[ACE inhibitor-induced angioedema: remarkable new perspectives for intensive care/emergency medicine]

Abstract

1. Early and late onset of angio-oedema. The report reviews angio-oedema as a rare but potential life threatening adverse effect associated with angiotensin converting enzyme (ACE) inhibitors. This class of drugs, widely used in the treatment of hypertension and congestive heart failure, may often induce mild angio-oedema of the skin (face, lips, cheeks) but may rarely involve tongue, subglottis, pharyngeal and laryngeal tissues. Angio-oedema has been previously reported to occur early after start of treatment, mostly within the first 3-4 weeks. However, according to later reports since 1990, first onset may be delayed for months and even until 7 years of treatment. Analysis of patients exhibiting angio-oedema reported to the National Drug Commission in Germany revealed that the number of patients with late onset of angio-oedema is continually increasing over time. The percentage of patients with delayed onset ranging from after six months up to six years was as follows: 1992: 8.9% (of a total of n = 56), 1996: 28% (of a total of n = 79), and 1998: 54% (of a total of n = 46). Eleven cases of patients of the latter group were classified as life-threatening. 2. Recurrence of Angio-oedema. Furthermore, many patients experienced multiple episodes of angio-oedema because even clinicians in emergency departments are not familiar with the association between angio-oedema and ACE inhibitors. In our series from 1992 until early 1998 17% of 125 patients exhibiting angio-oedema had relapses with a maximum of seven events over a period of three years. 3. Widespread Use of ACE Inhibitors, Tactical Approach to Diagnosing Angio-oedema and Prevention of Relapses. Hence, from a practical point of view, it seems very useful to suggest that nowadays every angio-oedema is caused by ACE inhibitor treatment until it is definitely excluded by a thorough review of all medications. Thirteen ACE inhibitors gained more widespread application worldwide. Unfortunately, a large number of drug combinations (> 93) are meanwhile on the market. Therefore, much effort is needed to improve the knowledge and awareness of this insidious adverse effect by well-documented case reports. Moreover, each case of ACE inhibitor-associated angio-oedema should be immediately brought to the attention of the practitioner/cardiologist to emphasise that this class of antihypertensive agents is contraindicated in the affected person to prevent the occurrence of another potentially life-threatening event.