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Letter to the Editor

In the review about drug treatment of elevated blood pressure (Aust Prescr 2010;33:108-12), angioedema is not mentioned as a comorbid condition. I believe it would be helpful to do so.

Angioedema occurring with ACE inhibitors was first reported in 1980,1and may account for 40% of angioedema presentations to hospital.2Onset may be delayed.3Epidemiological studies have confirmed a significant excess exposure to ACE inhibitors in patients with angioedema with an estimated attributable risk of 80% (CI*51–92).3An incidence of 0.68% over six months has been reported, so annual incidence may be greater than 1%.4Rates in people of African origin are even higher, at 1.62% over six months, so may be over 3% annually.4This is relevant in Australia, with recent immigration from Africa.

The importance of the relationship between ACE inhibitors and angioedema is underappreciated. In 2008 a patient reported a history of four episodes of angioedema, including admission to intensive care, followed by use of perindopril. He subsequently had further angioedema and the ACE inhibitor was stopped. In a recent audit of angioedema, four out of 25 patients on ACE inhibitors reported previous (sometimes multiple) episodes of angioedema.5In 2010 a 78-year-old woman on trandolapril was referred with her second episode of 'macroglossus of uncertain aetiology'. Unfortunately she developed airway obstruction and died nine days later.

There is a need for increased awareness of angioedema associated with ACE inhibitors, to reduce avoidable catastrophic outcomes. Including angioedema in tables of comorbid conditions to be considered when prescribing antihypertensives would assist with increasing awareness of this important association.

Genevieve Gabb
Consultant physician
Royal Adelaide Hospital

* CI confidence interval