Solutions for management of angiotensin-converting enzyme–induced angioedema in a high risk population: a single center retrospective observational study

Abstract

Background: There is an increasing rate of angiotensin-converting enzyme (ACE) inhibitor-induced angioedema in the United States which has not plateaued since this side effect was first described in 1980. There are no studies reporting a plateau, decrease in the incidence or decrease in the rate of rise in high risk populations. High risk populations are defined as African Americans, female sex, and age older than 65. Objectives: The objective of this manuscript is to determine the incidence of angioedema in a high risk, urban population over a 7-year period, and to determine impactful solutions on its management by anesthesiologists. Methods: PubMed was queried with the keywords angioedema, ACE inhibitor-induced angioedema, and anesthesiology angioedema management. Subset keyword searches included angioedema incidence and high risk populations, and emergency room anesthesiology angioedema management. Our medical center’s data repository was queried to identify the number of emergency department visits between January 2007 and December 2013. We then queried the database to determine the number of cases that were diagnosed as angioedema. A subset of patients was identified that included all patients that presented with angioedema, and who had a current ACE inhibitor prescription. The medical records of the admitted patients were reviewed to determine whether angioedema was induced by an ACE inhibitor or another etiology. The annual occurrence rates of angioedema and ACE inhibitor-induced angioedema were then calculated. Analysis of the medical records also determined the extent of anesthesiology involvement. Results: There were a total of 478 cases of ACE inhibitor-induced angioedema during the 7-year period. The incidence of ACE inhibitor-induced angioedema rose from 0.17 in 2007 to 0.53 in 2013. There is no evidence of plateau for this rise and current rate of rise appears to be exponential. African Americans, female sex, and age 65 and younger were associated with a greater incidence of ACE inhibitor-induced angioedema. One hundred thirty-three patients that presented to the emergency department with ACE inhibitor-induced angioedema were admitted, and 22 of these patients required intubation. Anesthesiology was consulted 23 times, and performed 14 (63.6%) of the intubations.