison Within Class =====Compared to other [[cardio:raas:acei|ACE inhibitors]]:  * Not a prodrug (active form)  * Long duration (once-daily dosing)  * Fully renally cleared  * Similar mortality benefit to enalapril in HFrEF----===== Related =====  * [[cardio:raas:acei|ACE Inhibitors]]  * [[cardio:hypertension:start|Hypertension Module]]  * [[cardio:heart_failure:start|Heart Failure Module]]  * [[cardio:intro:start|Cardiovascular Pharmacology]]