What are the risks factors for developing hypotension in patients receiving ACEI?

Those patients with serum sodium <130mmol/L, patients with renal impairment, patients on multiple or high dose diuretics, patients with pre-existing hypotension and elderly patients are at higher risk of developing hypotension on ACEI therapy. Patients should have adequate volume before ACEI is started and it may be wise to stop diuretic therapy for one or two days before commencement of ACEI therapy, unless the patient is obviously fluid overloaded. A low test-dose may be useful.

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Can ACEI reduce diabetic complications and renal complications?

Yes. In the Micro-HOPE study, ramipril, in patients with known DM, reduced cardiovascular risk and diabetic complications substantially. (Lancet 2000;355:253-259). Even in non-diabetic renal failure, in the REIN study, ramipril have demonstrated a reduction in the rate of renal deterioration in patients with significant proteinuria. (Lancet 1998;352:1252-1256). Other ACEIs like lisinopril and captopril are also licensed for use in diabetic nephropathy.

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Can ACEI reduce cardiovascular morbidity and mortality in patients with coronary or vascular disease?

Yes. In the HOPE study, which recruited around 10,000 patients who were followed up for 4-6 years, ramipril, in patients at known cardiovascular disease, DM and other coronary risk factors, reduced cardiovascular mortality, myocardial infarction and stroke by 22%. All cause mortality was reduced by 16% and there was a 34% reduction in the incidence of new DM. The benefits were extended beyond simple blood pressure reduction. (N Engl J Med 2000; 342:145-153). Perindopril, in EUROPA study, also demonstrated significant vascular protective effects (Lancet 2003 Dec 6;362(9399):1936-7).

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Are effects of ACEI class-effects?

Not certain. In general, there is no striking advantage of one ACEI over another. However, in the era of evidence-based medicine, results of properly conducted randomized trials should be respected. In addition, the specific dosage for a specific indication is clearer for those drugs that have been studied in major clinical trials.

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The features are suggestive of a collagen vascular disease. Differential diagnoses include dermatomyositis, systemic lupus erythematosus, and mixed connective tissue disease.

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What laboratory tests would help to confirm the diagnosis?

The tests include muscle enzymes, electromyography (EMG), muscle biopsy and serum autoantibodies. The patient showed elevated creatinine kinase, aldolase, transaminases and lactate dehydrogenase. The EMG features were polyphasic, short, small motor-unit potentials, fibrillation and abnormal high-frequency repetitive discharges. A muscle biopsy of a proximal striated muscle showed patchy mononuclear perivascular and interstitial infiltration, degeneration with loss of transverse striations, hyalinization of sarcoplasm, and fragmentation of fibres.

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Adults with dermatomyositis have a greater risk of malignancy. The malignancy could occur before, concurrent with, or after the diagnosis of dermatomyositis.

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Heliotrope rash describes the purplish-red violaceous erythema on the face especially the eyelids. Gottron papules describe scaly, bluish-red plaques around the base of the nails, dorsal surface of fingers and especially over the backs of knuckles.

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What is the treatment for the skin rash?

While systemic corticosteroid and/or immunosuppressive form the mainstay of treatment for the myositis in dermatomyositis, the skin lesions may not be so responsive. On the other hand, topical steroid and oral hydroxychloroquine can improve the skin lesions. Since the rash is photosensitive, sun exposure should be avoided and appropriate sunscreen should be used whenever necessary.

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