Clinical Features and Outcomes Associated with Angioedema in the Emergency Department

Overview

Journal West J Emerg Med

Specialty Emergency Medicine

Date 2019 Sep 21

PMID 31539333

Citations 1

Authors

Benjamin J Sandefur

Lucas Oliveira J E Silva

Christine M Lohse

Kiran A Goyal

David W Barbara

Ana Castaneda-Guarderas

Xiao-Wei Liu

Ronna L Campbell

Affiliations

Soon will be listed here.

Abstract

Introduction: Angioedema represents self-limited, localized swelling of submucosal or subcutaneous tissues. While the underlying etiology may be undeterminable in the emergent setting, nonhistaminergic and histaminergic angioedema respond differently to therapeutic interventions, with implications for empiric treatment. Clinical features and outcome differences among nonhistaminergic vs histaminergic angioedema patients in the emergency department (ED) are poorly characterized. We aim to describe the clinical characteristics and outcomes among ED patients with angioedema by suspected etiology.

Methods: This was a 10-year retrospective study of adult ED patients with angioedema, using data abstracted from the electronic health record. We evaluated univariable associations of select clinical features with etiology and used them to develop a multivariable logistic regression model for nonhistaminergic vs histaminergic angioedema.

Results: Among 450 adult angioedema patients, the mean +/- standard deviation age was 57 +/- 18 years, and 264 (59%) were female. Among patients, 30% had suspected nonhistaminergic angioedema, 30% had suspected histaminergic angioedema, and 40% were of unknown etiology. As compared to histaminergic angioedema, nonhistaminergic angioedema was associated with angiotensin-converting enzyme inhibitors (ACEI) or use of angiotensin II receptor blockers (ARB) (odds ratio [OR] [60.9]; 95% confidence interval [CI], 23.16-160.14) and time of onset one hour or more prior to ED arrival (OR [5.91]; 95% CI,1.87-18.70) and was inversely associated with urticaria (OR [0.05]; 95% CI, 0.02-0.15), dyspnea (OR [0.23]; 95% CI, 0.08-0.67), and periorbital or lip edema (OR [0.25]; 95% CI, 0.08-0.79 and OR [0.32]; 95% CI, 0.13-0.79, respectively).

Conclusion: As compared to histaminergic angioedema, patients with nonhistaminergic angioedema were more likely to present one hour or more after symptom onset and take ACEI or ARB medications, and were less likely to have urticaria, dyspnea, or periorbital or lip angioedema. Identification of characteristics associated with the etiology of angioedema may assist providers in more rapidly initiating targeted therapies.

Citing Articles

Nasopharyngolaryngoscopy as a Triage Tool for Airway Compromise in Angioedema: A Retrospective Cohort Study.

Gayen S, Sinha T, Dronamraju V, Lashari B, Zhao H, Dhungana S Cureus. 2022; 14(4):e23759.

PMID: 35518546 PMC: 9064709. DOI: 10.7759/cureus.23759.

References

Ishoo E, SHAH U, Grillone G, STRAM J, Fuleihan N . Predicting airway risk in angioedema: staging system based on presentation. Otolaryngol Head Neck Surg. 1999; 121(3):263-8. DOI: 10.1016/S0194-5998(99)70182-8. View

Zirkle M, Bhattacharyya N . Predictors of airway intervention in angioedema of the head and neck. Otolaryngol Head Neck Surg. 2000; 123(3):240-5. DOI: 10.1067/mhn.2000.107515. View

Bentsianov B, Parhiscar A, Azer M, Har-El G . The role of fiberoptic nasopharyngoscopy in the management of the acute airway in angioneurotic edema. Laryngoscope. 2000; 110(12):2016-9. DOI: 10.1097/00005537-200012000-00007. View

Chiu A, Newkirk K, Davidson B, Burningham A, Krowiak E, Deeb Z . Angiotensin-converting enzyme inhibitor-induced angioedema: a multicenter review and an algorithm for airway management. Ann Otol Rhinol Laryngol. 2001; 110(9):834-40. DOI: 10.1177/000348940111000906. View

Dean D, Schultz D, Powers R . Asphyxia due to angiotensin converting enzyme (ACE) inhibitor mediated angioedema of the tongue during the treatment of hypertensive heart disease. J Forensic Sci. 2001; 46(5):1239-43. View

Ulmer J, Garvey M . Fatal angioedema associated with lisinopril. Ann Pharmacother. 1992; 26(10):1245-6. DOI: 10.1177/106002809202601012. View

Sondhi D, Lippmann M, Murali G . Airway compromise due to angiotensin-converting enzyme inhibitor-induced angioedema: clinical experience at a large community teaching hospital. Chest. 2004; 126(2):400-4. DOI: 10.1378/chest.126.2.400. View

Megerian C, Arnold J, Berger M . Angioedema: 5 years' experience, with a review of the disorder's presentation and treatment. Laryngoscope. 1992; 102(3):256-60. DOI: 10.1288/00005537-199203000-00005. View

von Elm E, Altman D, Egger M, Pocock S, Gotzsche P, Vandenbroucke J . The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. PLoS Med. 2007; 4(10):e296. PMC: 2020495. DOI: 10.1371/journal.pmed.0040296. View

10.

Grant N, Deeb Z, Chia S . Clinical experience with angiotensin-converting enzyme inhibitor-induced angioedema. Otolaryngol Head Neck Surg. 2007; 137(6):931-5. DOI: 10.1016/j.otohns.2007.08.012. View

11.

Bernstein J . Hereditary angioedema: a current state-of-the-art review, VIII: current status of emerging therapies. Ann Allergy Asthma Immunol. 2008; 100(1 Suppl 2):S41-6. DOI: 10.1016/s1081-1206(10)60585-6. View

12.

Banerji A, Clark S, Blanda M, LoVecchio F, Snyder B, Camargo Jr C . Multicenter study of patients with angiotensin-converting enzyme inhibitor-induced angioedema who present to the emergency department. Ann Allergy Asthma Immunol. 2008; 100(4):327-32. DOI: 10.1016/S1081-1206(10)60594-7. View

13.

Lin R, Shah S . Increasing hospitalizations due to angioedema in the United States. Ann Allergy Asthma Immunol. 2008; 101(2):185-92. DOI: 10.1016/S1081-1206(10)60208-6. View

14.

Zuraw B . Clinical practice. Hereditary angioedema. N Engl J Med. 2008; 359(10):1027-36. DOI: 10.1056/NEJMcp0803977. View

15.

Harris P, Taylor R, Thielke R, Payne J, Gonzalez N, Conde J . Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2008; 42(2):377-81. PMC: 2700030. DOI: 10.1016/j.jbi.2008.08.010. View

16.

Prematta M, Kemp J, Gibbs J, Mende C, Rhoads C, Craig T . Frequency, timing, and type of prodromal symptoms associated with hereditary angioedema attacks. Allergy Asthma Proc. 2009; 30(5):506-11. DOI: 10.2500/aap.2009.30.3279. View

17.

Bluestein H, Hoover T, Banerji A, Camargo Jr C, Reshef A, Herscu P . Angiotensin-converting enzyme inhibitor-induced angioedema in a community hospital emergency department. Ann Allergy Asthma Immunol. 2010; 103(6):502-7. DOI: 10.1016/S1081-1206(10)60267-0. View

18.

McCormick M, Folbe A, Lin H, Hooten J, Yoo G, Krouse J . Site involvement as a predictor of airway intervention in angioedema. Laryngoscope. 2011; 121(2):262-6. DOI: 10.1002/lary.21277. View

19.

Manivannan V, Decker W, Bellolio M, Stead L, Li J, Vedula A . Prescriptions for self-injectable epinephrine in emergency department angioedema management. Ann Allergy Asthma Immunol. 2011; 106(6):489-93. DOI: 10.1016/j.anai.2011.01.028. View

20.

Wiler J, Ross M, Ginde A . National study of emergency department observation services. Acad Emerg Med. 2011; 18(9):959-65. DOI: 10.1111/j.1553-2712.2011.01151.x. View