Serum metabolism of bradykinin and des-Arg9-bradykinin in patients with angiotensin-converting enzyme inhibitor-associated angioedema

Abstract

Angioedema (AE) associated with angiotensin-converting enzyme inhibitors (ACEi) is a rare, but potentially life-threatening adverse reaction. Several studies have suggested that bradykinin (BK) is responsible for ACEi-induced AE, but the mechanism remains unclear. We investigated the metabolism of BK and des-Arg⁹-BK in the serum of 20 patients with a history of ACEi-associated AE and 21 control (C) subjects. Synthetic BK was incubated with the sera for various periods of time and residual BK and generated des-Arg⁹-BK were quantified by specific and sensitive enzyme immunoassays. No significant difference of half-life (t_1/2) of both BK and des-Arg⁹-BK could be measured between C subjects and patients with AE (AE) in absence of ACEi. However, an analysis according to the prolonged (+) or not (−) t_1/2 of des-Arg⁹-BK allowed a new stratification of C subjects and AE patients in four subgroups. The preincubation of sera with enalaprilat at a concentration inhibiting ACE significantly prevented the rapid degradation of BK and des-Arg⁹-BK in these four subgroups. In presence of ACEi, a subgroup (50%) of AE patients (AE+) had a particularly significant rise of the t_1/2 of des-Arg⁹-BK. Once ACE was inhibited, the concentration or the nature of the ACEi had no significant effect on the t_1/2 of des-Arg⁹-BK. However, a test dilution of AE+ sera with a control (C) serum showed that an enzyme defect rather than a circulating inhibitor could be responsible for the abnormal metabolism of des-Arg⁹-BK when ACE is inhibited. In conclusion, half of the patients with ACEi-associated AE present in serum had an enzyme defect involved in the des-Arg⁹-BK metabolism leading to its accumulation. The B₁ agonist could be responsible, at least in part, for the local inflammatory reaction associated with the AE.