ACE inhibitor angioedema: characterization and treatment versus non-ACE angioedema in acute hospitalized patients

Abstract

Background: ACE angioedema has not been characterized in comparison with angioedema from other causes in acute hospitalized patients. Methods: We retrospectively compared ACE-angioedema and non-ACE angioedema patients from January 2013 to May 2017. Results: Of 855 cases screened, 575 met the inclusion criteria of angioedema diagnosis and an electronic medical record. Of these, 297 (51.7%) had ACE angioedema and 278 had angioedema from other causes, of these 31 who were taking an ACE inhibitor that was not considered to be the cause of angioedema (ACE other cause). At least 80% of cases in all groups were African American. Epinephrine was prescribed in 21% of ACE angioedema cases. One-third of patients in all groups were admitted to the ICU, and about 25% required intubation. Previous history of ACE inhibitor-induced angioedema was found in 63 of 278 non-ACE cause angioedema patients (23%) and in 23 (8%) in the ACE cause group. Conclusion: ACE angioedema was the cause of half of angioedema admissions over a 4.5-year period. Mortality, morbidity, and treatment did not differ between the groups. Patients on ACE inhibitors were often treated with medications known not to be effective for ACE angioedema. Over one-fourth of patients not taking an ACE inhibitor had a previous history of ACE angioedema, and 31 patients taking ACE inhibitors were diagnosed with non-ACE angioedema. Regardless of the etiology of angioedema, 25% of patients required airway protection in the form of intubation.

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

“…The discrepancy between our findings and previous evidence may be owing to angioedema occurring more commonly among certain populations (e.g., African Americans or heart failure patients) [ 40 , 41 , 42 ], while the RCTs included in our meta-analysis involved study populations with diverse ethnicities and underlying conditions. 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 ].…”

Critical angioedema induced by a renin angiotensin system blocker in the contemporary era of increasing heart failure: A case report and commentary

“…1 The incidence of ACEI-AE among patients taking ACE inhibitors is reported to be 0.1%-0.7%, [2][3][4] which is the highest incidence among drug-induced angioedema cases. 5 ACEI-AE mainly affects the lips, face, neck, tongue, and sometimes bowels and is life-threatening when it extends to the larynx and compresses the airway. 6 It was reported that angioedema occurred in 86 (0.68%) of 12 577 enalapril-treated patients, but only two patients (0.01%) required hospitalization and none required mechanical airway management.…”

“…6 On the other hand, there are cases of ACEI-AE requiring tracheal intubation or tracheostomy, and leading to death. 5 Angioedema often in 48-72 h with discontinuation of the causative agent. 7 In clinical settings, antihistamines, steroids, and adrenaline are often used for bradykinin-mediated angioedema, but the efficacy of these drugs has not been proven.…”

“…ACEI‐AE presents with nonpitting subcutaneous edema and without urticaria and has a longer onset, whereas histamine‐mediated angioedema causes flushing, pruritus, and urticaria, and generally presents within 60 min of antigen exposure 1 . The incidence of ACEI‐AE among patients taking ACE inhibitors is reported to be 0.1%–0.7%, 2–4 which is the highest incidence among drug‐induced angioedema cases 5 . ACEI‐AE mainly affects the lips, face, neck, tongue, and sometimes bowels and is life‐threatening when it extends to the larynx and compresses the airway 6 …”

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

“…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.…”