Case Diagnosis and Treatment
As suspected, Bernice is diagnosed with hypertension. Her primary care physician prescribes her with 40 milligrams Lisinopril (an ACEI) daily and also advises her to control environmental risk factors by limiting her use of cigarettes and alcohol as well as partaking in a more nutritious diet and frequent exercise. The ACEI works by inhibiting angiotensin converting enzyme and thereby blocking a point in the pathway from converting angiotensin I to angiotensin II. The Lisinopril should work to alleviate Bernice’s symptoms by increasing vasodilation of her arterioles as well as decreasing the degradation of bradykinin.
Potential Health Risks of ACE Inhibitors
ACEI use has several risks.5 Since ACEI are responsible for the regulation of blood volume and solute balance in the kidneys, most of these risks involve the imbalance of either water or solutes.5 Severe side effects of ACEIs include angioedema, acute kidney injury, and sleep apnea which can ultimately be life threatening.4,9-11 Angioedema, the swelling of superficial tissues, is the most common adverse side effect of ACEI prescriptions and has been the target of many research studies.4,9 The mechanism of ACEI-associated angioedema is normally attributed to the accumulation of vasoactive bradykinin secondary to the inhibition of ACE, one of the enzymes that degrades it. The excess bradykinin can then act on bradykinin B2 receptors, leading to a change in vascular integrity and subsequent edema.4,9
One study focused on determining the appropriate Emergency Department (ED) management of patients with ACEI angioedema. Researchers reviewed 562 papers and 27 appropriate articles and found that up to 68% of cases of isolated angioedema were a result of certain ACEIs.9 As such, the researchers recommended that ACEI angioedema should be considered in any patient presenting with isolated, asymmetric swelling of the lips, tongue, mouth, face, eyelids, and neck.4,9 Another report focused on two patient case studies who presented with angioedema as a result of ACEI prescriptions. The normal window period of angioedema as a result of ACEIs is one month after beginning prescription medication; however, these case studies demonstrated that angioedema from ACEIs can onset far after this window period.4 Usually, side effects of ACEI prescription onset within one month after prescribing the medication; however, in the case report presented, it becomes apparent that these side-effects can occur years after initial prescription.4 ACEI-induced angioedema can cause the drug to be overlooked as the causative agent and delay its discontinuation.4 This experiment highlights the importance of ruling out drug-induced causes for angioedema and monitoring for ACEI-associated angioedema, even after long periods of treatment.4
Another severe symptom of ACEI prescription is induced cough and rhinopharyngeal inflammation.11 As a result of angioedema, obstructive sleep apnea (OSA) can ensue and...