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Cardiology - Hypertension
A 58-year-old man with a five-year history of essential hypertension was started on an angiotensin-converting enzyme (ACE) inhibitor. Twelve days later, he presented to the emergency department with acute swelling of the lips and tongue without urticaria or respiratory compromise. ACE inhibitor-induced angioedema was diagnosed, and the drug was discontinued.
At the time of his original hypertension diagnosis, his blood pressure had averaged 168/98 mmHg, and electrocardiography (ECG) demonstrated left ventricular hypertrophy (LVH) by voltage criteria. He had no history of heart failure, coronary artery disease or chronic kidney disease. Following discontinuation of the ACE inhibitor, continued antihypertensive therapy was required.
After complete resolution of the angioedema, the treating team considered whether an angiotensin receptor blocker (ARB) could be used. Six weeks after ACE inhibitor discontinuation, losartan was initiated at a low dose, with counselling regarding the small residual risk of recurrent angioedema and instructions to seek urgent medical attention if facial, lip or tongue swelling occurred.
The patient tolerated losartan without recurrence of angioedema. The dose was subsequently titrated, with blood pressure progressively controlled to target. At follow-up, repeat ECG demonstrated regression of LVH.
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