What are the risk factors for severe manifestation and recurrent episodes of angioedema (AE), and how effective are current short- and long-term management strategies among a high-risk population?
Background: AE includes rapid swelling of the deep dermis, subcutaneous, or submucosal tissue due to vascular leakage. Most patients with non-hereditary AE respond well to treatment with steroids and antihistamines, while others require prolonged hospitalization or airway intervention. Although previous studies have suggested obesity, diabetes, and airway manipulation are potential risk factors for severe AE, all factors are not clearly defined.
Explore this issue:November 2014
Study design: Retrospective review of 875 adult patients with AE diagnosis treated from January 2008 to December 2013.
Setting: Montefiore Medical Center, Bronx, New York.
Synopsis: The most common race affected by AE among men and women was black, followed by multiracial. The most common AE cause for all patients presenting to the ED was angiotensin converting enzyme inhibitor (ACEi)-induced, followed by allergic and idiopathic. For both men and women, it was ACEi-induced, followed by allergic, while in the black, multiracial, Hispanic, and white populations it was ACEi-induced. The most common cause for patients younger than the mean age was ACEi-induced, followed by allergic; for patients older than the mean, it was ACEi-induced, followed by idiopathic. Only 93 patients required admission, 33 required intubation, and one required an emergent surgical airway. Risk factors associated with these severe episodes included age over 63 years, white Hispanic race, ACEi-induced AE type, ASA class of III or above, coexistent cardiopulmonary disease, and a positive smoking history. The mean hospitalization length was 19.0 hours, with a median stay of 5.8 hours. The average length of stay for patients treated and released from the ED was 6.0 hours; for patients admitted to the hospital, it was 48.0 hours. All AE patients presenting to the ED received uniform treatment with an antihistamine, an H2-blocker, and a steroid. Otolaryngology consultations were called 35.8% of the time. The main limitation was the lack of patient data due to possible coding issues.
Bottom line: Older age, Hispanic race, ACEi-associated AE, ASA class III/IV/V, coexistent cardiopulmonary disease, and a positive smoking history were associated with severe AE cases requiring hospital admission and/or airway intervention.
Citation: Loftus PA, Tan M, Patel G, et al. Risk factors associated with severe and recurrent angioedema: an epidemic linked to ACE-inhibitors. Laryngoscope. 2014;124:2502-2507.
—Reviewed by Amy Eckner