Risk of severe COVID-19 disease with ACE inhibitors and angiotensin receptor blockers: cohort study including 8.3 million people

Clinical risk factors for mortality in patients with cancer and COVID-19: a systematic review and meta-analysis of recent observational studies

INTRODUCTION

Patients with cancer are more vulnerable to COVID-19 than the general population. Accordingly, it is necessary to identify the risk factors for death in patients with cancer and COVID-19.

METHODS

PubMed, Cochrane Library, and Embase Ovid databases were searched for relevant articles published before July 31^st, 2020. Studies that explored the risk factors for mortality were included. The effect size was relative risk (RR) and 95% confidence interval (CI).

RESULTS

We included 17 observational studies involving 3268 patients. The pooled mortality was 24.8%. Male gender, age above 65 years, and comorbidities (especially hypertension and COPD) were risk factors for death (RR 1.16, 1.27, 1.12; 95% CI 0.7-1.95, 1.08-1.49, 1.04-1.2; P = 0.006, 0.004, and 0.002, respectively). Recent anti-cancer treatments did not increase mortality (P > 0.05). Dyspnea, cough, and sputum canused an elevated risk of death (P < 0.05). Antibiotics, glucocorticoids, interferons, invasive ventilation, and complications were associated with a high probability of death (P < 0.05).

CONCLUSIONS

Various demographic and clinical characteristics, such as male gender, advanced age, comorbidities, and symptoms, were risk factors for mortality in patients with cancer and COVID-19. Our findings suggest recent anti-cancer treatments do not increase mortality.

Ins and Outs: Perspectives of Inpatient Prescribing for Sacubitril/Valsartan

Heart failure is a major public health concern with a rising prevalence and significant financial detriment. Although sacubitril/valsartan was shown to reduce the risk of death and hospitalization from heart failure in a contemporary cohort, it continues to remain substantially underutilized. A recent article in the Annals highlights the evidence behind inpatient initiation of sacubitril/valsartan. We provide further considerations and summarize the evidence for inpatient initiation of other guideline directed medical therapies. Overall, there is a need to improve methods to identify ideal populations and increase utilization in those who may benefit from sacubitril/valsartan. Further research is also needed to identify the risks versus benefits among underrepresented populations (i.e., advanced heart failure, heart failure with preserved ejection fraction, in conjunction with other contemporary evidence-based therapies that can lower blood pressure, etc.).

Beyond dexamethasone, emerging immuno-thrombotic therapies for COVID-19

Host immunity is required to clear SARS-CoV-2, and inability to clear the virus because of host or pathogen factors renders those infected at risk of poor outcomes. Estimates of those who are able to clear the virus with asymptomatic or paucisymptomatic COVID-19 remain unclear, and dependent on widespread testing. However, evidence is emerging that in severe cases, pathological mechanisms of hyperinflammation and coagulopathy ensue, the former supported by results from the RECOVERY trial demonstrating a reduction in mortality with dexamethasone in advanced COVID-19. It remains unclear whether these pathogenic pathways are secondary to a failure to clear the virus because of maladaptive immune responses or if these are sequential COVID-19 defining illnesses. Understanding the pathophysiological mechanisms underpinning these cascades is essential to formulating rationale therapeutic approaches beyond the use of dexamethasone. Here, we review the pathophysiology thought to underlie COVID-19 with clinical correlates and the current therapeutic approaches being investigated.

Endothelial dysfunction in COVID-19: Current findings and therapeutic implications

Coronavirus disease 2019 (COVID-19) increases the risk of several non-pulmonary complications such as acute myocardial injury, renal failure or thromboembolic events. A possible unifying explanation for these phenomena may be the presence of profound endothelial dysfunction and injury. This review provides an overview on the association of endothelial dysfunction with COVID-19 and its therapeutic implications. Endothelial dysfunction is a common feature of the key comorbidities that increase risk for severe COVID-19 such as hypertension, obesity, diabetes mellitus, coronary artery disease or heart failure. Preliminary studies indicate that vascular endothelial cells can be infected by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and evidence of widespread endothelial injury and inflammation is found in advanced cases of COVID-19. Prior evidence has established the crucial role of endothelial cells in maintaining and regulating vascular homeostasis and blood coagulation. Aggravation of endothelial dysfunction in COVID-19 may therefore impair organ perfusion and cause a procoagulatory state resulting in both macro- and microvascular thrombotic events. Angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs) and statins are known to improve endothelial dysfunction. Data from smaller observational studies and other viral infections suggests a possible beneficial effect in COVID-19. Other treatments that are currently under investigation for COVID-19 may also act by improving endothelial dysfunction in patients. Focusing therapies on preventing and improving endothelial dysfunction could improve outcomes in COVID-19. Several clinical trials are currently underway to explore this concept.

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New evidence implicates endothelial dysfunction in the pathophysiology of COVID-19.

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It may explain complications such as multi-organ damage or thrombotic events.

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Targeted interventions such as RAS inhibitors or statins may improve outcomes.

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Studies on interventions that affect endothelial dysfunction are underway in COVID-19.