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ACEIs, ARBs do not worsen COVID-19 in hypertensive patients

Tristan Manalac
29 Apr 2020

Inhibitors of the renin-angiotensin system may not exacerbate the coronavirus disease 2019 (COVID-19) in patients with hypertension, according to a recent study.

“This study was limited by a small number of patients with hypertension taking angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs) who were hospitalized with COVID-19,” said researchers. “The current findings may not be generalizable to all patients with hypertension, and it is possible that ACEIs/ ARBs could affect the chance of hospitalization.”

The retrospective case series included 1,178 COVID-19 patients (median age, 55.5 years; 46.3 percent male), of whom 30.7 percent (n=362) had hypertension. Those with the cardiovascular condition tended to have worse COVID-19, manifesting as significantly higher rates of acute respiratory distress syndrome and in-hospital mortality (p<0.001). [JAMA Cardiol 20202;doi:10.1001/jamacardio.2020.1624]

Of the hypertensive COVID-19 patients, 71.5 percent were older than 60 years of age and 31.8 percent (n=115) were taking ACEIs/ARBs. Seventy-seven patients died, yielding an in-hospital mortality rate of 21.3 percent in this subgroup.

ACEIs/ARBs did not seem to affect infection outcomes. The use of ACEIs, for instance, did not differ between those with severe vs nonsevere infections (9.2 percent vs 10.1 percent; p=0.80), nor did the use of ARBs (24.9 percent vs 21.2 percent; p=0.40).

Calcium channel blockers, the most common antihypertensive medication, likewise saw comparable rates of use in patients with severe vs nonsevere COVID-19 (45.7 percent vs 47.1 percent; p=0.79). The same was true for β receptor blockers (4.6 percent vs 3.2 percent; p=0.48).

Moreover, the combination of calcium channel blockers with either ARBs (p=0.28) or ACEIs (p=0.39) likewise did not differ between severe and nonsevere COVID-19 patients.

Trends remained the same when analysed according to survival. Twenty-eight survivors were on ACEIs, as compared with seven nonsurvivors. The resulting rates of use were 9.8 percent and 9.1 percent (p=0.85). ARB use was likewise similar (23.9 percent vs 19.5 percent; p=0.42).

The principal findings were robust to subsequent analyses adjusting for comorbidities such as coronary heart disease, cerebrovascular disease, diabetes, chronic renal diseases and neurological diseases. That is, severe illness and death did not occur in excess in patients treated with or without ACEIs/ARBs.

“Our data provide some reassurance that ACEIs/ARBs are not associated with the progression or outcome of COVID-19 hospitalizations in patients with hypertension,” the researchers said.

COVID-19 patients admitted to the Central Hospital of Wuhan were enrolled in the present study. Severe infection was defined as blood oxygen saturation 93 percent, with respiratory frequency of at least 30 per minute. Septic shock, lung infiltrates, partial pressure of arterial oxygen, and multiple organ dysfunction or failure were also considered.

“Currently, almost all major societies recommend that patients with hypertension do not discontinue using ACEIs, ARBs or other renin-angiotensin-aldosterone antagonists in this setting except for clinical reasons rather than COVID-19. The clinical data in the current report supports these societal recommendations,” the researchers said.

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