Refractory shock after converting enzyme administration - Usefulness of angiotensin II

BACKGROUND: Angiotensin-converting enzyme (ACE) inhibitors are commonly use d during the early phase after myocardial infarction but severe hypotension and shade have been described. CASE REPORT: A 42-year old woman underwent a conservative management for an anterior acute myocardial infarction, initially associated with a pulmonar y edema. Two hours after the initiation of a treatment with ACE inhibitor a dministered orally (lisinopril, Zestril(R)), a circulatory failure in conju nction with an acute renal insufficiency occurred. Right heart catheterizat ion disclosed markedly decreased systemic vascular resistance in the presen ce of a preserved cardiac index. Repeated fluid challenges and intravenous administration of norepinephrine failed to improve the hemodynamic status. The refractoriness of shark raised the hypothesis of a dysregulation of the renin-angiotensin system, secondary to the treatment by ACE inhibitor. Acc ordingly, the patient was given angiotensin II intravenously (Hypertensine( R)) which markedly raised systemic vascular resistance, and result in subse quent regression of shock The patient was discharged after an otherwise une ventful course. DISCUSSION: We reported a refractory shock to fluid challenges and norepine phrine after the first dose of ACE inhibitor during acute myocardial infarc tion. Regression of shock was possible only with angiotensin II.