Angioedema induced by angiotensin-converting enzyme inhibitors: an analysis of hospitalizations during the COVID-19 pandemic

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BACKGROUND: The pathogenesis of angioedema induced by angiotensin-converting enzyme inhibitors is based on the accumulation of bradykinin as a result of angiotensin-converting enzyme blockade. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) binds to the angiotensin-converting enzyme 2 receptor, which may inhibit its production and thereby lead to an increase in bradykinin levels. Thus, SARS-CoV-2 infection may be a likely trigger for the development of angioedema.

AIMS: This study aimed to analyze cases of hospitalizations of patients with angioedema associated with the use of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers during the coronavirus disease 2019 (COVID-19) pandemic.

MATERIALS AND METHODS: This study retrospectively analyzed medical records of patients admitted to the Vitebsk Regional Clinical Hospital between May 2020 and December 2020 with isolated (without urticaria) angioedema while receiving angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. In all patients, smears from the naso- and oropharynx for COVID-19 were analyzed by polymerase chain reaction.

RESULTS: Fifteen inpatients (9 men and 6 women) aged 44–72 years were admitted because of emergent events, of which 53.6% had isolated angioedema. In two cases, a concomitant diagnosis of mild COVID-19 infection was established with predominant symptoms of angioedema, including edema localized in the face, tongue, sublingual area, and soft palate. All patients had favorable disease outcomes.

CONCLUSIONS: Patients with аngiotensin-converting enzyme inhibitor-induced angioedema may require hospitalization to monitor upper respiratory tract patency. There were cases of a combination of аngiotensin-converting enzyme inhibitor-induced angioedema and mild COVID-19. Issues requiring additional research include the effect of SARS-CoV-2 infection on the levels of bradykinin and its metabolites, the triggering role of COVID-19 in the development of angioedema in patients receiving angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, recommendations for the management of patients with аngiotensin-converting enzyme inhibitor-induced angioedema, and a positive result for COVID-19.

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About the authors

Tatiiana М. Sabalenka

Educational Establishment Vitebsk State Order of Peoples’ Friendship Medical University

Author for correspondence.
ORCID iD: 0000-0002-8702-6486
SPIN-code: 9309-5550

MD, Cand. Sci. (Med.), Associate Professor

Belarus, 27, Frunze av., Vitebsk, 210009

Volha V. Zakharava

Vitebsk Regional Clinical Hospital

ORCID iD: 0000-0002-6696-0704
SPIN-code: 8993-3484


Belarus, Vitebsk

Natallia R. Prakoshyna

Educational Establishment Vitebsk State Order of Peoples’ Friendship Medical University

ORCID iD: 0000-0002-3471-6977
SPIN-code: 4022-5469

MD, Cand. Sci. (Med.)

Belarus, 27, Frunze av., Vitebsk, 210009


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Supplementary files

Supplementary Files
1. Fig. 1. Localization of angioedema.

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2. Fig. 2. Causal angiotensin-converting enzyme inhibitors / angiotensin receptor blockers.

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