• Jone Jackeviciute, Vidas Pilvinis, and Rugile Pilviniene.
• Medical Academy Department of Intensive Care Institute of Physiology and Pharmacology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania.
• Medicine (Baltimore). 2018 Aug 1; 97 (31): e11695.

RationaleAngiotensin-converting enzyme (ACE) inhibitors are one of the most used medication among patients with arterial hypertension. In most cases, ACE inhibitors caused side effects are mild; however, from 0.1% to 0.7% of patients can develop life threatening adverse effect, angioedema. Unlike histamine mediated, ACE inhibitor-related angioedema can develop at any time during the treatment course.Patient ConcernsAn 89-year-old woman with a medical history for arterial hypertension, ischemic heart disease, heart failure, chronic atrial fibrillation developed ACE inhibitor-induced angioedema after 5 years of daily ramipril administration.DiagnosesArterial hypertension, ischemic heart disease, heart failure, chronic atrial fibrillation and late onset ACE inhibitor-induced angioedema.InterventionsThe ACE inhibitor was used for arterial hypertension on a daily basis for the past 5 years. Patient developed airway obstruction requiring intubation. Standard therapy with epinephrine, methylprednisolone and clemastine was administered. Treatment was ineffective, considering that angioedema persisted.OutcomesAngioedema resolved after 13 days from the discontinuation of ramipril. Death due to cardiopulmonary insufficiency occurred 24 days after the admission to intensive care unit, despite full clinical resolution of ACE inhibitor-induced angioedema.LessonsOur case highlight the importance of educating clinicians about ACE inhibitor-induced angioedema, as potentially fatal adverse drug reaction. Considering the fact, that no laboratory or confirmatory test exist to diagnose ACE inhibitor-induced angioedema, clinicians' knowledge is the key element in recognition of ACE inhibitor-related angioedema.

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