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Fastbom J, Jonasdottir Bergman G, Holm J, Hanberger H, Strålin K, Walther S, Alfredsson J, State M, Borg N, Nyman Iliadou A. Use of drugs for hypertension or heart failure and the risk of death in COVID-19: association with loop-diuretics. Eur J Clin Pharmacol 2024; 80:1515-1522. [PMID: 38913169 PMCID: PMC11393138 DOI: 10.1007/s00228-024-03709-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 06/03/2024] [Indexed: 06/25/2024]
Abstract
PURPOSE To study the association between the use of drugs for hypertension or heart failure, particularly diuretics, and risk of death in COVID-19. METHODS We conducted a cohort study, based on record linked individual-based data from national registers, of all Swedish inhabitants 50 years and older (n = 3,909,321) at the start of the first SARS-CoV-2 wave in Sweden. The association between use of angiotensin-converting enzyme inhibitors (ACEI), angiotensin II receptor blockers (ARB), thiazides, loop diuretics, aldosterone antagonists, beta blocking agents and calcium channel blockers at the index date 6 March 2020, and death in COVID-19 during 7 March to 31 July 2020, was analysed using Cox-proportional hazards regression, adjusted for a wide range of possible confounders. RESULTS Use of loop diuretics was associated with higher risk [adjusted hazard ratio (HR) 1.26; 95% confidence interval (95% CI) 1.17-1.35] and thiazides with reduced risk (0.78; 0.69-0.88) of death in COVID-19. In addition, lower risk was observed for ACEI and higher risk for beta-blocking agents, although both associations were weak. For ARB, aldosterone antagonists and calcium channel blockers no significant associations were found. CONCLUSION In this nationwide cohort of nearly 4 million persons 50 years and older, the use of loop diuretics was associated with increased risk of death in COVID-19 during the first SARS-CoV-2 wave in Sweden. This contrasted to the decreased risk observed for thiazides. As treatment with loop diuretics is common, particularly in the elderly, the group most affected by severe COVID-19, this finding merit further investigation.
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Affiliation(s)
- Johan Fastbom
- National Board of Health and Welfare (Socialstyrelsen), Stockholm, Sweden.
- Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden.
| | | | - Johanna Holm
- National Board of Health and Welfare (Socialstyrelsen), Stockholm, Sweden
| | - Håkan Hanberger
- Department of Clinical and Experimental Medicine, Infectious Diseases, Faculty of Health Sciences, Linköping University, Linköping, Sweden
| | - Kristoffer Strålin
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Sten Walther
- Department of Cardiothoracic and Vascular Surgery. Heart Centre, Linköping University Hospital and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Joakim Alfredsson
- Department of Health Medicine and Caring Sciences and Department of Cardiology, Linköping University, Linköping, Sweden
| | - Maria State
- National Board of Health and Welfare (Socialstyrelsen), Stockholm, Sweden
| | - Natalia Borg
- National Board of Health and Welfare (Socialstyrelsen), Stockholm, Sweden
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Ibrahim R. The effect of pre-hospital use of RAS inhibitors on COVID-19 mortality. J Investig Med 2024:10815589241270417. [PMID: 39075674 DOI: 10.1177/10815589241270417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2024]
Abstract
The effect of pre-hospital use of renin-angiotensin system (RAS) inhibitors (angiotensin-converting enzyme inhibitors (ACEis)/angiotensin receptor blockers (ARBs)) on clinical outcomes of hypertensive patients with COVID-19 has been questioned due to conflicting reports on this issue. After applying exclusion criteria, 175 COVID-19 hospitalized patients admitted to the Tishreen Hospital from January 1 to July 31, 2021 were retrospectively enrolled in this study. Baseline characteristics and in-hospital mortality rate were assessed between hypertensive (N = 91, 52%) and non-hypertensive (N = 84, 48%) patients, as well as between patients taking ACEis/ARBs and non-ACEis/ARBs within the hypertensive group. A lower mortality rate (51.2 versus 31.9%, p = 0.009) was observed in the hypertensive group (mean age 64.6 years, 64.8% males) compared to the non-hypertensive (mean age 62.6 years, 66.7% males). Patients' mortality in the non-hypertensive group was associated with lower blood oxygen saturation (SPO2 = 75 versus 86%, p = 0.002), increased levels of inflammatory (CRP, white blood cell and neutrophils count), and tissue/renal injury markers (LDH, urea, and creatinine). In the hypertensive group, a lower mortality rate was noted in the ACEis/ARBs group compared to the non-ACEis/ARBs (24.1 versus 45.5%, p = 0.036), and this was associated with a decrease in D-DIMER levels, although not significant (1723 versus 2683 ng/mL, p > 0.05). Death in the non-ACEis/ARBs group was associated with decreased SPO2 and tissue/renal injury markers (LDH, CK, AST, urea, and creatinine). We concluded that hypertension is not a direct cause of poor prognosis in COVID-19 patients and that multi-organ damage is a significant indicator of death from COVID-19. RAS inhibitors could improve the survival of hypertensive COVID-19 patients.
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Affiliation(s)
- Rama Ibrahim
- Department of Biochemistry and Microbiology, Faculty of Pharmacy,Al-Sham Private University (ASPU), Lattakia, Syria
- Department of Biochemistry and Microbiology, Faculty of Pharmacy, Tishreen University, Lattakia, Syria
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Rathkolb V, Traugott MT, Heinzel A, Poglitsch M, Aberle J, Eskandary F, Abrahamowicz A, Mueller M, Knollmueller P, Shoumariyeh T, Stuflesser J, Seeber I, Gibas G, Mayfurth H, Tinhof V, Schmoelz L, Zeitlinger M, Schoergenhofer C, Jilma B, Genser B, Hoepler W, Omid S, Karolyi M, Wenisch C, Oberbauer R, Zoufaly A, Hecking M, Reindl-Schwaighofer R. Renin-angiotensin system inhibitor discontinuation in COVID-19 did not modify systemic ACE2 in a randomized controlled trial. iScience 2023; 26:108146. [PMID: 37867935 PMCID: PMC10585392 DOI: 10.1016/j.isci.2023.108146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 09/01/2023] [Accepted: 10/02/2023] [Indexed: 10/24/2023] Open
Abstract
Despite the similar clinical outcomes after renin-angiotensin system (RAS) inhibitor (RASi) continuation or withdrawal in COVID-19, the effects on angiotensin-converting enzyme 2 (ACE2) and RAS metabolites remain unclear. In a substudy of the randomized controlled Austrian Corona Virus Adaptive Clinical Trial (ACOVACT), patients with hypertension and COVID-19 were randomized 1:1 to either RASi continuation (n = 30) or switch to a non-RASi medication (n = 29). RAS metabolites were analyzed using a mixed linear regression model (n = 30). Time to a sustained clinical improvement was equal and ACE2 did not differ between the groups but increased over time in both. Overall ACE2 was higher with severe COVID-19. ACE-S and Ang II levels increased as expected with ACE inhibitor discontinuation. These data support the safety of RASi continuation in COVID-19, although RASi were frequently discontinued in our post hoc analysis. The study was not powered to draw definite conclusions on clinical outcomes using small sample sizes.
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Affiliation(s)
- Vincent Rathkolb
- Department of Internal Medicine III, Clinical Division of Nephrology & Dialysis, Medical University of Vienna, Wien, Austria
| | - Marianna T. Traugott
- Department of Internal Medicine IV with Infectious Diseases and Tropical Medicine, Clinic Favoriten, Vienna, Austria
| | - Andreas Heinzel
- Department of Internal Medicine III, Clinical Division of Nephrology & Dialysis, Medical University of Vienna, Wien, Austria
| | | | - Judith Aberle
- Institute of Virology, Medical University of Vienna, Wien, Austria
| | - Farsad Eskandary
- Department of Internal Medicine III, Clinical Division of Nephrology & Dialysis, Medical University of Vienna, Wien, Austria
| | - Agnes Abrahamowicz
- Department of Internal Medicine III, Clinical Division of Nephrology & Dialysis, Medical University of Vienna, Wien, Austria
| | - Martin Mueller
- Department of Clinical Pharmacology, Medical University of Vienna, Wien, Austria
| | - Petra Knollmueller
- Department of Clinical Pharmacology, Medical University of Vienna, Wien, Austria
| | - Tarik Shoumariyeh
- Department of Internal Medicine III, Clinical Division of Nephrology & Dialysis, Medical University of Vienna, Wien, Austria
| | - Jasmin Stuflesser
- Department of Internal Medicine IV with Infectious Diseases and Tropical Medicine, Clinic Favoriten, Vienna, Austria
| | - Ivan Seeber
- Department of Internal Medicine IV with Infectious Diseases and Tropical Medicine, Clinic Favoriten, Vienna, Austria
| | - Georg Gibas
- Department of Internal Medicine IV with Infectious Diseases and Tropical Medicine, Clinic Favoriten, Vienna, Austria
| | - Hannah Mayfurth
- Department of Internal Medicine III, Clinical Division of Nephrology & Dialysis, Medical University of Vienna, Wien, Austria
| | - Viktoria Tinhof
- Department of Internal Medicine III, Clinical Division of Nephrology & Dialysis, Medical University of Vienna, Wien, Austria
| | - Lukas Schmoelz
- Department of Internal Medicine III, Clinical Division of Nephrology & Dialysis, Medical University of Vienna, Wien, Austria
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Wien, Austria
| | | | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Wien, Austria
| | - Bernd Genser
- Center for Preventive Medicine and Digital Health, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Wolfgang Hoepler
- Department of Internal Medicine IV with Infectious Diseases and Tropical Medicine, Clinic Favoriten, Vienna, Austria
| | - Sara Omid
- Department of Internal Medicine IV with Infectious Diseases and Tropical Medicine, Clinic Favoriten, Vienna, Austria
| | - Mario Karolyi
- Department of Internal Medicine IV with Infectious Diseases and Tropical Medicine, Clinic Favoriten, Vienna, Austria
| | - Christoph Wenisch
- Department of Internal Medicine IV with Infectious Diseases and Tropical Medicine, Clinic Favoriten, Vienna, Austria
| | - Rainer Oberbauer
- Department of Internal Medicine III, Clinical Division of Nephrology & Dialysis, Medical University of Vienna, Wien, Austria
| | - Alexander Zoufaly
- Department of Internal Medicine IV with Infectious Diseases and Tropical Medicine, Clinic Favoriten, Vienna, Austria
- Faculty of Medicine, Sigmund Freud University, Vienna, Austria
| | - Manfred Hecking
- Department of Internal Medicine III, Clinical Division of Nephrology & Dialysis, Medical University of Vienna, Wien, Austria
| | - Roman Reindl-Schwaighofer
- Department of Internal Medicine III, Clinical Division of Nephrology & Dialysis, Medical University of Vienna, Wien, Austria
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Chen C, He W, Wang DW. Wuhan 3 years after the outbreak of the pandemic-cardiological insights and perspectives. Herz 2023:10.1007/s00059-023-05176-4. [PMID: 37106075 PMCID: PMC10136403 DOI: 10.1007/s00059-023-05176-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2023] [Indexed: 04/29/2023]
Abstract
In November 2019, Wuhan, a city in Central China, became the center of an outbreak of pneumonia of unknown cause, which was later named "coronavirus disease 2019" (COVID-19). COVID-19 is caused by the novel severe acute respiratory distress syndrome coronavirus 2 (SARS-CoV-2) infection. The emergence of novel SARS-CoV‑2 strains and mutations exerted a serious global public health threat. Although various vaccines have been developed, specific anti-SARS-CoV‑2 drugs are limited. As cardiologists, we believe that because SARS-CoV‑2 can bind to the angiotensin 2 receptor on the surface of cardiomyocytes, it may also lead to cardiac injury. COVID-19-associated cardiac injury is not rare in clinical practice, and most of these cases are mild, while a few might progress to fulminant myocarditis (FM). Overactivated immune response and inflammatory storm represent the core pathogenesis of COVID-19-associated FM. Early identification and diagnosis of COVID-19-associated FM are critical for its treatment. Recently, Wuhan was hit by the Omicron variant again. We proposed managing COVID-19-associated cardiac injury according to the severity, which has had a significant effect on outcome.
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Affiliation(s)
- Chen Chen
- Division of Cardiology, Department of Internal Medicine, and Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095# Jiefang Ave., 430030, Wuhan, China
| | - Wu He
- Division of Cardiology, Department of Internal Medicine, and Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095# Jiefang Ave., 430030, Wuhan, China
| | - Dao Wen Wang
- Division of Cardiology, Department of Internal Medicine, and Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095# Jiefang Ave., 430030, Wuhan, China.
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Recent highlights on myocarditis, cardiovascular complications of COVID-19, and cardiomyopathies from the International Journal of Cardiology: Heart & Vasculature. IJC HEART & VASCULATURE 2022; 43:101154. [PMCID: PMC9678833 DOI: 10.1016/j.ijcha.2022.101154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Sharma R, Kumar A, Majeed J, Thakur AK, Aggarwal G. Drugs acting on the renin-angiotensin-aldosterone system (RAAS) and deaths of COVID-19 patients: a systematic review and meta-analysis of observational studies. Egypt Heart J 2022; 74:64. [PMID: 36068392 PMCID: PMC9448845 DOI: 10.1186/s43044-022-00303-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 08/24/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARBs) are two of the most commonly used antihypertensive drugs acting on the renin-angiotensin-aldosterone system (RAAS). Previous research has shown that RAAS inhibitors increase the expression of angiotensin-converting enzyme, a cellular receptor for the severe acute respiratory syndrome coronavirus 2, raising concerns that the use of ACEi and ARBs in hypertensive patients may increase COVID-19 patient mortality. Therefore, the main aim of the current study was to find out the role of drugs acting on RAAS, particularly ACEi/ARBs in the deaths of COVID-19 patients. RESULTS In total, 68 studies were found to be appropriate, reporting a total of 128,078 subjects. The odds ratio was found to be 1.14 [0.95, 1.36], which indicates the non-significant association of ACEi/ARBs with mortality of COVID-19 patients. Further, the association of individual ACEi/ARBs with mortality of COVID-19 patients was also found non-significant. The sensitivity analysis results have shown no significant effect of outliers on the outcome. CONCLUSIONS Based on available evidence, ACEi/ARB were not significantly associated with deaths of COVID-19 patients.
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Affiliation(s)
- Ruchika Sharma
- Centre for Precision Medicine and Pharmacy, Delhi Pharmaceutical Sciences and Research University, New Delhi, 110017, India
| | - Anoop Kumar
- Department of Pharmacology, Delhi Pharmaceutical Sciences and Research University (DPSRU), New Delhi, 110017, India.
| | - Jaseela Majeed
- Department of Pharmaceutical Management, Delhi Pharmaceutical Sciences and Research University, New Delhi, 110017, India
| | - Ajit K Thakur
- Department of Pharmacology, Delhi Pharmaceutical Sciences and Research University (DPSRU), New Delhi, 110017, India
| | - Geeta Aggarwal
- Department of Pharmaceutics, Delhi Pharmaceutical Sciences and Research University (DPSRU), New Delhi, 110017, India.
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Loader J, Taylor FC, Lampa E, Sundström J. Renin-Angiotensin Aldosterone System Inhibitors and COVID-19: A Systematic Review and Meta-Analysis Revealing Critical Bias Across a Body of Observational Research. J Am Heart Assoc 2022; 11:e025289. [PMID: 35624081 PMCID: PMC9238740 DOI: 10.1161/jaha.122.025289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 04/07/2022] [Indexed: 12/18/2022]
Abstract
Background Renin-angiotensin aldosterone system (RAAS) inhibitor-COVID-19 studies, observational in design, appear to use biased methods that can distort the interaction between RAAS inhibitor use and COVID-19 risk. This study assessed the extent of bias in that research and reevaluated RAAS inhibitor-COVID-19 associations in studies without critical risk of bias. Methods and Results Searches were performed in MEDLINE, EMBASE, and CINAHL databases (December 1, 2019 to October 21, 2021) identifying studies that compared the risk of infection and/or severe COVID-19 outcomes between those using or not using RAAS inhibitors (ie, angiotensin-converting enzyme inhibitors or angiotensin II type-I receptor blockers). Weighted hazard ratios (HR) and 95% CIs were extracted and pooled in fixed-effects meta-analyses, only from studies without critical risk of bias that assessed severe COVID-19 outcomes. Of 169 relevant studies, 164 had critical risks of bias and were excluded. Ultimately, only two studies presented data relevant to the meta-analysis. In 1 351 633 people with uncomplicated hypertension using a RAAS inhibitor, calcium channel blocker, or thiazide diuretic in monotherapy, the risk of hospitalization (angiotensin-converting enzyme inhibitor: HR, 0.76; 95% CI, 0.66-0.87; P<0.001; angiotensin II type-I receptor blockers: HR, 0.86; 95% CI, 0.77-0.97; P=0.015) and intubation or death (angiotensin-converting enzyme inhibitor: HR, 0.64; 95% CI, 0.48-0.85; P=0.002; angiotensin II type-I receptor blockers: HR, 0.74; 95% CI, 0.58-0.95; P=0.019) with COVID-19 was lower in those using a RAAS inhibitor. However, these protective effects are probably not clinically relevant. Conclusions This study reveals the critical risk of bias that exists across almost an entire body of COVID-19 research, raising an important question: Were research methods and/or peer-review processes temporarily weakened during the surge of COVID-19 research or is this lack of rigor a systemic problem that also exists outside pandemic-based research? Registration URL: www.crd.york.ac.uk/prospero/; Unique identifier: CRD42021237859.
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Affiliation(s)
- Jordan Loader
- Department of Medical SciencesUppsala UniversityUppsalaSweden
- Inserm U1300 – HP2CHU Grenoble AlpesGrenobleFrance
| | - Frances C. Taylor
- Baker Heart and Diabetes InstituteMelbourneVictoriaAustralia
- Mary MacKillop Institute for Health Research, Australian Catholic UniversityMelbourneVictoriaAustralia
| | - Erik Lampa
- Department of Medical SciencesUppsala UniversityUppsalaSweden
| | - Johan Sundström
- Department of Medical SciencesUppsala UniversityUppsalaSweden
- The George Institute for Global HealthUniversity of New South WalesSydneyAustralia
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Degarege A, Naveed Z, Kabayundo J, Brett-Major D. Heterogeneity and Risk of Bias in Studies Examining Risk Factors for Severe Illness and Death in COVID-19: A Systematic Review and Meta-Analysis. Pathogens 2022; 11:563. [PMID: 35631084 PMCID: PMC9147100 DOI: 10.3390/pathogens11050563] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 05/02/2022] [Accepted: 05/05/2022] [Indexed: 02/07/2023] Open
Abstract
This systematic review and meta-analysis synthesized the evidence on the impacts of demographics and comorbidities on the clinical outcomes of COVID-19, as well as the sources of the heterogeneity and publication bias of the relevant studies. Two authors independently searched the literature from PubMed, Embase, Cochrane library, and CINAHL on 18 May 2021; removed duplicates; screened the titles, abstracts, and full texts by using criteria; and extracted data from the eligible articles. The variations among the studies were examined by using Cochrane, Q.; I2, and meta-regression. Out of 11,975 articles that were obtained from the databases and screened, 559 studies were abstracted, and then, where appropriate, were analyzed by meta-analysis (n = 542). COVID-19-related severe illness, admission to the ICU, and death were significantly correlated with comorbidities, male sex, and an age older than 60 or 65 years, although high heterogeneity was present in the pooled estimates. The study design, the study country, the sample size, and the year of publication contributed to this. There was publication bias among the studies that compared the odds of COVID-19-related deaths, severe illness, and admission to the ICU on the basis of the comorbidity status. While an older age and chronic diseases were shown to increase the risk of developing severe illness, admission to the ICU, and death among the COVID-19 patients in our analysis, a marked heterogeneity was present when linking the specific risks with the outcomes.
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Affiliation(s)
- Abraham Degarege
- Department of Epidemiology, College of Public Health, University of Nebraska Medical Center, Omaha, NE 68198, USA; (Z.N.); (J.K.); (D.B.-M.)
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Aparisi Á, Catalá P, Amat-Santos IJ, Marcos-Mangas M, López-Otero D, Veras C, López-Pais J, Cabezón-Villalba G, Cacho Antonio CE, Candela J, Antúnez-Muiños P, Gil JF, González Ferrero T, Rojas G, Pérez-Poza M, Uribarri A, Otero-García O, García-Granja PE, Jiménez Ramos V, Revilla A, Dueñas C, Gómez I, González-Juanatey JR, San Román JA. Chronic use of renin–angiotensin–aldosterone inhibitors in hypertensive COVID-19 patients: Results from a Spanish registry and meta-analysis. MEDICINA CLÍNICA (ENGLISH EDITION) 2022; 158:315-323. [PMID: 35531305 PMCID: PMC9063316 DOI: 10.1016/j.medcle.2021.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 04/13/2021] [Indexed: 11/08/2022]
Abstract
Background Hypertension is a prevalent condition among SARS-CoV-2 infected patients. Whether renin–angiotensin–aldosterone system (RAAS) inhibitors are beneficial or harmful is controversial. Methods We have performed a national retrospective, nonexperimental comparative study from two tertiary hospitals to evaluate the impact of chronic use of RAAS inhibitors in hypertensive COVID-19 patients. A meta-analysis was performed to strengthen our findings. Results Of 849 patients, 422 (49.7%) patients were hypertensive and 310 (73.5%) were taking RAAS inhibitors at baseline. Hypertensive patients were older, had more comorbidities, and a greater incidence of respiratory failure (−0.151 [95% CI −0.218, −0.084]). Overall mortality in hypertensive patients was 28.4%, but smaller among those with prescribed RAAS inhibitors before (−0.167 [95% CI −0.220, −0.114]) and during hospitalization (0.090 [−0.008,0.188]). Similar findings were observed after two propensity score matches that evaluated the benefit of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers among hypertensive patients. Multivariate logistic regression analysis of hypertensive patients found that age, diabetes mellitus, C-reactive protein, and renal failure were independently associated with all-cause mortality. On the contrary, ACEIs decreased the risk of death (OR 0.444 [95% CI 0.224–0.881]). Meta-analysis suggested a protective benefit of RAAS inhibitors (OR 0.6 [95% CI 0.42–0.8]) among hypertensive COVID-19. Conclusion Our data suggest that RAAS inhibitors may play a protective role in hypertensive COVID-19 patients. This finding was supported by a meta-analysis of the current evidence. Maintaining these medications during hospital stay may not negatively affect COVID-19 outcomes.
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Xu C, Chen Y, Yu J. Foe and friend in the COVID-19-associated acute kidney injury: an insight on intrarenal renin-angiotensin system. Acta Biochim Biophys Sin (Shanghai) 2022; 54:1-11. [PMID: 35130610 PMCID: PMC9828085 DOI: 10.3724/abbs.2021002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 09/08/2021] [Indexed: 01/08/2023] Open
Abstract
Since the first reported case in December of 2019, the coronavirus disease 2019 (COVID-19) has became an international public health emergency. So far, there are more than 228,206,384 confirmed cases including 4,687,066 deaths. Kidney with high expression of angiotensin-converting enzyme 2 (ACE2) is one of the extrapulmonary target organs affected in patients with COVID-19. Acute kidney injury (AKI) is one of the independent risk factors for the death of COVID-19 patients. The imbalance between ACE2-Ang(1-7)-MasR and ACE-Ang II-AT1R axis in the kidney may contribute to COVID-19-associated AKI. Although series of research have shown the inconsistent effects of multiple common RAS inhibitors on ACE2 expression and enzyme activity, most of the retrospective cohort studies indicated the safety and protective effects of ACEI/ARB in COVID-19 patients. This review article highlights the current knowledge on the possible involvement of intrarenal RAS in COVID-19-associated AKI with a primary focus on the opposing effects of ACE2-Ang(1-7)-MasR and ACE-Ang II-AT1R signaling in the kidney. Human recombinant soluble ACE2 or ACE2 variants with preserved ACE2-enzymatic activity may be the best options to improve COVID-19-associated AKI.
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Affiliation(s)
- Chuanming Xu
- Translational Medicine CentreJiangxi University of Chinese MedicineNanchang330002China
| | - Yanting Chen
- Institute of HypertensionSun Yat-sen University School of MedicineGuangzhou510080China
| | - Jun Yu
- Center for Metabolic Disease Research and Department of PhysiologyLewis Katz School of MedicineTemple UniversityPhiladelphiaPA19140USA
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Nozari F, Hamidizadeh N. The Effects of Different Classes of Antihypertensive Drugs on Patients with COVID-19 and Hypertension: A Mini-Review. Int J Hypertens 2022; 2022:5937802. [PMID: 35075396 PMCID: PMC8783136 DOI: 10.1155/2022/5937802] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 09/04/2021] [Accepted: 01/06/2022] [Indexed: 12/22/2022] Open
Abstract
Hypertension is a major risk factor for cardiovascular disease. Previous studies showed that patients with hypertension are at an increased risk of developing severe COVID-19 infection. Therefore, proper blood pressure control in hypertensive patients with COVID-19 is of great importance. In this review, we discussed the effects of different classes of antihypertensive drugs on patients with hypertension and COVID-19.
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Affiliation(s)
- Farnoosh Nozari
- Molecular Dermatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Nasrin Hamidizadeh
- Molecular Dermatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Li C, Wang DW, Zhao C. Cardiovascular Involvement in Patients with 2019 Novel Coronavirus Disease. J Transl Int Med 2021; 9:152-160. [PMID: 34900625 PMCID: PMC8629421 DOI: 10.2478/jtim-2021-0016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
2019 novel coronavirus disease (COVID-19) is caused by the infection of severe acute respiratory syndrome novel coronavirus (SARS-CoV-2). It is characterized by substantial respiratory symptoms and complicated with widespread other organ injuries. Cardiovascular impairment is one of the notable extrapulmonary manifestations, in terms of the deterioration of pre-existing cardiovascular diseases and newly onset acute events. We hereby review the high-quality reports about cardiovascular involvement in COVID-19 and summarize the main clinical characteristics of cardiac relevance for the all the first line clinical physicians. Additionally, the possible underlying mechanisms and the rationale for the application of specific medications, such as renin-angiotensin-aldosterone system inhibitors and hydroxychloroquine are also discussed.
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Affiliation(s)
- Chenze Li
- Department of Cardiology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Dao Wen Wang
- Division of Cardiology, Department of Internal Medicine and Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan430030, Hubei Province, China
| | - Chunxia Zhao
- Division of Cardiology, Department of Internal Medicine and Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan430030, Hubei Province, China
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Loader J, Lampa E, Gustafsson S, Cars T, Sundström J. Renin-Angiotensin Aldosterone System Inhibitors in Primary Prevention and COVID-19. J Am Heart Assoc 2021; 10:e021154. [PMID: 34320843 PMCID: PMC8475700 DOI: 10.1161/jaha.120.021154] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Considering the widespread risk of collider bias and confounding by indication in previous research, the associations between renin‐angiotensin aldosterone system (RAAS) inhibitor use and COVID‐19 remain unknown. Accordingly, this study tested the hypothesis that RAAS inhibitors influence the summation effect of COVID‐19 and its progression to severe outcomes. Methods and Results This nationwide cohort study compared all residents of Sweden, without prior cardiovascular disease, in monotherapy (as of January 1, 2020) with a RAAS inhibitor to those using a calcium channel blocker or a thiazide diuretic. Comparative cohorts were balanced using machine‐learning‐derived propensity score methods. Of 165 355 people in the analysis (51% women), 367 were hospitalized or died with COVID‐19 (246 using a RAAS inhibitor versus 121 using a calcium channel blocker or thiazide diuretic; Cox proportional hazard ratio [HR], 0.97; 95% CI, 0.74–1.27). When each outcome was assessed separately, 335 people were hospitalized with COVID‐19 (HR, 0.92; 95% CI, 0.70–1.22), and 64 died with COVID‐19 (HR, 1.22; 95% CI, 0.68–2.19). The severity of COVID‐19 outcomes did not differ between those using a RAAS inhibitor and those using a calcium channel blocker or thiazide diuretic (ordered logistic regression odds ratio, 1.01; 95% CI, 0.89–1.14). Conclusions Despite potential limitations, this study is among the best available evidence that RAAS inhibitor use in primary prevention does not increase the risk of severe COVID‐19 outcomes; presenting strong data from which scientists and policy makers alike can base, with greater confidence, their current position on the safety of using RAAS inhibitors during the COVID‐19 pandemic.
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Affiliation(s)
- Jordan Loader
- Department of Medical Sciences Uppsala University Uppsala Sweden
| | - Erik Lampa
- Department of Medical Sciences Uppsala University Uppsala Sweden
| | | | - Thomas Cars
- Department of Medical Sciences Uppsala University Uppsala Sweden
| | - Johan Sundström
- Department of Medical Sciences Uppsala University Uppsala Sweden.,The George Institute for Global HealthUniversity of New South Wales Sydney NSW Australia
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14
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Chu C, Zeng S, Hasan AA, Hocher C, Krämer BK, Hocher B. Comparison of infection risks and clinical outcomes in patients with and without SARS-CoV-2 lung infection under renin-angiotensin-aldosterone system blockade: Systematic review and meta-analysis. Br J Clin Pharmacol 2021; 87:2475-2492. [PMID: 33217033 PMCID: PMC7753617 DOI: 10.1111/bcp.14660] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 10/28/2020] [Accepted: 11/10/2020] [Indexed: 02/06/2023] Open
Abstract
AIMS Angiotensin-converting enzyme-2 (ACE2) is the receptor for SARS-CoV-2. Animal studies suggest that renin-angiotensin-aldosterone system (RAAS) blockers might increase the expression of ACE2 and potentially increase the risk of SARS-CoV-2 infection. METHODS AND RESULTS The effect of ACE inhibitor (ACEI) treatment on the pneumonia incidence in non-COVID-19 patients (25 studies, 330 780 patients) was associated with a 26% reduction of pneumonia risk (odds ratio [OR]: 0.74, P < .001). Pneumonia-related death cases in ACEI-treated non-COVID-19 patients were reduced by 27% (OR: 0.73, P = .004). However, angiotensin II receptor blockers (ARB) treatment (10 studies, 275 621 non-COVID-19 patients) did not alter pneumonia risk in patients. Pneumonia-related death cases in ARB-treated non-COVID-19 patients was analysed only in 1 study and was significantly reduced (OR, 0.47; 95% confidence interval, 0.30 to 0.72). Results from 11 studies (8.4 million patients) showed that the risk of getting infected with the SARS-CoV-2 virus was reduced by 13% (OR: 0.87, P = .014) in patients treated with ACEI, whereas analysis from 10 studies (8.4 million patients) treated with ARBs showed no effect (OR, 0.92, P = .354). Results from 34 studies in 67 644 COVID-19 patients showed that RAAS blockade reduces all-cause mortality by 24% (OR = 0.76, P = .04). CONCLUSION ACEIs reduce the risk of getting infected with the SARS-CoV-2 virus. Blocking the RAAS may decrease all-cause mortality in COVID-19 patients. ACEIs also reduce the risk of non-COVID pneumonia. All-cause mortality due to non-COVID pneumonia is reduced by ACEI and potentially by ARBs.
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Affiliation(s)
- Chang Chu
- Fifth Department of Medicine (Nephrology/Endocrinology/Rheumatology)University Medical Centre Mannheim, University of HeidelbergGermany
- Department of NephrologyCharité‐Universitätsmedizin Berlin, Campus MitteBerlinGermany
| | - Shufei Zeng
- Fifth Department of Medicine (Nephrology/Endocrinology/Rheumatology)University Medical Centre Mannheim, University of HeidelbergGermany
- Department of NephrologyCharité‐Universitätsmedizin Berlin, Campus MitteBerlinGermany
| | - Ahmed A. Hasan
- Fifth Department of Medicine (Nephrology/Endocrinology/Rheumatology)University Medical Centre Mannheim, University of HeidelbergGermany
- Department of Nutritional Toxicology, Institute of Nutritional ScienceUniversity of PotsdamNuthetalGermany
- Department of Biochemistry, Faculty of PharmacyZagazig UniversityEgypt
| | - Carl‐Friedrich Hocher
- Fifth Department of Medicine (Nephrology/Endocrinology/Rheumatology)University Medical Centre Mannheim, University of HeidelbergGermany
| | - Bernhard K. Krämer
- Fifth Department of Medicine (Nephrology/Endocrinology/Rheumatology)University Medical Centre Mannheim, University of HeidelbergGermany
- European Center of Angioscience, Medical Faculty MannheimUniversity of HeidelbergGermany
| | - Berthold Hocher
- Fifth Department of Medicine (Nephrology/Endocrinology/Rheumatology)University Medical Centre Mannheim, University of HeidelbergGermany
- Key Laboratory of Study and Discovery of Small Targeted Molecules of Hunan Province, School of MedicineHunan Normal UniversityChangshaChina
- Reproductive and Genetic Hospital of CITIC‐XiangyaChangshaChina
- IMD Institut für Medizinische Diagnostik Berlin‐Potsdam GbRBerlinGermany
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15
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Aparisi Á, Catalá P, Amat-Santos IJ, Marcos-Mangas M, López-Otero D, Veras C, López-Pais J, Cabezón-Villalba G, Cacho Antonio CE, Candela J, Antúnez-Muiños P, Gil JF, González Ferrero T, Rojas G, Pérez-Poza M, Uribarri A, Otero-García O, García-Granja PE, Jiménez Ramos V, Revilla A, Dueñas C, Gómez I, González-Juanatey JR, San Román JA. Chronic use of renin-angiotensin-aldosterone inhibitors in hypertensive COVID-19 patients: Results from a Spanish registry and meta-analysis. Med Clin (Barc) 2021; 158:315-323. [PMID: 34088524 PMCID: PMC8101788 DOI: 10.1016/j.medcli.2021.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 04/11/2021] [Accepted: 04/13/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Hypertension is a prevalent condition among SARS-CoV-2 infected patients. Whether renin-angiotensin-aldosterone system (RAAS) inhibitors are beneficial or harmful is controversial. METHODS We have performed a national retrospective, nonexperimental comparative study from two tertiary hospitals to evaluate the impact of chronic use of RAAS inhibitors in hypertensive COVID-19 patients. A meta-analysis was performed to strengthen our findings. RESULTS Of 849 patients, 422 (49.7%) patients were hypertensive and 310 (73.5%) were taking RAAS inhibitors at baseline. Hypertensive patients were older, had more comorbidities, and a greater incidence of respiratory failure (-0.151 [95% CI -0.218, -0.084]). Overall mortality in hypertensive patients was 28.4%, but smaller among those with prescribed RAAS inhibitors before (-0.167 [95% CI -0.220, -0.114]) and during hospitalization (0.090 [-0.008,0.188]). Similar findings were observed after two propensity score matches that evaluated the benefit of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers among hypertensive patients. Multivariate logistic regression analysis of hypertensive patients found that age, diabetes mellitus, C-reactive protein, and renal failure were independently associated with all-cause mortality. On the contrary, ACEIs decreased the risk of death (OR 0.444 [95% CI 0.224-0.881]). Meta-analysis suggested a protective benefit of RAAS inhibitors (OR 0.6 [95% CI 0.42-0.8]) among hypertensive COVID-19. CONCLUSION Our data suggest that RAAS inhibitors may play a protective role in hypertensive COVID-19 patients. This finding was supported by a meta-analysis of the current evidence. Maintaining these medications during hospital stay may not negatively affect COVID-19 outcomes.
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Affiliation(s)
- Álvaro Aparisi
- Servicio de Cardiología, Hospital Clínico Universitario, Valladolid, Spain.
| | - Pablo Catalá
- Servicio de Cardiología, Hospital Clínico Universitario, Valladolid, Spain
| | - Ignacio J Amat-Santos
- Servicio de Cardiología, Hospital Clínico Universitario, Valladolid, Spain; Centro de Investigación Biomédica en Red - Cardiovascular (CIBERCV), Spain
| | | | - Diego López-Otero
- Centro de Investigación Biomédica en Red - Cardiovascular (CIBERCV), Spain; Servicio de Cardiología, Hospital Clínico Universitario, Santiago de Compostela, Spain
| | - Carlos Veras
- Servicio de Cardiología, Hospital Clínico Universitario, Valladolid, Spain
| | - Javier López-Pais
- Centro de Investigación Biomédica en Red - Cardiovascular (CIBERCV), Spain; Servicio de Cardiología, Hospital Clínico Universitario, Santiago de Compostela, Spain
| | | | | | - Jordi Candela
- Servicio de Cardiología, Hospital Clínico Universitario, Valladolid, Spain
| | - Pablo Antúnez-Muiños
- Servicio de Cardiología, Hospital Clínico Universitario, Santiago de Compostela, Spain
| | - José Francisco Gil
- Servicio de Cardiología, Hospital Clínico Universitario, Valladolid, Spain
| | - Teba González Ferrero
- Servicio de Cardiología, Hospital Clínico Universitario, Santiago de Compostela, Spain
| | - Gino Rojas
- Servicio de Cardiología, Hospital Clínico Universitario, Valladolid, Spain
| | - Marta Pérez-Poza
- Servicio de Cardiología, Hospital Clínico Universitario, Santiago de Compostela, Spain
| | - Aitor Uribarri
- Servicio de Cardiología, Hospital Clínico Universitario, Valladolid, Spain; Centro de Investigación Biomédica en Red - Cardiovascular (CIBERCV), Spain
| | - Oscar Otero-García
- Servicio de Cardiología, Hospital Clínico Universitario, Santiago de Compostela, Spain
| | - Pablo Elpidio García-Granja
- Servicio de Cardiología, Hospital Clínico Universitario, Valladolid, Spain; Centro de Investigación Biomédica en Red - Cardiovascular (CIBERCV), Spain
| | - Víctor Jiménez Ramos
- Servicio de Cardiología, Hospital Clínico Universitario, Santiago de Compostela, Spain
| | - Ana Revilla
- Servicio de Cardiología, Hospital Clínico Universitario, Valladolid, Spain; Centro de Investigación Biomédica en Red - Cardiovascular (CIBERCV), Spain
| | - Carlos Dueñas
- Servicio de Enfermedades Infecciosas, Hospital Clínico Universitario, Valladolid, Spain
| | - Itzíar Gómez
- Servicio de Cardiología, Hospital Clínico Universitario, Valladolid, Spain; Centro de Investigación Biomédica en Red - Cardiovascular (CIBERCV), Spain
| | - José Ramón González-Juanatey
- Centro de Investigación Biomédica en Red - Cardiovascular (CIBERCV), Spain; Servicio de Cardiología, Hospital Clínico Universitario, Santiago de Compostela, Spain
| | - J Alberto San Román
- Servicio de Cardiología, Hospital Clínico Universitario, Valladolid, Spain; Centro de Investigación Biomédica en Red - Cardiovascular (CIBERCV), Spain
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16
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Spaccarotella C, Mazzitelli M, Migliarino S, Curcio A, De Rosa S, Torti C, Indolfi C. Therapy with RAS inhibitors during the COVID-19 pandemic. J Cardiovasc Med (Hagerstown) 2021; 22:329-334. [PMID: 33795584 DOI: 10.2459/jcm.0000000000001160] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Coronavirus disease 2019 (COVID-19) is caused by the novel coronavirus first identified in Wuhan, China. The global number of confirmed cases of COVID-19 has surpassed 28,285,700 with mortality that appears higher than for seasonal influenza. About 20% of COVID-19 patients have experienced cardiac involvement and myocardial infarction in patients infected with SARS-CoV-2 had a worse prognosis. Furthermore, the widespread use of antiviral drugs can be linked to a worsening of heart function. Arrhythmias and hypertension have also been reported in patients with Covid-19. On the other hand, previous cardiac diseases are present in 30% of patients infected with SARS-CoV-2. There is uncertainty in the use of ace inhibitors and angiotensin II (Ang II) antagonists in the COVID-19 era. The mechanism of action of SARS-CoV-2 has been elucidated. It has been demonstrated that angiotensin-converting enzyme 2 (ACE2) is the cellular receptor for the new coronavirus SARS-CoV-2 and it is required for host cell entry and subsequent viral replication. The effect of the SARS-CoV-2 infection is the downregulation of ACE2 that may contribute to the severity of lung pathologies as well as the cardiac function. ACE2, a homolog of ACE, is a monocarboxypeptidase that converts Ang II into angiotensin 1-7 (Ang 1-7) that with its vasodilatory, antifibrotic, antihypertrophic effects counterbalances the negative effects of Ang II. On the other hand, angiotensin-converting enzyme inhibitors (ACEi) and AT1R blockers have been shown to upregulate the expression of ACE2. Based on the mechanism of action of SARS-CoV-2, the use of renin angiotensin system (RAS) inhibitors was questioned although all scientific societies did not recommend discontinuation when clinically recommended. The BRACE CORONA, a phase 4, randomized study tested two strategies: temporarily stopping the ACE inhibitor/angiotensin receptor blockers (ARB) for 30 days versus continuing ACE inhibitors/ARBs in patients who were taking these medications chronically and were hospitalized with a confirmed diagnosis of COVID-19 was also discussed. Therefore, the goal of this review is to summarize recent laboratory and clinical investigations concerning the use of ACEi and ARBs during the COVID-19 pandemic. The available data, based also on a randomized trial, suggest that ACEIs or ARBs, when clinically indicated, should be regularly used in the COVID-19 era.
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Affiliation(s)
| | - Maria Mazzitelli
- Division of Infectious and Tropical Diseases, 'Magna Graecia' University of Catanzaro, Catanzaro, Italy
| | | | - Antonio Curcio
- Division of Cardiology, University Magna Graecia, Catanzaro
| | | | - Carlo Torti
- Division of Infectious and Tropical Diseases, 'Magna Graecia' University of Catanzaro, Catanzaro, Italy
| | - Ciro Indolfi
- Division of Cardiology, University Magna Graecia, Catanzaro
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17
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Oz M, Lorke DE, Kabbani N. A comprehensive guide to the pharmacologic regulation of angiotensin converting enzyme 2 (ACE2), the SARS-CoV-2 entry receptor. Pharmacol Ther 2021; 221:107750. [PMID: 33275999 PMCID: PMC7854082 DOI: 10.1016/j.pharmthera.2020.107750] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/18/2020] [Accepted: 11/19/2020] [Indexed: 02/06/2023]
Abstract
The recent emergence of coronavirus disease-2019 (COVID-19) as a global pandemic has prompted scientists to address an urgent need for defining mechanisms of disease pathology and treatment. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent for COVID-19, employs angiotensin converting enzyme 2 (ACE2) as its primary target for cell surface attachment and likely entry into the host cell. Thus, understanding factors that may regulate the expression and function of ACE2 in the healthy and diseased body is critical for clinical intervention. Over 66% of all adults in the United States are currently using a prescription drug and while earlier findings have focused on possible upregulation of ACE2 expression through the use of renin angiotensin system (RAS) inhibitors, mounting evidence suggests that various other widely administered drugs used in the treatment of hypertension, heart failure, diabetes mellitus, hyperlipidemias, coagulation disorders, and pulmonary disease may also present a varied risk for COVID-19. Specifically, we summarize mechanisms on how heparin, statins, steroids and phytochemicals, besides their established therapeutic effects, may also interfere with SARS-CoV-2 viral entry into cells. We also describe evidence on the effect of several vitamins, phytochemicals, and naturally occurring compounds on ACE2 expression and activity in various tissues and disease models. This comprehensive review aims to provide a timely compendium on the potential impact of commonly prescribed drugs and pharmacologically active compounds on COVID-19 pathology and risk through regulation of ACE2 and RAS signaling.
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Key Words
- adam17, a disintegrin and metalloprotease 17
- ace, angiotensin i converting enzyme
- ace-inh., angiotensin i converting enzyme inhibitor
- ampk, amp-activated protein kinase
- ang-ii, angiotensin ii
- arb, angiotensin ii type 1-receptor blocker
- ards, acute respiratory distress syndrome
- at1-r, angiotensin ii type 1-receptor
- βarb, β-adrenergic receptor blockers
- bk, bradykinin
- ccb, calcium channel blockers
- ch25h, cholesterol-25-hydroxylase
- copd, chronic obstructive lung disease
- cox, cyclooxygenase
- covid-19, coronavirus disease-2019
- dabk, [des-arg9]-bradykinin
- erk, extracellular signal-regulated kinase
- 25hc, 25-hydroxycholesterol
- hs, heparan sulfate
- hspg, heparan sulfate proteoglycan
- ibd, inflammatory bowel disease
- map, mitogen-activated protein
- mers, middle east respiratory syndrome
- mrb, mineralocorticoid receptor blocker
- nos, nitric oxide synthase
- nsaid, non-steroid anti-inflammatory drug
- ras, renin-angiotensin system
- sars-cov, severe acute respiratory syndrome coronavirus
- sh, spontaneously hypertensive
- s protein, spike protein
- sirt1, sirtuin 1
- t2dm, type 2 diabetes mellitus
- tcm, traditional chinese medicine
- tmprss2, transmembrane protease, serine 2
- tnf, tumor necrosis factor
- ufh, unfractionated heparin
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Affiliation(s)
- Murat Oz
- Department of Pharmacology and Therapeutics, Faculty of Pharmacy, Kuwait University, Safat 13110, Kuwait.
| | - Dietrich Ernst Lorke
- Department of Anatomy and Cellular Biology, College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, United Arab Emirates; Center for Biotechnology, Khalifa University of Science and Technology, Abu Dhabi, United Arab Emirates
| | - Nadine Kabbani
- School of Systems Biology, George Mason University, Fairfax, VA 22030, USA
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18
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Gault N, Esposito-Farèse M, Revest M, Inamo J, Cabié A, Polard É, Hulot JS, Ghosn J, Chirouze C, Deconinck L, Diehl JL, Poissy J, Epaulard O, Lefèvre B, Piroth L, De Montmollin E, Oziol E, Etienne M, Laouénan C, Rossignol P, Costagliola D, Vidal-Petiot E. Chronic use of renin-angiotensin-aldosterone system blockers and mortality in COVID-19: A multicenter prospective cohort and literature review. Fundam Clin Pharmacol 2021; 35:1141-1158. [PMID: 33876439 PMCID: PMC8250758 DOI: 10.1111/fcp.12683] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 03/22/2021] [Accepted: 04/14/2021] [Indexed: 01/09/2023]
Abstract
Aims The role of renin‐angiotensin‐aldosterone system (RAAS) blockers on the course of coronavirus disease 2019 (COVID‐19) is debated. We assessed the association between chronic use of RAAS blockers and mortality among inpatients with COVID‐19 and explored reasons for discrepancies in the literature. Methods and results We included adult hypertensive patients from a prospective nationwide cohort of 3512 inpatients with COVID‐19 up to June 30, 2020. Cox proportional hazard models with various adjustment or propensity weighting methods were used to estimate the hazard ratios (HR) of 30‐day mortality for chronic users versus non‐users of RAAS blockers. We analyzed data of 1160 hypertensive patients: 719 (62%) were male and 777 (67%) were older than 65 years. The main comorbidities were diabetes (n = 416, 36%), chronic cardiac disease (n = 401, 35%), and obesity (n = 340, 29%); 705 (61%) received oxygen therapy. We recorded 135 (11.6%) deaths within 30 days of diagnosis. We found no association between chronic use of RAAS blockers and mortality (unadjusted HR = 1.13, 95% CI [0.8–1.6]; propensity inverse probability treatment weighted HR = 1.09 [0.86‐1.39]; propensity standardized mortality ratio weighted HR = 1.08 [0.79–1.47]). Our comprehensive review of previous studies highlighted that significant associations were mostly found in unrestricted populations with inappropriate adjustment, or with biased in‐hospital exposure measurement. Conclusion Our results do not support previous concerns regarding these drugs, nor a potential protective effect as reported in previous poorly designed studies and meta‐analyses. RAAS blockers should not be discontinued during the pandemic, while in‐hospital management of these drugs will be clarified by randomized trials. NCT04262921.
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Affiliation(s)
- Nathalie Gault
- Centre d'Investigations cliniques-Epidémiologie Clinique 1425, INSERM, Hôpital Bichat, Paris, 75018, France.,Département Epidémiologie Biostatistiques et Recherche Clinique, AP-HP, Hôpital Bichat, Paris, 75018, France
| | - Marina Esposito-Farèse
- Centre d'Investigations cliniques-Epidémiologie Clinique 1425, INSERM, Hôpital Bichat, Paris, 75018, France.,URC Paris Nord, AP-HP DRCI, Hôpital Bichat, Paris, 75018, France
| | - Matthieu Revest
- Service des Maladies Infectieuses et Réanimation Médicale, Univ Rennes, INSERM UMR 1230, Bacterial Regulatory RNA and Medicine, CHU Rennes, Rennes, France
| | - Jocelyn Inamo
- Département de Cardiologie, EA7525, CHU Martinique, Fort-de-France, France
| | - André Cabié
- Inserm CIC 1424, Université des Antilles EA 7524, Service de maladies infectieuses et tropicales, CHU de Martinique, Fort-de-France, France
| | - Élisabeth Polard
- Department of Clinical Pharmacology, Pharmacovigilance, Pharmacoepidemiology and Drug Information Centre, Rennes University Hospital, Rennes, France
| | - Jean-Sébastien Hulot
- PARCC, INSERM, Université de Paris, Paris, 75015, France.,INSERM Centre d'Investigations cliniques-plurithématique 1418 and DMU CARTE, F-CRIN INI-CRCT network, AP-HP, Hôpital Européen Georges-Pompidou, Paris, 751015, France
| | - Jade Ghosn
- Service de Maladie Infectieuses et Tropicales, AP-HP, Hôpital Bichat, Paris, France
| | - Catherine Chirouze
- Service de Maladie Infectieuses et Tropicales, CHU Besançon, Besançon, France
| | - Laurène Deconinck
- Service de Maladie Infectieuses et Tropicales, AP-HP, Hôpital Bichat, Paris, France
| | - Jean-Luc Diehl
- Service de Médecine Intensive Réanimation, Laboratoire de Recherche Biochirurgicale (Fondation Carpentier), AP-HP, Hôpital Européen Georges-Pompidou, Paris, France.,UMR_S 1140, Innovations thérapeutiques en Hémostase, Université de Paris, INSERM, Paris, France
| | - Julien Poissy
- Inserm U1285, CHU Lille, Pôle de réanimation, UMR 8576 - UGSF - Unité de Glycobiologie Structurale et Fonctionnelle, Université de Lille, CNRS, Lille, France
| | - Olivier Epaulard
- Service de Maladies Infectieuses et Médecine Tropicale, CHU Grenoble Rhône Alpes, Grenoble, France
| | - Benjamin Lefèvre
- Service des Maladies Infectieuses et Tropicales, CHRU Nancy, Université de Lorraine, Nancy, France.,APEMAC, Université de Lorraine, Nancy, France
| | - Lionel Piroth
- Département d'infectiologie, Université de Bourgogne, CHU Dijon Bourgogne, Dijon, France
| | - Etienne De Montmollin
- Service de réanimation médicale et des maladies infectieuses, AP-HP, Hôpital Bichat, Paris, France.,IAME UMR 1137, INSERM, Université de Paris, Paris, France
| | - Eric Oziol
- Service de Médecine Hospitalière, CHU Beziers, Beziers, France
| | - Manuel Etienne
- Service des Maladies Infectieuses et Tropicales, CHU Rouen, Rouen, France
| | - Cédric Laouénan
- Centre d'Investigations cliniques-Epidémiologie Clinique 1425, INSERM, Hôpital Bichat, Paris, 75018, France.,Département Epidémiologie Biostatistiques et Recherche Clinique, AP-HP, Hôpital Bichat, Paris, 75018, France.,IAME UMR 1137, INSERM, Université de Paris, Paris, France
| | - Patrick Rossignol
- Centre d'Investigations cliniques-plurithématique 1433, INSERM U1116, CHRU Nancy, Université de Lorraine, INSERM, Nancy, France.,F-CRIN INI-CRCT network, Nancy, France
| | - Dominique Costagliola
- Institut Pierre Louis d'Épidémiologie et de Santé Publique (IPLESP), Sorbonne Université, INSERM, Paris, France
| | - Emmanuelle Vidal-Petiot
- Service de Physiologie rénale, AP-HP, Hôpital Bichat, Paris, France.,U1149, INSERM, Université de Paris, Paris, France
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19
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Naveed H, Elshafeey A, Al-Ali D, Janjua E, Nauman A, Kawas H, Kaul R, Saed Aldien A, Elshazly MB, Zakaria D. The Interplay Between the Immune System, the Renin-Angiotensin-Aldosterone System (RAAS), and RAAS Inhibitors May Modulate the Outcome of COVID-19: A Systematic Review. J Clin Pharmacol 2021; 61:987-1000. [PMID: 33635546 PMCID: PMC8014479 DOI: 10.1002/jcph.1852] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 02/22/2021] [Indexed: 01/18/2023]
Abstract
Since the discovery of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), numerous research has been undertaken to delineate the various effects of the virus which manifests in many ways all over the body. The association between the SARS-CoV-2 invasion mechanism and the renin-angiotensin-aldosterone system (RAAS) receptors, created many debates about the possible consequences of using RAAS-modulating drugs including angiotensin-converting enzyme inhibitors (ACEi) and angiotensin II receptor blockers (ARBs) during the pandemic. Many clinical studies were conducted to assess the outcomes of coronavirus disease 2019 (COVID-19) in patients who use ACEi/ARBs following the arguments claiming to discontinue these drugs as a precautionary measure. Although several studies mainly analyzed the outcomes of the disease, this review aimed to compare specific blood markers in both groups of COVID-19 patients to gain better insight into the interaction of ACEi/ARBs with different body functions during the infection. Several databases were searched using a combination of keywords followed by screening and data extraction. Only 28 studies met our inclusion criteria, the majority of which showed no significant difference between the inflammation markers of COVID-19 patients who used or did not use ACEi/ARBs. Interestingly, 6 studies reported lower inflammatory markers in COVID-19 patients who used ACEi/ARBs, and 6 studies reported better outcomes among the same group. We therefore concluded that the use of ACEi/ARBs may not lead to worse prognosis of COVID-19 and may even play a protective role against the hyperinflammatory response associated with COVID-19.
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Affiliation(s)
- Hiba Naveed
- Weill Cornell Medicine Qatar, Qatar Foundation, Education City, Doha, Qatar
| | - Abdallah Elshafeey
- Weill Cornell Medicine Qatar, Qatar Foundation, Education City, Doha, Qatar
| | - Dana Al-Ali
- Weill Cornell Medicine Qatar, Qatar Foundation, Education City, Doha, Qatar
| | - Emmad Janjua
- Weill Cornell Medicine Qatar, Qatar Foundation, Education City, Doha, Qatar
| | - Areej Nauman
- Weill Cornell Medicine Qatar, Qatar Foundation, Education City, Doha, Qatar
| | - Hussam Kawas
- Weill Cornell Medicine Qatar, Qatar Foundation, Education City, Doha, Qatar
| | - Ridhima Kaul
- Weill Cornell Medicine Qatar, Qatar Foundation, Education City, Doha, Qatar
| | - Arwa Saed Aldien
- Weill Cornell Medicine Qatar, Qatar Foundation, Education City, Doha, Qatar
| | - Mohamed B Elshazly
- Weill Cornell Medicine Qatar, Qatar Foundation, Education City, Doha, Qatar
| | - Dalia Zakaria
- Weill Cornell Medicine Qatar, Qatar Foundation, Education City, Doha, Qatar
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20
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Baral R, Tsampasian V, Debski M, Moran B, Garg P, Clark A, Vassiliou VS. Association Between Renin-Angiotensin-Aldosterone System Inhibitors and Clinical Outcomes in Patients With COVID-19: A Systematic Review and Meta-analysis. JAMA Netw Open 2021; 4:e213594. [PMID: 33787911 PMCID: PMC8013817 DOI: 10.1001/jamanetworkopen.2021.3594] [Citation(s) in RCA: 84] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
IMPORTANCE The chronic receipt of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) has been assumed to exacerbate complications associated with COVID-19 and produce worse clinical outcomes. OBJECTIVE To conduct an updated and comprehensive systematic review and meta-analysis comparing mortality and severe adverse events (AEs) associated with receipt vs nonreceipt of ACEIs or ARBs among patients with COVID-19. DATA SOURCES PubMed and Embase databases were systematically searched from December 31, 2019, until September 1, 2020. STUDY SELECTION The meta-analysis included any study design, with the exception of narrative reviews or opinion-based articles, in which COVID-19 was diagnosed through laboratory or radiological test results and in which clinical outcomes (unadjusted or adjusted) associated with COVID-19 were assessed among adult patients (≥18 years) receiving ACEIs or ARBs. DATA EXTRACTION AND SYNTHESIS Three authors independently extracted data on mortality and severe AEs associated with COVID-19. Severe AEs were defined as intensive care unit admission or the need for assisted ventilation. For each outcome, a random-effects model was used to compare the odds ratio (OR) between patients receiving ACEIs or ARBs vs those not receiving ACEIs or ARBs. MAIN OUTCOMES AND MEASURES Unadjusted and adjusted ORs for mortality and severe AEs associated with COVID-19. RESULTS A total of 1788 records from the PubMed and Embase databases were identified; after removal of duplicates, 1664 records were screened, and 71 articles underwent full-text evaluation. Clinical data were pooled from 52 eligible studies (40 cohort studies, 6 case series, 4 case-control studies, 1 randomized clinical trial, and 1 cross-sectional study) enrolling 101 949 total patients, of whom 26 545 (26.0%) were receiving ACEIs or ARBs. When adjusted for covariates, significant reductions in the risk of death (adjusted OR [aOR], 0.57; 95% CI, 0.43-0.76; P < .001) and severe AEs (aOR, 0.68; 95% CI, 0.53-0.88; P < .001) were found. Unadjusted and adjusted analyses of a subgroup of patients with hypertension indicated decreases in the risk of death (unadjusted OR, 0.66 [95% CI, 0.49-0.91]; P = .01; aOR, 0.51 [95% CI, 0.32-0.84]; P = .008) and severe AEs (unadjusted OR, 0.70 [95% CI, 0.54-0.91]; P = .007; aOR, 0.55 [95% CI, 0.36-0.85]; P = .007). CONCLUSIONS AND RELEVANCE In this systematic review and meta-analysis, receipt of ACEIs or ARBs was not associated with a higher risk of multivariable-adjusted mortality and severe AEs among patients with COVID-19 who had either hypertension or multiple comorbidities, supporting the recommendations of medical societies. On the contrary, ACEIs and ARBs may be associated with protective benefits, particularly among patients with hypertension. Future randomized clinical trials are warranted to establish causality.
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Affiliation(s)
- Ranu Baral
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, United Kingdom
- Department of Cardiology, Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Vasiliki Tsampasian
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - Maciej Debski
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - Brendan Moran
- National Health Service 111 COVID-19 Clinical Assessment Service, Bicester, United Kingdom
- Neasden Medical Centre, London, United Kingdom
- Healix International, Esher, United Kingdom
| | - Pankaj Garg
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, United Kingdom
- Department of Cardiology, Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Allan Clark
- Department of Medical Statistics, Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Vassilios S. Vassiliou
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, United Kingdom
- Department of Cardiology, Norwich Medical School, University of East Anglia, Norwich, United Kingdom
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21
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Zhong Y, Zhao L, Wu G, Hu C, Wu C, Xu M, Dong H, Zhang Q, Wang G, Yu B, Lv J, Wu C, Zhang S, Cao C, Shu L, Pan Y, Liu X, Wu F. Impact of renin-angiotensin system inhibitors use on mortality in severe COVID-19 patients with hypertension: a retrospective observational study. J Int Med Res 2020; 48:300060520979151. [PMID: 33322988 PMCID: PMC7745588 DOI: 10.1177/0300060520979151] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 11/12/2020] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVE Association of angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) use with coronavirus disease 2019 (COVID-19) remains controversial. We aimed to investigate the impact of ACEI/ARB use on all-cause mortality in severe COVID-19 patients with hypertension. METHODS We enrolled 650 COVID-19 patients from Changsha and Wuhan city between 17 January 2020 and 8 March 2020. Demographic, clinical characteristics, and outcomes were collected. Multivariable analysis and propensity-score matching were performed to assess the impact of ACEI/ARB therapy on mortality. RESULTS Among the 650 patients, 126 who had severe COVID-19 concomitant with hypertension were analyzed. The average age was 66 years and 56 (44.4%) were men. There were 37 ACEI/ARB users and 21 in-hospital deaths (mortality rate, 16.7%). Male sex (odds ratio [OR], 5.13; 95% confidence interval [CI], 1.75 to 17.8), but not ACEI/ARB use (OR, 1.09; 95%CI, 0.31 to 3.43), was an independent risk factor for mortality in severe COVID-19 patients with hypertension. After propensity-score matching, 60 severe COVID-19 patients were included and no significant correlation between use of ACEI/ARB and mortality was observed. CONCLUSIONS There was no significant association of ACEI/ARB use with mortality in severe COVID-19 patients with hypertension. These findings support the continuation of ACEI/ARB therapy for such patients.
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Affiliation(s)
- Yanjun Zhong
- Department of Critical Care Medicine, the Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Lishu Zhao
- Department of Oncology, the Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Guobao Wu
- Department of Critical Care Medicine, the Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Chunhong Hu
- Department of Oncology, the Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Chenfang Wu
- Department of Critical Care Medicine, the Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Min Xu
- Department of Critical Care Medicine, the Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Haiyun Dong
- Department of Critical Care Medicine, the Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Quan Zhang
- Department of Critical Care Medicine, the First Hospital of Changsha, Hunan, China
| | - Guyi Wang
- Department of Critical Care Medicine, the Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Bo Yu
- Department of Critical Care Medicine, the Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Jianlei Lv
- Department of Critical Care Medicine, the First Hospital of Changsha, Hunan, China
| | - Chao Wu
- Department of Metabolism & Endocrinology, the Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Key Laboratory of Diabetes Immunology (Central South University), Ministry of Education; National Clinical Research Center for Metabolic Diseases, Changsha, Hunan, China
| | - Siye Zhang
- Department of Critical Care Medicine, the Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Chenghui Cao
- Xiangya School of Medicine, Central South University, Changsha, Hunan, China
| | - Long Shu
- Department of Oncology, the Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yue Pan
- Department of Oncology, the Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Xianling Liu
- Department of Oncology, the Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Fang Wu
- Department of Oncology, the Second Xiangya Hospital, Central South University, Changsha, Hunan, China
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22
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Hasan SS, Kow CS, Hadi MA, Zaidi STR, Merchant HA. Mortality and Disease Severity Among COVID-19 Patients Receiving Renin-Angiotensin System Inhibitors: A Systematic Review and Meta-analysis. Am J Cardiovasc Drugs 2020; 20:571-590. [PMID: 32918209 PMCID: PMC7486167 DOI: 10.1007/s40256-020-00439-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The use of renin-angiotensin system (RAS) inhibitors, including angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), was alleged to cause a more severe course of novel coronavirus disease 2019 (COVID-19). METHODS We systematically reviewed the published studies to assess the association of RAS inhibitors with mortality as well as disease severity in COVID-19 patients. A systematic literature search was performed to retrieve relevant original studies investigating mortality and severity (severe/critical disease) in COVID-19 patients with and without exposure to RAS inhibitors. RESULTS A total of 59 original studies were included for qualitative synthesis. Twenty-four studies that reported adjusted effect sizes (24 studies reported mortality outcomes and 16 studies reported disease severity outcomes), conducted in RAS inhibitor-exposed and unexposed groups, were pooled in random-effects models to estimate overall risk. Quality assessment of studies revealed that most of the studies included were of fair quality. The use of an ACEI/ARB in COVID-19 patients was significantly associated with lower odds (odds ratio [OR] = 0.73, 95% confidence interval [CI] 0.56-0.95; n = 18,749) or hazard (hazard ratio [HR] = 0.75, 95% CI 0.60-0.95; n = 26,598) of mortality compared with non-use of ACEI/ARB. However, the use of an ACEI/ARB was non-significantly associated with lower odds (OR = 0.91, 95% CI 0.75-1.10; n = 7446) or hazard (HR = 0.73, 95% CI 0.33-1.66; n = 6325) of developing severe/critical disease compared with non-use of an ACEI/ARB. DISCUSSION Since there was no increased risk of harm, the use of RAS inhibitors for hypertension and other established clinical indications can be maintained in COVID-19 patients.
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Affiliation(s)
- Syed Shahzad Hasan
- Department of Pharmacy, University of Huddersfield, Huddersfield, HD1 3DH, UK.
| | - Chia Siang Kow
- School of Postgraduate Studies, International Medical University, Kuala Lumpur, 57000, Malaysia
| | - Muhammad Abdul Hadi
- Institute of Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Syed Tabish Razi Zaidi
- School of Healthcare, University of Leeds, Leeds, LS2 9JT, UK
- Leeds Teaching Hospitals NHS Trust, Leeds, LS2 9JT, UK
| | - Hamid A Merchant
- Department of Pharmacy, University of Huddersfield, Huddersfield, HD1 3DH, UK
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23
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Chen C, Wang F, Chen P, Jiang J, Cui G, Zhou N, Moroni F, Moslehi JJ, Ammirati E, Wang DW. Mortality and Pre-Hospitalization use of Renin-Angiotensin System Inhibitors in Hypertensive COVID-19 Patients. J Am Heart Assoc 2020; 9:e017736. [PMID: 32807002 PMCID: PMC7763411 DOI: 10.1161/jaha.120.017736] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background There has been significant controversy regarding the effects of pre‐hospitalization use of renin‐angiotensin system (RAS) inhibitors on the prognosis of hypertensive COVID‐19 patients. Methods and Results We retrospectively assessed 2,297 hospitalized COVID‐19 patients at Tongji Hospital in Wuhan, China, from January 10th to March 30th, 2020; and identified 1,182 patients with known hypertension on pre‐hospitalization therapy. We compared the baseline characteristics and in‐hospital mortality between hypertensive patients taking RAS inhibitors (N=355) versus non‐RAS inhibitors (N=827). Of the 1,182 hypertensive patients (median age 68 years, 49.1% male), 12/355 (3.4%) patients died in the RAS inhibitors group vs. 95/827 (11.5%) patients in the non‐RAS inhibitors group (p<0.0001). Adjusted hazard ratio for mortality was 0.28 (95% CI 0.15‐0.52, p<0.0001) at 45 days in the RAS inhibitors group compared with non‐RAS inhibitors group. Similar findings were observed when patients taking angiotensin receptor blockers (N=289) or angiotensin converting enzyme inhibitors (N=66) were separately compared with non‐RAS inhibitors group. The RAS inhibitors group compared with non‐RAS inhibitors group had lower levels of C‐reactive protein (median 13.5 vs. 24.4 pg/mL; p=0.007) and interleukin‐6 (median 6.0 vs. 8.5 pg/mL; p=0.026) on admission. The protective effect of RAS inhibitors on mortality was confirmed in a meta‐analysis of published data when our data were added to previous studies (odd ratio 0.44, 95% CI 0.29–0.65, p<0.0001). Conclusions In a large single center retrospective analysis we observed a protective effect of pre‐hospitalization use of RAS inhibitors on mortality in hypertensive COVID‐19 patients; which might be associated with reduced inflammatory response.
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Affiliation(s)
- Chen Chen
- Division of CardiologyDepartment of Internal Medicine and Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders Tongji HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan China
| | - Feng Wang
- Division of CardiologyDepartment of Internal Medicine and Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders Tongji HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan China
| | - Peng Chen
- Division of CardiologyDepartment of Internal Medicine and Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders Tongji HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan China
| | - Jiangang Jiang
- Division of CardiologyDepartment of Internal Medicine and Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders Tongji HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan China
| | - Guanglin Cui
- Division of CardiologyDepartment of Internal Medicine and Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders Tongji HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan China
| | - Ning Zhou
- Division of CardiologyDepartment of Internal Medicine and Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders Tongji HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan China
| | | | - Javid J Moslehi
- Cardio-Oncology ProgramDepartment of MedicineVanderbilt University Medical CenterNashville TN
| | - Enrico Ammirati
- De Gasperis Cardio Center and Transplant CenterASST Grande Ospedale Metropolitano NiguardaMilano Italy
| | - Dao Wen Wang
- Division of CardiologyDepartment of Internal Medicine and Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders Tongji HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan China
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