Analysis of Heart-Rate Variability during Angioedema Attacks in Patients with Hereditary C1-Inhibitor Deficiency.

C1-inhibitor hereditary angioedema (C1-INH-HAE) is a rare disease characterized by self-limiting edema associated with localized vasodilation due to increased levels of circulating bradykinin. C1-INH-HAE directly influences patients' everyday lives, as attacks are unpredictable in frequency, severity, and the involved anatomical site. The autonomic nervous system could be involved in remission. The cardiac autonomic profile has not yet been evaluated during the attack or prodromal phases. In this study, a multiday continuous electrocardiogram was obtained in four C1-INH-HAE patients until attack occurrence. Power spectral heart rate variability (HRV) indices were computed over the 4 h preceding the attack and during the first 4 h of the attack in three patients. Increased vagal modulation of the sinus node was detected in the prodromal phase. This finding may reflect localized vasodilation mediated by the release of bradykinin. HRV analysis may furnish early markers of an impending angioedema attack, thereby helping to identify patients at higher risk of attack recurrence. In this perspective, it could assist in the timing, titration, and optimization of prophylactic therapy, and thus improve patients' quality of life.

Mutation screening of C1 inhibitor gene in 108 unrelated families with hereditary angioedema: functional and structural correlates.

Hereditary angioedema (HAE) is an autosomal dominant disorder characterized by the deficiency of the inhibitor of the first component of complement system (C1-INH), which is due to mutations in its structural gene. There are two phenotypic variants: HAE type I, with reduced plasma antigen levels and HAE type II with normal antigen levels and reduced functional C1 inhibitor activity. The aim of this study was to determine the disease-causing mutations in 108 unrelated HAE families, followed at a single center in Italy, and in 50 normal controls by a genetic screening strategy of the C1-INH gene (SERPIN1G). To detect small mutations we either used fluorescence assisted mismatch analysis, followed by sequencing, or direct sequencing. Patients negative for mutations at this screening were further analyzed by long-range PCR to detect the presence of large deletions or insertions. Overall we identified 81 different mutations possibly responsible for the disease in 102 families, in the remaining 6 families no mutation was detected except for a synonymous substitution in a single probant. Sixty-seven of these mutations (23 missense, 22 frameshift, 8 splicing defects, 8 nonsense and 6 large insertion/deletions) had not been previously published. In addition, 4 rare variants, 2 synonymous alterations and 1 new polymorphism in the 3'UTR of the C1-INH gene were found. Mutations were distributed over all exons, at splice sites and in introns. Our study identified a large number of new mutations related to HAE providing additional evidence of the genetic heterogeneity of this disease. Our results also point toward particular amino acid residues important for protein function that may represent mutation hot spots.

The use of plasma-derived C1 inhibitor in the treatment of hereditary angioedema.

C1-inhibitor (C1-INH) deficiency is the genetic defect underlying hereditary angioedema (HAE). Subjects with HAE suffer from recurrent angioedema that may result in death when it affects the larynx, severe abdominal pain when it affects the gastrointestinal mucosa and disfiguration when it affects the skin. The use of plasma-derived C1-INH concentrates to revert angioedema in HAE patients started in the 1970s. Since that time, three different preparations arrived onto the market, two of them are still present. Controlled studies and a large clinical experience indicate that C1-INH concentrate should be considered the treatment of choice for disabling angioedema attacks at any site. Efficacy has also been shown in preventing angioedema induced by invasive medical manoeuvres. Limited experience with repeated weekly infusions indicates that C1-INH can be used for long-term prophylaxis in selected patients. The safety profile is excellent and there are no reports of transmission of viral infections with the preparations available at present. C1-INH is licensed only in a limited number of countries. Clinical trials are ongoing at present to expand registration.

Acquired deficiency of the inhibitor of the first complement component: presentation, diagnosis, course, and conventional management.

Acquired deficiency of the inhibitor of the first complement component (C1-INH) is a rare, potentially life-threatening disease whose cause, course, and management are not completely defined. This article analyzes the etiopathogenetic mechanism, the clinical presentation, and the relationship between acquired C1-INH deficiency and lymphoproliferative disorders. Moreover, the authors give an overview of the outcome of the disease and the different therapies proposed to cure it.