This Article Submit a scholarly reply Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Adachi, Y. U. Articles by Katoh, T. Search for Related Content PubMed PubMed Citation Articles by Adachi, Y. U. Articles by Katoh, T.

Angioedema, angiotensin converting enzyme inhibitors, and angiotensin receptor blocking drugs

Hamamatsu University School of Medicine, Hamamatsu, Japan, E-mail: yuadachi{at}hama-med.ac.jp

To the Editor:

We read the review by Sarkar et al.¹ with great interest. Although angioedema can cause rapid, progressive airway compromise, facial and oral cavity edema as a complication of angiotensin converting enzyme inhibitors (ACEIs) therapy is under-recognized, as described in the review article.¹ A potential role of angiotensin receptor blocking (ARB) drugs should also be considered.

Recently, we experienced two cases strongly suspected of being secondary to angioedema, following cardiopulmonary bypass (CPB) surgery. Both patients had obvious tongue swelling immediately after their operations (Figure, upper panels). We initially suspected impaired venous return or traumatic sequelae resulting from the endotracheal tube or bite block as potential etiologies. However, the tongues of both patients were pink-coloured, without evidence of venous congestion, thus making an obstructive circulatory disturbance unlikely. Eyelid edema was not observed, and fluid balance and serum protein and albumin concentrations were within normal ranges. Heart failure and increases in central venous pressure were also excluded as possible causes in the setting of pulmonary catheter measurements that were within accepted physiological ranges.

View larger version (139K): [in this window] [in a new window]   FIGURE The pictures in the upper panels show the extent of tongue angioedema in two patients immediately after cardiopulmonary bypass surger y. The lower panels demonstrate complete resolution in both patients two days postoperatively, with conser vative management.

Although tongue swelling disappeared within a few hours in both patients with conservative management (Figure, lower panels), we monitored them carefully for several days to ensure airway patency. Considering the increasingly common use of ACEIs and ARBs for the treatment of hypertension and heart failure, anesthesiologists should consider these drug-related factors as a potential cause of angioedema in the perioperative setting, especially for cardiac surgery patients.

Footnotes

Accepted for publication November 10, 2006.

References

1 Sarkar P, Nicholson G, Hall G. Brief review: angiotensin converting enzyme inhibitors and angioedema: anesthetic implications. Can J Anesth 2006; 53: 994–1003.[Abstract/Free Full Text]

2 Bonner G, Preis S, Schunk U, Toussaint C, Kaufmann W. Hemodynamic effects of bradykinin on systemic and pulmonary circulation in healthy and hypertensive humans. J Cardiovasc Pharmacol 1990; 15(suppl. 6): S46–56.

3 Pretorius M, McFarlane JA, Vaughan DE, Brown NJ, Murphey LJ. Angiotensin-converting enzyme inhibition and smoking potentiate the kinin response to cardiopulmonary bypass. Clin Pharmacol Ther 2004; 76: 379–87.[Medline]

4 Cugno M, Nussberger J, Biglioli P, Alamanni F, Coppola R, Agostoni A. Increase of bradykinin in plasma of patients undergoing cardiopulmonary bypass: the importance of lung exclusion. Chest 2001; 120: 1776–82.

5 Abdi R, Dong VM, Lee CJ, Ntoso KA. Angiotensin II receptor blocker-associated angioedema: on the heels of ACE inhibitor angioedema. Pharmacotherapy 2002; 22: 1173–5.[Medline]

6 Irons BK, Kumar A. Valsartan-induced angioedema. Ann Pharmacother 2003; 37: 1024–7.[Abstract/Free Full Text]

This Article Submit a scholarly reply Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Adachi, Y. U. Articles by Katoh, T. Search for Related Content PubMed PubMed Citation Articles by Adachi, Y. U. Articles by Katoh, T.