Can angiotensin-converting enzyme (ACE) inhibitors cause your blood pressure to get too low?

Dizziness is a reported side effect occurring in 0.5-2% greater frequency in patients treated with ACE inhibitors than placebo. Patients report lightheadedness especially in the first few days of treatment.

Manufacturers warn that hypotension can occur in patients with salt/volume depletion, such as those taking diuretics. Other causes of volume depletion such as excessive perspiration, dehydration, vomiting, or diarrhea may also lead to a fall in blood pressure. Transient hypotensive episodes are not a contraindication to further treatment. Once blood pressure is stabilized, most patients can continue treatment without difficulty. Manufacturers recommend that if actual syncope occurs, the patient should discontinue the drug until they have spoken to their doctor.^1-16

Patients with heart failure, ischemic heart disease, cerebrovascular disease, hyponatremia, high dose diuretic therapy, renal dialysis, or severe volume and/or salt depletion of any etiology who are also taking an ACE inhibitor are more likely to have symptomatic hypotension.^1-18

Rates of hypotension vary in studies and depend on dosage, risk factors, and whether it was asymptomatic or symptomatic. In a study of 4,849 patients with hypertension being treated with captopril, there was a 2.5% incidence of hypotension. A clinical trial of 2,314 patients being treated with enalapril reported a 0.9% incidence of hypotension as opposed to a 0.4% incidence in the placebo group.¹⁶

References

1. Lotensin [package insert]. Parsippany, NJ: Validus Pharmaceuticals LLC; 2019.
2. Capoten [package insert]. Chestnut Ridge, NY: Par Pharmaceutical; 2017.
3. Epaned [package insert]. Wilmington, MA: Azurity Pharmaceuticals, Inc.; 2020.
4. Vasotec [package insert]. Bridgewater, NJ: Bausch Health US LLC; 2018.
5. Enalaprilat [package insert]. Lake Forest, IL: Hospira, Inc.; 2021.
6. Monopril [package insert]. Princeton, NJ: Bristol-Myers Squibb Company; 2003.
7. Qbrelis [package insert]. Wilmington, MA: Azurity Pharmaceuticals, Inc.; 2020.
8. Prinivil [package insert]. Whitehouse Station, NJ: Merck Sharp & Dohme Corp.; 2021.
9. Zestril [package insert]. Morristown, NJ: Almatica Pharma LLC; 2020.
10. Univasc [package insert]. Smyrna, GA: USB, Inc; 2012.
11. Aceon [package insert]. Cincinnati, OH: Patheon Pharmaceuticals, Inc.; 2017.
12. Accupril [package insert]. New York, NY: Parke Davis, Pfizer; 2021.
13. Altace [package insert]. New York, NY: Pfizer Laboratories; 2022.
14. Mavik [package insert]. Whippany, NJ: Halo Pharmaceutical Inc.; 2017.
15. Sica DA. Angiotensin-converting enzyme inhibitors side effects--physiologic and non-physiologic considerations. J Clin Hypertens (Greenwich) 2004; 6 (7): 410-416.
16. Izzo JL, Jr., Weir MR. Angiotensin-converting enzyme inhibitors. J Clin Hypertens (Greenwich) 2011; 13 (9): 667-675.
17. Warner NJ, Rush JE. Safety profiles of the angiotensin-converting enzyme inhibitors. Drugs 1988; 35 Suppl 5: 89-97.