ClinCalc Pro
Menu
Calculators Drugs Pathways AI Dx Donate Get the App
ACE Inhibitor / HFrEF Pregnancy: Contraindicated in 2nd/3rd trimester — ACEi fetopathy (renal agenesis, oligohydramnios, skull hypoplasia).

Lisinopril (HFrEF / Post-MI)

Brand names: Zestril, Carace

Adult dose

Dose: HFrEF: 2.5-5 mg OD initially; titrate to target 30-35 mg OD. Post-MI: 2.5 mg within 24h, 5 mg at 24h, 10 mg at 48h, then 10 mg OD.
Route: Oral
Frequency: Once daily
Max: 35 mg/day (HFrEF)
ACE inhibitor. First-line for all HFrEF (SOLVD, GISSI-3 trials). Blocks angiotensin-II — reduces preload/afterload, prevents cardiac remodelling. ACEi + beta-blocker is the foundation of HFrEF therapy. A 36-hour washout required before switching to sacubitril/valsartan.

Paediatric dose

Dose: 0.1 mg/kg
Route: Oral
Frequency: Once daily
Max: 0.6 mg/kg/day (max 40 mg/day)
Licensed for hypertension in children 6-16 years. Not licensed for HF in children.

Dose adjustments

Renal

eGFR 10-30: start 2.5 mg OD. Expect up to 20% creatinine rise on initiation — acceptable haemodynamic effect. If >30% rise — halve dose. If >50% — stop (investigate renal artery stenosis).

Hepatic

No dose adjustment required — lisinopril is not metabolised

Paediatric weight-based calculator

Licensed for hypertension in children 6-16 years. Not licensed for HF in children.

Clinical pearls

  • Creatinine rise: up to 20-30% acceptable — reflects reduced intraglomerular pressure. This is the desired renoprotective effect, NOT renal injury. Investigate bilateral RAS if rise >50%.
  • Angioedema: higher risk in Afro-Caribbean patients (up to 3x more common). Can occur years after starting. Tongue/lip/laryngeal swelling = medical emergency. Treat with adrenaline 0.5 mg IM + chlorphenamine + hydrocortisone.
  • Sacubitril/valsartan upgrade (ESC 2021): upgrade ACEi to Entresto in symptomatic HFrEF on optimal therapy. Mandatory 36-hour ACEi washout before starting — without washout, severe angioedema risk from neprilysin inhibition + bradykinin.
  • Dry cough: switch to ARB (candesartan/valsartan). Do NOT rechallenge with a different ACEi for cough — class effect.
  • GISSI-3: lisinopril started within 24h of STEMI — 11% reduction in 6-week mortality. Early ACEi beneficial especially in anterior MI, HF, or hypertension.

Contraindications

  • Bilateral renal artery stenosis
  • History of ACEi-induced angioedema
  • Pregnancy (2nd/3rd trimester)
  • Concurrent sacubitril/valsartan (36-hour washout required)
  • Concurrent aliskiren in diabetes or CKD

Side effects

  • Dry cough (10-15% — bradykinin accumulation; class effect)
  • Hyperkalaemia
  • First-dose hypotension
  • Renal impairment (haemodynamic — expect 10-20% creatinine rise)
  • Angioedema (rare but life-threatening — higher risk in Afro-Caribbean patients)
  • Rash

Interactions

  • Potassium-sparing diuretics/ARBs/aliskiren — hyperkalaemia
  • NSAIDs — blunt antihypertensive effect + AKI
  • Lithium — increased lithium toxicity
  • Sacubitril/valsartan — angioedema if no washout

Monitoring

  • Blood pressure
  • eGFR and potassium (1 week and 1 month after initiation/dose change)
  • Angioedema symptoms
  • Dry cough assessment

Reference: BNFc; BNF 90; SOLVD Trial; GISSI-3 Trial; ESC HF Guidelines 2021; NICE NG106; SPC Zestril. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

Calculators
Pathways