A 64-year-old man comes to the emergency department complaining of facial swelling. He has not had such symptoms before and has no associated itching or rash. The patient's medical problems include type 2 diabetes mellitus, hypertension, and coronary artery disease. He had a myocardial infarction 7 years ago. He was recently diagnosed with congestive heart failure with systolic dysfunction. The patient's medications include ramipril, metoprolol, furosemide, spironolactone, aspirin, glyburide, and simvastatin. Physical examination shows prominent lip and tongue swelling without stridor. His symptoms subside within 24 hours after he is admitted. Which of the following is the best statement concerning the management of this patient?

Question

A 64-year-old man comes to the emergency department complaining of facial swelling.  He has not had such symptoms before and has no associated itching or rash.  The patient's medical problems include type 2 diabetes mellitus, hypertension, and coronary artery disease.  He had a myocardial infarction 7 years ago.  He was recently diagnosed with congestive heart failure with systolic dysfunction.  The patient's medications include ramipril, metoprolol, furosemide, spironolactone, aspirin, glyburide, and simvastatin.  Physical examination shows prominent lip and tongue swelling without stridor.  His symptoms subside within 24 hours after he is admitted.  Which of the following is the best statement concerning the management of this patient?

Quizplus · Accepted Answer

Explanation: The facial swelling with prominent lip and tongue swelling in this patient are consistent with angioedema, an uncommon (<1%) but well-recognized side effect of angiotensin-converting-enzyme (ACE) inhibitors such as ramipril. Some patients may also develop abdominal pain due to intestinal swelling. ACE catalyzes the degradation of bradykinin; inhibition of ACE leads to elevated levels of bradykinin that can cause angioedema as well as a dry cough. Angioedema associated with ACE inhibitors is usually self-limited, lasts 24-48 hours, and, unlike allergic angioedema, is not associated with itching or urticaria. Half of all cases of ACE inhibitor-related angioedema occur in the first few weeks of therapy, although it can occur even in patients who have been on the medication for several years. ACE inhibitor-related angioedema affecting the airway can be life- threatening. Patients who develop angioedema should not receive ACE inhibitors again (Choices A and D). Angiotensin-receptor blockers (ARBs) are generally used as a replacement for ACE inhibitors in this situation as they do not affect the bradykinin system and otherwise have the same general benefits. Some patients may have a recurrence of angioedema during the first few months after discontinuing the ACE inhibitor and still need monitoring on the ARB. It is not clear whether this is a direct effect of the ARB, residual effect of the ACE inhibitors, or an underlying tendency of the patient to develop angioedema. (Choice C) Although ACE inhibitors and ARBs are structurally related, the angioedema is not immune mediated and does not involve cross-reactivity. Angioedema is due to the bradykinin pathway. (Choice E) Antihistamines such as diphenhydramine are effective in histamine-mediated angioedema (ie, allergic angioedema) but have no effect on the bradykinin-mediated angioedema of ACE inhibitors. Educational objective: Angioedema is a possible side effect of angiotensin-converting-enzyme inhibitors that occurs in <1% of patients. Those with this reaction should discontinue the drug or switch to an angiotensin-receptor blocker (ARB) if needed. The risk of angioedema with ARBs is low, and ARBs have benefits similar to those of ACE inhibitors. References: Meta-analysis of randomized trials of angioedema as an adverse event of renin-angiotensin system inhibitors. (http://www.ncbi.nlm.nih.gov/pubmed/22521308) Comparative risk for angioedema associated with the use of drugs that target the renin-angiotensin-aldosterone system. (http://www.ncbi.nlm.nih.gov/pubmed/23147456)

A 64-Year-Old Man Comes to the Emergency Department Complaining of Facial