[Refractory shock after converting enzyme inhibitor administration. Usefulness of angiotensin II]

Angiotensin-converting enzyme (ACE) inhibitors are commonly used during the early phase after myocardial infarction but severe hypotension and shock have been described.

A 42-year old woman underwent a conservative management for an anterior acute myocardial infarction, initially associated with a pulmonary edema. Two hours after the initiation of a treatment with ACE inhibitor administered orally (lisinopril, Zestril), a circulatory failure in conjunction with an acute renal insufficiency occurred. Right heart catheterization disclosed markedly decreased systemic vascular resistance in the presence of a preserved cardiac index. Repeated fluid challenges and intravenous administration of norepinephrine failed to improve the hemodynamic status. The refractoriness of shock raised the hypothesis of a dysregulation of the renin-angiotensin system, secondary to the treatment by ACE inhibitor. Accordingly, the patient was given angiotensin II intravenously (Hypertension) which markedly raised systemic vascular resistance, and result in subsequent regression of shock. The patient was discharged after an otherwise uneventful course.

We reported a refractory shock to fluid challenges and norepinephrine after the first dose of ACE inhibitor during acute myocardial infarction. Regression of shock was possible only with angiotensin II.