Pre‐operative cessation of angiotensin‐converting enzyme inhibitors may not necessarily protect against angioedema

Abstract

Angiotensin-converting enzyme (ACE) inhibitors are recommended as first-line antihypertensive therapy in many patients.Angiotensin-converting enzyme inhibition leads to the accumulation of bradykinin, a potent vasodilator and likely mediator of ACE inhibitor-induced angioedema. It is estimated that 0.7% of patients prescribed ACE inhibitors develop angioedema within 5 years of starting treatment [1]. Angioedema in the peri-operative period can lead to considerable diagnostic uncertainty as it can be the result of either anaphylaxis or ACE inhibition. Numerous case reports indicate a possible association between airway surgery and increased risk of ACE inhibitor-associated angioedema, potentially as a consequence of local tissue injury [1,2]. Interestingly, angioedema can also occur when ACE inhibitor therapy is resumed following a brief period of discontinuation [3].To our knowledge, what is not yet described is the risk of ACE inhibitor-associated angioedema in patients who have stopped their ACE inhibitor for the peri-operative period. Many institutions routinely advise patients to suspend ACE inhibitor perioperatively to reduce the risk of intra-operative hypotension, with a 24-h period of pre-operative suspension supported by the recent study by Roshanov et al. [4].We recently anaesthetised an 82-year-old man for an elective panendoscopy and biopsy of a vallecular lesion. He was taking lisinopril 30 mg daily and took his last dose approximately 24 h before surgery, in line with pre-operative advice. After establishing routine monitoring, intravenous access and adequate pre-oxygenation, general anaesthesia was induced with fentanyl 50 lg and propofol 120 mg. Neuromuscular blockade was achieved with atracurium 25 mg. After gentle facemask ventilation, tracheal intubation was performed using a McGrath TM videolaryngoscope (Medtronic, Watford, UK) with MAC 4 blade and 8-mm reinforced tracheal tube. A full glottic view was obtained with no evidence of traction or trauma to the lips.Anaesthesia was maintained with sevoflurane in air and oxygen. Surgery was uncomplicated and completed in 20 min. Figure 1 Angioedema of the patient's lips.