Abstract
Background
Despite multiple treatment options, antihypertensive overdose remains a cause of significant
morbidity and mortality. Intravenous angiotensin II (AG II) is approved for use in
vasodilatory shock. We describe 2 cases of refractory shock from antihypertensive
overdose that were successfully treated using AG II.
Case Reports
A 24-year-old female presented after an overdose of multiple antihypertensive medications,
including an angiotensin converting enzyme inhibitor (ACEI). She developed hypotension
that was refractory to norepinephrine, epinephrine, and vasopressin, with a mean arterial
pressure (MAP) of 57 mm Hg 9 h after emergency department arrival. Fifteen minutes
after starting AG II at 10 ng/kg/min, her heart rate and MAP rose by 7 beats/min and
12 mm Hg, respectively. Her hemodynamic parameters continued to improve thereafter.
She developed acute kidney injury, which resolved prior to discharge. The second patient,
a 65-year-old male, presented after an overdose of multiple antihypertensive medications,
including an ACEI. Despite norepinephrine, epinephrine, and hyperinsulinemia-euglycemia,
he remained bradycardic and hypotensive, with a heart rate of 47 beats/min and MAP
of 59 mm Hg. Thirty minutes after starting AG II at 10 ng/kg/min, his heart rate was
61 beats/min and MAP was 66 mm Hg. He recovered without apparent sequelae.
Why Should an Emergency Physician Be Aware of This?
Antihypertensive overdose can lead to shock refractory to catecholamine and vasopressin
therapy. Our experience suggests that AG II is efficacious in antihypertensive overdose
and may be particularly efficacious in instances of ACEI overdose. However, further
study is required to confirm the appropriate indication(s).
Keywords
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References
- 2016 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 34th Annual Report.Clin Toxicol. 2017; 55: 1072-1254
- Cardiologic principles II: hemodynamics.in: Hoffman R. Howland M. Lewin N. Nelson L. Goldfrank L. Goldfrank’s Toxicologic Emergencies. 10th ed. McGraw-Hill, New York2015: 222-230
- Experts consensus recommendations for the management of calcium channel blocker poisoning in adults.Crit Care Med. 2017; 45: e306
- Utilization of hyperinsulinemia euglycemia and intravenous fat emulsion following poison center recommendations.J Med Toxicol. 2013; 9: 226-230
- Adherence to calcium channel blocker poisoning treatment recommendations in two Canadian cities.Clin Toxicol. 2012; 50: 424-430
- Hyperinsulin therapy for calcium channel antagonist poisoning: a seven-year retrospective study.Am J Ther. 2013; 20: 29-31
- Enalapril overdose treated with angiotensin infusion.Lancet. 1993; 341: 703
- Lisinopril overdose and management with intravenous angiotensin II.Ann Pharmacother. 1994; 28: 1165-1168
- Enalapril overdose and the corrective effect of intravenous angiotensin II.Br J Clin Pharmacol. 1995; 40: 103-104
- Treatment of severe combined overdose of calcium antagonists and converting enzyme inhibitors with angiotensin II.Nephron. 1997; 77: 239
- Summary Review: NDA 209360.US Food and Drug Administration, Washington, DC2017
- Critical Care Reviews Book.2018 (Available at:)
- Angiotensin II for the treatment of vasodilatory shock.N Engl J Med. 2017; 377: 419-430
- Angiotensin in critical care.Crit Care. 2018; 22: 69
- Clinical experience with IV angiotensin II administration: a systematic review of safety.Crit Care Med. 2017; 45: 1285
- The effect of angiotensin II on blood pressure in patients with circulatory shock: a structured review of the literature.Crit Care. 2017; 21: 324
- Consequences of angiotensin-converting enzyme inhibitor overdose.Am J Hypertens. 1989; 2: 355-357
- Poisoning with anti-hypertensive drugs: angiotensin converting enzyme inhibitors.J Hum Hypertens. 1995; 9: 711-715
- Angiotensin converting enzyme defects in shock: implications for future therapy.Crit Care. 2018; 22: 274
- Effects of captopril related to increased levels of prostacyclin and angiotensin-(1-7) in essential hypertension.J Hypertens. 1996; 14: 799-805
- Differential actions of angiotensin-(1-7) in the kidney.Kidney Int Suppl. 1998; 54: S3-S6
- Kallikreins and kinins: molecular characteristics and cellular and tissue responses.Diabetes. 1996; 45: S14-S19
- Additive effects of combined angiotensin-converting enzyme inhibition and angiotensin II antagonism on blood pressure and renin release in sodium-depleted normotensives.Circulation. 1995; 92: 825-834
- Baseline angiotensin levels and ACE effects in patients with vasodilatory shock treated with angiotensin II.Intensive Care Med Exp. 2017; 5: 0703
- Angiotensin II: a new therapeutic option for vasodilatory shock.Ther Clin Risk Manage. 2018; 14: 1287
- Severe sepsis: low expression of the renin-angiotensin system is associated with poor prognosis.Exp Ther Med. 2014; 7: 1342-1348
- Hydrocortisone therapy for patients with septic shock.N Engl J Med. 2008; 358: 111-124
Article info
Publication history
Published online: July 03, 2019
Accepted:
May 6,
2019
Received in revised form:
April 25,
2019
Received:
January 17,
2019
Identification
Copyright
© 2019 Elsevier Inc. All rights reserved.
