We read with interest the case report by Svarstad et al. [1]. Although this article was intended to reveal a plausible relationship between angiotensin II and regulation of the fibrinolytic pathway, it raised concern over the appropriateness of the use of ACE inhibitors in patients with diffuse atherosclerosis. The finding of a systolic murmur at the physical examination of both carotid arteries and of the left subclavian artery could have led the authors to perform a duplex scan of the renal arteries to rule out a stenosis, even though the kidneys were of normal size on ultrasound. ACE inhibitors are contraindicated in a setting of bilateral renal artery stenosis or renal artery stenosis in a single kidney. The fact that the authors did not monitor closely renal function 4872 h after prescription of ACE inhibitors might have contributed to the late discovery of renal function impairment. Furthermore, finding an increment in serum creatine after ACE inhibitors or angiotensin II receptor inhibitors should lead to the withdrawal of such drugs, awaiting further investigation. The switch from Irbesartan to Enalapril was not appropriate, in our opinion. A patient of that age who presented with such a severe hypertension should have been investigated for a potential cause prior to the prescription of ACE inhibitors. The failure to respect such a prescription may unfortunately lead to an unwanted and embarrassing situation, such as the one reported.
In a patient with a severe stenosis, thrombosis is inevitably expected. Dehydration may have been the only promoting factor for thrombosis. The fact that thrombosis occurred after ACE inhibitor withdrawal may have been purely coincidental. Dehydration may have triggered initial thrombosis, which then could have evolved on its own even if dehydration was corrected subsequently. Attributing thrombosis to ACE inhibitor withdrawal might question the well founded contraindication of ACE inhibitors in a setting of bilateral renal artery stenosis.
Conflict of interest statement. None declared.
Yopougon Teaching Hospital Nephrology Abidjan Cote dIvoire Email: k_alimata{at}hotmail.com
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