Angioedema linked to ACE inhibitor use leads to man’s cardiac arrest
Researchers stress 'need for emergency airway management' in severe cases
A man in his 60s who developed severe angioedema after the use of an ACE, or angiotensin-converting enzyme, inhibitor to treat high blood pressure required several emergency interventions before making a full recovery, according to a case study from France.
Swelling in the man’s throat obstructed his breathing, ultimately causing him to go into cardiac and respiratory arrest. After undergoing multiple procedures to clear his airway, the patient recovered fully without any specific treatment, the researchers reported.
“This case highlights the severity [of ACE inhibitor]-induced angioedema, the importance of early detection, and the need for emergency airway management in critical cases,” the team wrote.
While noting that such cases are rare — at 0.7 per 10,000 emergency department visits — the researchers stressed that angioedema due to ACE inhibitor use “is a medical emergency that necessitates immediate medical attention.”
The study, “Cardiac arrest due to airway obstruction in Angiotensin-converting enzyme inhibitor-induced angioedema,” was published in The American Journal of Emergency Medicine.
Man, 63, prescribed ACE inhibitor to treat high blood pressure
ACE inhibitors are widely prescribed to treat hypertension, or high blood pressure, and diabetes. By blocking the activity of the enzyme ACE, these medications prevent the normal breakdown of a signaling molecule called bradykinin. Reducing ACE activity and increasing bradykinin levels can relax blood vessels, lowering blood pressure.
However, abnormally high levels of bradykinin can lead to drug-induced nonallergic angioedema.
Like other types of angioedema, ACE inhibitor-induced angioedema is marked by swelling. In this specific type of angioedema, swelling tends to affect the face, lips, tongue, and throat. When swelling occurs in the throat, it can cause problems breathing, which can be life-threatening.
In this study, a pair of researchers from Haute-Savoie described the case of a 63-year-old man who went into cardiac arrest after swelling in the throat — presumably due to ACE inhibitor-induced angioedema — blocked his airway and prevented him from breathing. The patient had a history of heart attack and diabetes and was on several medications, including an ACE inhibitor called ramipril (sold as Altace).
After seeking emergency department treatment with signs of low blood oxygen, the man’s heart stopped. Eight minutes of cardiopulmonary resuscitation (CPR) and administration of epinephrine restarted his heartbeat, but his airway was still blocked, the team reported.
Physicians in the emergency department and intensive care unit (ICU) were not able to insert a breathing tube or deliver oxygen through a mask. Thus, they performed a cricothyroidotomy, a rare emergency procedure in which an airway is created by cutting through a membrane in the neck that stands between the thyroid cartilage, known as the Adam’s apple, and the cricoid cartilage.
This case underscores the critical need to recognize [ACE inhibitor]-induced angioedema as a potential cause of life-threatening airway obstruction.
A CT scan revealed a bulky mass blocking the upper part of the man’s throat and airway. Close examination with an endoscopic camera suggested the mass was being caused by swelling rather than a tumor, and lab analysis of tissue biopsies confirmed that the cells were not cancerous or otherwise abnormal.
Based on these findings, the man was diagnosed with ACE inhibitor-induced angioedema and taken off ramipril. A couple of days later, a follow-up examination found no swelling or disruptions to his respiratory system, vocal cords, or sinuses.
Although he did not receive any specific treatment for angioedema, the steps that physicians took to stabilize him were effective, leading to a complete recovery, the researchers reported.
“This case underscores the critical need to recognize [ACE inhibitor]-induced angioedema as a potential cause of life-threatening airway obstruction,” the researchers wrote.
However, the team also noted that there is no treatment to quickly address this condition. While some studies have suggested that icatibant (sold as Firazyr), a medication approved for hereditary angioedema, may also be useful in cases of drug-induced nonallergic angioedema, other studies found no effect.
In light of the uncertain course of treatment for ACE inhibitor-induced angioedema, “close monitoring and early involvement of ICU physicians should be anticipated,” they wrote.
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