Angioedema

Angioedema is a clinical pattern—localized swelling from vascular leakage—not a single diagnosis. A patient who has taken ramipril for years and suddenly develops smooth, non-itchy tongue enlargement may have a bradykinin reaction, whereas wheals and itch after a food or medication exposure favour mast-cell mediator release. The distinction matters because the same emergency drugs are not equally useful in both pathways. Airway assessment comes before laboratory work or a detailed trigger history. If airway compromise or any anaphylaxis features are present and the mechanism is uncertain, give intramuscular epinephrine in the anterolateral thigh without delay. This is safer than withholding epinephrine from possible anaphylaxis, although it may not change bradykinin-mediated swelling. Once ACE-inhibitor angioedema is recognized, stop the drug permanently and prioritize airway protection and supportive care. That treatment fork—airway first, mediator second—organizes the assessment and prescribing decisions that follow.