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Initial data from a Chinese center on the use of angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) in patients admitted with COVID-19 may provide further reassurance on continued use of these drugs is.
According to a report from a hospital in Wuhan, High blood pressure When hospitalized with the COVID-19 virus, there was no difference in disease severity or mortality between patients taking ACE inhibitors or ARB and those not.
Data is Published online April 23 JAMA Cardiology.
This study Another recent report A beneficial effect of ACE inhibitors or ARB on mortality was suggested in a large number of COVID-19 patients from nine Chinese hospitals.
Additional research
Two other similar studies have also recently been published. Another study from China, Published online March 31 Emerging microbes and infectious diseasesIncluded a small sample of 42 COVID-19 hospitalized patients receiving antihypertensive therapy. upper ACE inhibitor/ ARB therapy had a lower incidence of serious illness and tended to lower IL-6 levels in peripheral blood. In addition, patients on ACE inhibitor / ARB therapy had higher peripheral blood CD3 + and CD8 + T cell counts and reduced peak viral load compared to other antihypertensive agents.
In addition, a yet unreviewed UK preliminary study found that treatment with ACE inhibitors was associated with a reduced risk of rapidly exacerbating severe COVID-19 disease.
the study, Available online at MedRxivWe report on 205 acute inpatients using COVID-19 at King’s College Hospital and Princess Royal College Hospital in London, UK, which are preprint servers for health sciences.
Of these, 51.2% have hypertension, 30.2% have diabetes, 14.6% have ischemic heart disease or heart failure. Of the 37 patients taking ACE inhibitors, 5 (14%) died, or emergency life support was compared to 29% (48/168) of those not taking ACE inhibitors. Was needed.
New Wuhan Study
Author of the new article published in JAMA CardiologyReports a case series of 1178 patients admitted with COVID-19 to a Central Hospital in Wuhan, Hubei Province, China between January 15 and March 15, 2020, led by Dr. Juyi Li.
The median age of patients was 55 years and 46% were male. They had an overall in-hospital mortality rate of 11%.
Of the 1178 patients, 362 (30.7%) were diagnosed with hypertension. These patients were older (median age, 66 years) and had a higher prevalence of chronic disease. Patients with hypertension have more severe COVID-19 symptoms compared to patients without hypertension, Acute respiratory distress syndrome In-hospital mortality rate (21.3% vs 6.5%).
Of 362 patients with hypertension, 31.8% were taking ACE inhibitors or ARBs.
Aside from more prevalence Coronary artery disease, Patients taking ACE inhibitors or ARB have similar comorbidities as patients not taking these drugs, including blood counts, inflammatory markers, renal and liver function tests, cardiac biomarkers Alkaline phosphatase with similar clinical test results
The most commonly used antihypertensive drug was the calcium blocker. The proportion of patients with hypertension taking the drug or drug combination did not differ between patients with severe and non-severe infections, and between survivors and dead patients.
Especially for ACE inhibitors / ARB, there was no difference in the use of ACE inhibitors between severe and non-severe (9.2% vs 10.1%; P = .80), ARB (24.9% vs. 21.2%; P = .40), or a combination of ACE inhibitor or ARB (32.9% vs. 30.7%; P = .65).
Similarly, there was no difference between survivors and nonsurvivors in the use of ACE inhibitors (9.1% vs. 9.8%; P = .85); ARB (19.5% vs. 23.9%; P = .42), or a combination of ACE inhibitor or ARB (27.3% vs. 33.0%; P = .34).
The frequency of serious illness and mortality is also different in patients with various chronic conditions such as hypertension, coronary heart disease, cerebrovascular disease, diabetes, nerve disease, chronic kidney disease, etc. There was no difference between the untreated patients.
The authors note that these data confirm previous reports showing that hypertensive patients have higher severe morbidity and mortality associated with COVID-19 than those without hypertension. .
“Our data confirm that ACE inhibitors / ARB are not associated with progression or outcome of COVID-19 hospitalization in hypertensive patients.”
They also note that these results support recommendations from almost all major cardiovascular societies that patients do not discontinue ACE inhibitors or ARB due to COVID-19 concerns. I will.
However, the authors noted some limitations of the study, such as the few patients with hypertension who were taking ACE inhibitors or ARB, and the fact that the non-severe disease course was severe enough to require hospitalization. I’m pointing out. In addition, it was unclear whether baseline ACE inhibitor / ARB therapy was maintained during hospitalization for all patients.
This is also an observational comparison, although baseline characteristics measured were similar in both groups, but could be biased by differences between patients taking ACE inhibitor or ARB at admission and those not taking it. There is.
However, the authors also emphasize the finding that in this cohort, patients with hypertension had a three-fold higher mortality rate than all other patients hospitalized with COVID-19.
They comment: “Hypertension means cardiovascular and cerebrovascular disease, diabetes, Chronic kidney disease Patients tend to be at increased risk of COVID-19 severity and mortality. Therefore, patients with these underlying disorders that develop COVID-19 require particularly intensive monitoring and care. “
Experts are cautiously optimistic
Cardiologist contacted by theheart.org | Medscape Cardiology I was cautiously optimistic about these latest results.
Michael A. Weber, MD, Professor, School of Medicine, State University of New York, Editor-in-Chief Clinical hypertension journal“This new report from Wuhan, China, reasonably warrants that the use of ACE inhibitors or ARBs in hypertensive patients with COVID-19 disease does not increase the risk of clinical deterioration or death.”
“More reliable studies in progress should help resolve competing hypotheses about the effects of these agents. The increased levels of the ACE2 enzyme they produce may increase the access of COVID viruses to lung tissue. Whether it worsens the results, or whether there are benefits associated with protection, the effect of increasing ACE2 on alveolar cell function, “Weber said.
“The new report contains a small number of patients, but hypertensives may have fatal consequences that appear to reflect their vulnerability to cardiovascular and metabolic comorbidities associated with hypertension.” Was surprisingly three times higher than non-hypertensive patients. “
“In any case, for now, clinicians should continue to treat hypertensive patients with drugs such as ACE inhibitors and ARBs, and it’s best to provide protection from adverse outcomes,” Weber concludes. It was
John McMurray, MD, of Cardiology at the University of Glasgow, UK, commented: “This study from Wuhan provides reassurance on one of the two questions about ACEI / ARB. Do these drugs increase susceptibility to infections? Would you like to increase the severity? This study addresses the latter question and suggests that there is no increase in severity. ”
However, McMurray pointed out that this study has many limitations. The number of patients was small and the data were not adjusted. “Patients treated with ACE inhibitors / ARBs seem to be at increased risk from the start.” This is an observational study, patients are not randomized and are mainly treated with ARBs, ACE inhibitors “I’m not sure if the concerns apply equally to these two classes of drugs, because they were not treated.”
“Other data published and unpublished to support this (and may even show better results in patients treated with ACE inhibitors / ARBs), and to date, no concerns have been established regarding these drugs, It seems prudent to prescribe guidance from the medical community to continue treating patients with these drugs. “
Franz H. Messari, MD, professor of medicine at the University of Bern in Switzerland, said: “The study from Wuhan is not a great study. I didn’t even have a multivariate analysis. The data, but it still gives me some relief.”
Messari said it was “interesting” that 30% of the patients admitted to the sample COVID-19 had high blood pressure. “Since it corresponds to the general population, hypertension has not been suggested to increase susceptibility to infection, but it appears to increase the risk of adverse consequences.”
Messali said there were two more similar studies due shortly, suggesting a beneficial or neutral effect of the ACE inhibitor / ARB on COVID-19 outcomes in hospitalized patients.
“This helps confidence in prescribing these drugs and strengthens recommendations for patients to continue taking these drugs,” he said.
“But none of these studies address the problem of infectivity. If their use upregulates the ACE2 receptor and the virus gains invasion into the cell, thus increasing its susceptibility to infection?” “Messali warned.” “But similar or better results with these drugs are promising,” he added.
The Wuhan study was supported by the Health and Family Planning Commission of Wuhan, China. The author has reported no relevant financial relationships.
JAMA Cardiole. Published April 23, 2020 Online. Full text
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