Fatal outcome of late-onset angiotensin-converting enzyme inhibitor induced angioedema

Abstract

Rationale:Angiotensin-converting enzyme (ACE) inhibitors are one of the most used medication among patients with arterial hypertension. In most cases, ACE inhibitors caused side effects are mild; however, from 0.1% to 0.7% of patients can develop life threatening adverse effect, angioedema. Unlike histamine mediated, ACE inhibitor-related angioedema can develop at any time during the treatment course.Patient concerns:An 89-year-old woman with a medical history for arterial hypertension, ischemic heart disease, heart failure, chronic atrial fibrillation developed ACE inhibitor-induced angioedema after 5 years of daily ramipril administration.Diagnoses:Arterial hypertension, ischemic heart disease, heart failure, chronic atrial fibrillation and late onset ACE inhibitor-induced angioedema.Interventions:The ACE inhibitor was used for arterial hypertension on a daily basis for the past 5 years. Patient developed airway obstruction requiring intubation. Standard therapy with epinephrine, methylprednisolone and clemastine was administered. Treatment was ineffective, considering that angioedema persisted.Outcomes:Angioedema resolved after 13 days from the discontinuation of ramipril. Death due to cardiopulmonary insufficiency occurred 24 days after the admission to intensive care unit, despite full clinical resolution of ACE inhibitor-induced angioedema.Lessons:Our case highlight the importance of educating clinicians about ACE inhibitor-induced angioedema, as potentially fatal adverse drug reaction. Considering the fact, that no laboratory or confirmatory test exist to diagnose ACE inhibitor-induced angioedema, clinicians’ knowledge is the key element in recognition of ACE inhibitor-related angioedema.

Angiotensin-Converting Enzyme Inhibitor-Induced Angioedema With Resultant Airway Obstruction Following Endotracheal Intubation

“…One rare but major complication of tracheal intubation and tracheostomy is post-intubation tracheal stenosis, yet the mechanism for intubation-induced tracheal stenosis is not fully understood [3,[16][17][18]. The underlying pathology of tracheal stenosis is thought to be attributed to cartilage ulceration and inflammatory reactions, leading to granulation and fibrous tissue formation, which ultimately causes stenosis [19].…”

“…Angioedema associated with ACEi presents with swelling in the face, tongue, and airways [ 2 , 13 ]. Symptoms can occur within a week to years after ACEi treatment [ 3 , 14 ]. This condition warrants emergency intervention as it can lead to life-threatening obstruction of airways [ 2 , 3 , 13 , 14 ].…”

“…Symptoms can occur within a week to years after ACEi treatment [ 3 , 14 ]. This condition warrants emergency intervention as it can lead to life-threatening obstruction of airways [ 2 , 3 , 13 , 14 ]. The preferred management for ACEi-induced angioedema depends on the clinical picture, as there are no laboratory studies available currently to establish this particular etiology and diagnosis compared to hereditary angioedema, which is diagnosed with low levels of C2, C4, and C1 esterase inhibitors [ 4 ].…”

“…Angiotensin-converting enzyme inhibitor (ACEi)-induced angioedema is a rare but life-threatening adverse effect of ACEi therapy with an incidence of approximately 0.1-0.7% [1]. There have been numerous instances in which patients with this clinical picture have required intubation or tracheostomy in severe cases [2][3][4][5]. This report presents a case of tracheal stenosis brought about by traumatic intubation.…”

Adverse Effects of Angiotensin-Converting Enzyme Inhibitors in Humans: A Systematic Review and Meta-Analysis of 378 Randomized Controlled Trials

“…Furthermore, it is possible that the trials did not have a follow-up period long enough to detect the incidence of angioedema, because more than half of the cases showing this adverse consequence may occur after one year (or longer) of ACE inhibitor treatment [ 43 , 44 ]. As documented earlier, angioedema is rare but life-threatening [ 45 , 46 , 47 ], so healthcare professionals should still be aware of this possible adverse consequence when ACE inhibitors are prescribed to their patients [ 48 ].…”