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Srinivasa S, Kaur S, Dharani A, Choi E, Kalidas A, Slater R, Mifflin S. Clinical Outcomes of Angiotensin Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers in COVID-19 Patients With Pre-existing Cardiac Comorbidities: A Literature Review. Cureus 2023; 15:e51244. [PMID: 38283421 PMCID: PMC10821793 DOI: 10.7759/cureus.51244] [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: 12/22/2023] [Indexed: 01/30/2024] Open
Abstract
The growing research regarding the implementation of angiotensin-converting enzyme-2 inhibitors (ACEi) and angiotensin receptor blockers (ARBs) in the treatment of COVID-19 in patients with pre-existing cardiac comorbidities has become a large topic of discussion since the onset of the pandemic. Previous research primarily associates positive outcomes to the use of these drug classes due to their mechanism of action, which involves the downregulation of angiotensin I-converting enzyme 2 (ACE2) in the renin-angiotensin-aldosterone-system (RAAS) pathway, inflammatory mediators, and cytokines. Thus, these medications can convey preventative and protective effects in patients suffering from a SARS-CoV-2 infection. While we explored the studies that supported the positive outcomes of the use of these drugs in the first half of this review, we also expanded on the limitations of these studies in the latter portion. We also further explored the contradictory studies that indicated that using these antihypertensives can paradoxically increase the severity of COVID-19 infection as well. The studies in support of the use of these medications should consider epigenetic variations, ACE2 variants and acknowledge inherent genetic variations in certain ethnic groups as some have a predisposition for a severe COVID-19 infection. Additionally, mortality rates need to be taken into consideration in these studies as they naturally differ throughout the trajectory of the COVID-19 pandemic. While some studies are in support of the use of these antihypertensives despite other studies suggesting otherwise, further research is needed to explore the long-term effects of these antihypertensives and observe whether they are truly beneficial or not in reducing the severity of COVID-19 infections.
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Affiliation(s)
- Sandhya Srinivasa
- Medicine, University of the Incarnate Word School of Osteopathic Medicine, San Antonio, USA
| | - Simran Kaur
- Medicine, University of the Incarnate Word School of Osteopathic Medicine, San Antonio, USA
| | - Anam Dharani
- Medicine, University of the Incarnate Word School of Osteopathic Medicine, San Antonio, USA
| | - Ellen Choi
- Medicine, University of the Incarnate Word School of Osteopathic Medicine, San Antonio, USA
| | - Amar Kalidas
- Medicine, University of the Incarnate Word School of Osteopathic Medicine, San Antonio, USA
| | - Robert Slater
- Integrative Medicine, University of the Incarnate Word School of Osteopathic Medicine, San Antonio, USA
| | - Steven Mifflin
- Research and Development, University of the Incarnate Word School of Osteopathic Medicine, San Antonio, USA
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Huang DQ, Ajmera V, Tomaszewski C, LaFree A, Bettencourt R, Thompson WK, Smith DM, Malhotra A, Mehta RL, Tolia V, Yin J, Insel PA, Leachman S, Jung J, Collier S, Richards L, Woods K, Amangurbanova M, Bhatt A, Zhang X, Penciu OM, Zarich S, Retta T, Harkins MS, Teixeira JP, Chinnock B, Utay NS, Lake JE, Loomba R. Ramipril for the Treatment of COVID-19: RAMIC, a Randomized, Double-Blind, Placebo-Controlled Clinical Trial. Adv Ther 2023; 40:4805-4816. [PMID: 37615850 PMCID: PMC10709987 DOI: 10.1007/s12325-023-02618-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 07/14/2023] [Indexed: 08/25/2023]
Abstract
INTRODUCTION Retrospective studies report that angiotensin-converting enzyme inhibitors (ACEIs) may reduce the severity of COVID-19, but prospective data on de novo treatment with ACEIs are limited. The RAMIC trial was a randomized, multicenter, placebo-controlled, double-blind, allocation-concealed clinical trial to examine the efficacy of de novo ramipril versus placebo for the treatment of COVID-19. METHODS Eligible participants were aged 18 years and older with a confirmed diagnosis of SARS-CoV-2 infection, recruited from urgent care clinics, emergency departments, and hospital inpatient wards at eight sites in the USA. Participants were randomly assigned to daily ramipril 2.5 mg or placebo orally in a 2:1 ratio, using permuted block randomization. Analyses were conducted on an intention-to-treat basis. The primary outcome was a composite of mortality, intensive care unit (ICU) admission, or invasive mechanical ventilation by day 14. RESULTS Between 27 May 2020 and 19 April 2021, a total of 114 participants (51% female) were randomized to ramipril (n = 79) or placebo (n = 35). The overall mean (± SD) age and BMI were 45 (± 15) years and 33 (± 8) kg/m2. Two participants in the ramipril group required ICU admission and one died, compared with none in the placebo group. There were no significant differences between ramipril and placebo in the primary endpoint (ICU admission, mechanical ventilation, or death) (3% versus 0%, p = 1.00) or adverse events (27% versus 29%, p = 0.82). The study was terminated early because of a low event rate and subsequent Emergency Use Authorization of therapies for COVID-19. CONCLUSION De novo ramipril was not different compared with placebo in improving or worsening clinical outcomes from COVID-19 but appeared safe in non-critically ill patients with COVID-19. TRIAL REGISTRATION Clinicaltrials.gov NCT04366050.
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Affiliation(s)
- Daniel Q Huang
- NAFLD Research Center, Division of Gastroenterology, University of California at San Diego, La Jolla, CA, USA
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Veeral Ajmera
- NAFLD Research Center, Division of Gastroenterology, University of California at San Diego, La Jolla, CA, USA
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Christian Tomaszewski
- Department of Emergency Medicine, University of California, San Diego and the El Centro Regional Medical Center, San Diego, CA, USA
| | - Andrew LaFree
- Department of Emergency Medicine, University of California, San Diego and the El Centro Regional Medical Center, San Diego, CA, USA
| | - Ricki Bettencourt
- NAFLD Research Center, Division of Gastroenterology, University of California at San Diego, La Jolla, CA, USA
| | - Wesley K Thompson
- Division of Biostatistics and Bioinformatics, Department of Family Medicine and Public Health, University of California San Diego, La Jolla, CA, USA
| | - Davey M Smith
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, CA, USA
- Veteran Affairs Medical Center, San Diego, CA, USA
| | - Atul Malhotra
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Ravindra L Mehta
- Division of Nephrology-Hypertension, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Vaishal Tolia
- Department of Emergency Medicine, University of California San Diego, La Jolla, CA, USA
| | - Jeffrey Yin
- Department of Pharmacy, University of California San Diego, La Jolla, CA, USA
| | - Paul A Insel
- Department of Pharmacology, University of California San Diego, La Jolla, CA, USA
- Division of Endocrinology and Metabolism, University of California San Diego, La Jolla, CA, USA
| | - Stone Leachman
- NAFLD Research Center, Division of Gastroenterology, University of California at San Diego, La Jolla, CA, USA
| | - Jinho Jung
- NAFLD Research Center, Division of Gastroenterology, University of California at San Diego, La Jolla, CA, USA
| | - Summer Collier
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Lisa Richards
- NAFLD Research Center, Division of Gastroenterology, University of California at San Diego, La Jolla, CA, USA
| | - Kristin Woods
- Clinical & Translational Research Institute, University of California, San Diego, La Jolla, CA, USA
| | - Maral Amangurbanova
- NAFLD Research Center, Division of Gastroenterology, University of California at San Diego, La Jolla, CA, USA
| | - Archana Bhatt
- Clinical & Translational Research Institute, University of California, San Diego, La Jolla, CA, USA
| | - Xinlian Zhang
- Division of Biostatistics and Bioinformatics, Herbert Wertheim School of Public Health, University of California San Diego, San Diego, CA, USA
| | | | - Stuart Zarich
- Section of Cardiovascular Medicine, Yale New Haven Health Bridgeport Hospital, Bridgeport, CT, USA
| | - Tamrat Retta
- Department of Internal Medicine, Howard University, Washington, DC, USA
| | - Michelle S Harkins
- Department of Internal Medicine, University of New Mexico, Albuquerque, NM, USA
| | - J Pedro Teixeira
- Department of Internal Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Brian Chinnock
- Department of Emergency Medicine, University of California San Francisco-Fresno Medical Education Program, Fresno, CA, USA
| | - Netanya S Utay
- Division of Infectious Diseases and Geographic Medicine, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jordan E Lake
- Division of Infectious Diseases, Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
| | - Rohit Loomba
- NAFLD Research Center, Division of Gastroenterology, University of California at San Diego, La Jolla, CA, USA.
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, CA, USA.
- Division of Epidemiology, Department of Family Medicine and Public Health, University of California at San Diego, San Diego, CA, USA.
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Chen Y, Cao B, Zhou Q, Liu Y, He Q, Zhao M. Bibliometric evaluation of 2020-2022 publications on COVID-19-related cardiovascular disease. Front Cardiovasc Med 2023; 9:1070336. [PMID: 36712251 PMCID: PMC9880207 DOI: 10.3389/fcvm.2022.1070336] [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: 10/14/2022] [Accepted: 12/23/2022] [Indexed: 01/15/2023] Open
Abstract
Objective This study aimed to investigate the international scientific output regarding the relationship between COVID-19 and cardiovascular diseases (CVDs) through a bibliometric analysis and explore research hotspots in this field. Methods We searched the Web of Science Core Collection for publications and used different types of software, such as R, CiteSpace, and VOSviewer, to analyze and visualize the data. Results A total of 10,055 publications were retrieved as of the 13 December 2022, based on the inclusion criteria after screening. The USA and China lead in the quantity and quality of publications in this field. Based on Bradford's law, 63 journals were considered core journals in the field. Co-cited references and keywords analysis indicated that researchers paid particular attention to cardiovascular comorbidities, outcomes, and COVID-19 regenerative medicine. In summary, with increasing COVID-19 research related to CVD, more attention might be drawn to the relationship between these two diseases. Conclusion The hotspots in this field may continue to revolve around cardiovascular comorbidities, outcomes, and COVID-19 regenerative medicine. Owing to the different situations faced by different groups with COVID-19, further exploration of the related factors specific to each of these groups, e.g., history or no history of heart failure, is needed, with a view to providing a reference for intervention measures in COVID-19 research.
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Affiliation(s)
- Yiru Chen
- Department of Pediatrics, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China,Xiangya School of Medicine, Central South University, Changsha, China
| | - Buzi Cao
- Department of Pediatrics, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China,Medical School, Hunan Normal University, Changsha, China
| | - Quan Zhou
- Department of Pediatrics, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China,Xiangya School of Medicine, Central South University, Changsha, China
| | - Yantong Liu
- Department of Pediatrics, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China,Xiangya School of Medicine, Central South University, Changsha, China
| | - Qingnan He
- Department of Pediatrics, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China,*Correspondence: Qingnan He ✉
| | - Mingyi Zhao
- Department of Pediatrics, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China,Mingyi Zhao ✉
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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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [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 Sciences Uppsala University Uppsala Sweden.,Inserm U1300 - HP2 CHU Grenoble Alpes Grenoble France
| | - Frances C Taylor
- Baker Heart and Diabetes Institute Melbourne Victoria Australia.,Mary MacKillop Institute for Health Research, Australian Catholic University Melbourne Victoria Australia
| | - Erik Lampa
- Department of Medical Sciences Uppsala University Uppsala Sweden
| | - Johan Sundström
- Department of Medical Sciences Uppsala University Uppsala Sweden.,The George Institute for Global Health University of New South Wales Sydney Australia
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A multicenter evaluation of computable phenotyping approaches for SARS-CoV-2 infection and COVID-19 hospitalizations. NPJ Digit Med 2022; 5:27. [PMID: 35260762 PMCID: PMC8904579 DOI: 10.1038/s41746-022-00570-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 02/04/2022] [Indexed: 01/20/2023] Open
Abstract
Diagnosis codes are used to study SARS-CoV2 infections and COVID-19 hospitalizations in administrative and electronic health record (EHR) data. Using EHR data (April 2020–March 2021) at the Yale-New Haven Health System and the three hospital systems of the Mayo Clinic, computable phenotype definitions based on ICD-10 diagnosis of COVID-19 (U07.1) were evaluated against positive SARS-CoV-2 PCR or antigen tests. We included 69,423 patients at Yale and 75,748 at Mayo Clinic with either a diagnosis code or a positive SARS-CoV-2 test. The precision and recall of a COVID-19 diagnosis for a positive test were 68.8% and 83.3%, respectively, at Yale, with higher precision (95%) and lower recall (63.5%) at Mayo Clinic, varying between 59.2% in Rochester to 97.3% in Arizona. For hospitalizations with a principal COVID-19 diagnosis, 94.8% at Yale and 80.5% at Mayo Clinic had an associated positive laboratory test, with secondary diagnosis of COVID-19 identifying additional patients. These patients had a twofold higher inhospital mortality than based on principal diagnosis. Standardization of coding practices is needed before the use of diagnosis codes in clinical research and epidemiological surveillance of COVID-19.
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6
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Understanding the role of nACE2 in neurogenic hypertension among COVID-19 patients. Hypertens Res 2022; 45:254-269. [PMID: 34848886 PMCID: PMC8630198 DOI: 10.1038/s41440-021-00800-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 09/20/2021] [Accepted: 10/15/2021] [Indexed: 12/15/2022]
Abstract
Currently, the third and fourth waves of the coronavirus disease -19 (COVID-19) pandemic are creating havoc in many parts of the world. Although vaccination programs have been launched in most countries, emerging new strains of the virus along with geographical variations are leading to varying success rates of the available vaccines. The presence of comorbidities such as diabetes, cardiovascular diseases and hypertension is responsible for increasing the severity of COVID-19 and, thus, the COVID-19 mortality rate. Angiotensin-converting enzyme 2 (ACE2), which is utilized by SARS-CoV-2 for entry into host cells, is widely expressed in the lungs, kidneys, testes, gut, adipose tissue, and brain. Infection within host cells mediates RAS overactivation, which leads to a decrease in the ACE2/ACE ratio, AT2R/AT1R ratio, and MasR/AT1R ratio. Such imbalances lead to the development of heightened inflammatory responses, such as cytokine storms, leading to post-COVID-19 complications and mortality. As the association of SARS-CoV-2 infection and hypertension remains unclear, this report provides an overview of the effects of SARS-CoV-2 infection on patients with hypertension. We discuss here the interaction of ACE2 with SARS-CoV-2, focusing on neuronal ACE2 (nACE2), and further shed light on the possible involvement of nACE2 in hypertension. SARS-CoV-2 enters the brain through neuronal ACE2 and spreads in various regions of the brain. The effect of viral binding to neuronal ACE2 in areas of the brain that regulate salt/water balance and blood pressure is also discussed in light of the neural regulation of hypertension in COVID-19.
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Cracowski JL, Hulot JS, Laporte S, Charvériat M, Roustit M, Deplanque D, Girodet PO. Clinical pharmacology: Current innovations and future challenges. Fundam Clin Pharmacol 2021; 36:456-467. [PMID: 34954839 DOI: 10.1111/fcp.12747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 11/08/2021] [Accepted: 12/18/2021] [Indexed: 11/28/2022]
Abstract
Clinical pharmacology is the study of drugs in humans, from first-in-human studies to randomized controlled trials (RCTs) and benefit-risk ratio assessment in large populations. The objective of this review is to present the recent innovations that may revolutionize the development of drugs in the future. On behalf of the French Society of Pharmacology and Therapeutics, we provide recommendations to address those future challenges in clinical pharmacology. Whatever the future will be, robust preliminary data on drug mechanism of action and rigorous study design will remain crucial prior to the start of pharmacological studies in human. At the present time, RCTs remains the gold standard to evaluate the efficacy of human drugs, although alternative designs (pragmatic trials, platform trials, etc.) are emerging. Innovations in healthy volunteers' studies and the contribution of new technologies such as artificial intelligence, machine learning and internet-based trials have the potential to improve drug development. In the field of precision medicine, new disease phenotypes and endotypes will probably help to identify new pharmacological targets, responders to therapies and patients at risk for drug adverse events. In such a moving landscape, the development of translational research through academic and private partnership, transparent sharing of clinical trial data and enhanced interactions between drug experts, patients and the general public are priority areas for action.
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Affiliation(s)
- Jean-Luc Cracowski
- Univ. Grenoble Alpes, U1042, INSERM, Grenoble, France.,CHU de Grenoble, Service de Pharmacologie - Pharmacosurveillance, CIC1406, Centre Régional de Pharmacovigilance, Grenoble, France
| | - Jean-Sébastien Hulot
- Université de Paris, INSERM, PARCC, Paris, France.,CIC1418 and DMU CARTE, AP-HP, Hôpital Européen Georges-Pompidou, Paris, France
| | - Silvy Laporte
- Univ. Jean-Monnet, Saint-Etienne, UMR1059, Saint-Etienne, France.,CHU de Saint-Etienne, Unité de recherche clinique, Innovation et pharmacologie, Saint-Etienne, France
| | | | - Matthieu Roustit
- Univ. Grenoble Alpes, U1042, INSERM, Grenoble, France.,CHU de Grenoble, Service de Pharmacologie - Pharmacosurveillance, CIC1406, Centre Régional de Pharmacovigilance, Grenoble, France
| | - Dominique Deplanque
- Univ. Lille, Inserm, CHU Lille, U1172 - Degenerative & vascular cognitive disorders, Lille, France.,Univ. Lille, Inserm, CHU Lille, CIC 1403 - Clinical Investigation Center, Lille, France
| | - Pierre-Olivier Girodet
- Univ. Bordeaux, CIC1401, U1045, INSERM, Bordeaux, France.,CHU de Bordeaux, CIC1401, Service de Pharmacologie Médicale, Bordeaux, France
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8
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Rizk JG, Wenziger C, Tran D, Hashemi L, Moradi H, Streja E, Ahluwalia A. Angiotensin-Converting Enzyme Inhibitor and Angiotensin Receptor Blocker Use Associated with Reduced Mortality and Other Disease Outcomes in US Veterans with COVID-19. Drugs 2021; 82:43-54. [PMID: 34914085 PMCID: PMC8675115 DOI: 10.1007/s40265-021-01639-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2021] [Indexed: 12/29/2022]
Abstract
Objective To determine the association between angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) use and coronavirus disease 2019 (COVID-19) severity and outcomes in US veterans. Patients and Methods We retrospectively examined 27,556 adult US veterans who tested positive for COVID-19 between March to November 2020. Logistic regression and Cox proportional hazards models using propensity score (PS) for weight, adjustment, and matching were used to examine the odds of an event within 60 days following a COVID-19–positive case date and time to death, respectively, according to ACEI and/or ARB prescription within 6 months prior to the COVID-19–positive case date. Results The overlap PS weighted logistic regression model showed lower odds of an intensive care unit (ICU) admission (odds ratio [OR] 95% CI 0.77, 0.61–0.98) and death within 60 days (0.87, 0.79–0.97) with an ACEI or ARB prescription. Veterans with an ARB-only prescription also had lower odds of an ICU admission (0.64, 0.44–0.92). The overlap PS weighted model similarly showed a lower risk of time to all-cause mortality in veterans with an ACEI or ARB prescription (HR [95% CI]: 0.87, 0.79–0.97) and an ARB only prescription (0.78, 0.67–0.91). Veterans with an ACEI prescription had higher odds of experiencing a septic event within 60 days after the COVID-19–positive case date (1.22, 1.02–1.46). Conclusion In this study of a national cohort of US veterans, we found that the use of an ACEI/ARB in patients with COVID-19 was not associated with increased mortality and other worse outcomes. Future studies should examine underlying pathways and further confirm the relationship of ACEI prescription with sepsis. Supplementary Information The online version contains supplementary material available at 10.1007/s40265-021-01639-2.
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Affiliation(s)
- John G Rizk
- Arizona State University, Edson College, Phoenix, AZ, USA.,Department of Pharmaceutical Health Services Research, University of Maryland, Baltimore, MD, USA
| | - Cachet Wenziger
- Research, Tibor Rubin VA Medical Center, VA Long Beach Healthcare System, 5901 East 7th Street, Long Beach, CA, 90822, USA.,Division of Nephrology and Hypertension, Harold Simmons Center for Kidney Disease Research and Epidemiology, School of Medicine, University of California Irvine, Orange, CA, USA
| | - Diana Tran
- Research, Tibor Rubin VA Medical Center, VA Long Beach Healthcare System, 5901 East 7th Street, Long Beach, CA, 90822, USA.,Division of Nephrology and Hypertension, Harold Simmons Center for Kidney Disease Research and Epidemiology, School of Medicine, University of California Irvine, Orange, CA, USA
| | - Leila Hashemi
- Greater Los Angeles VA Medical Center, Los Angeles, CA, USA.,UCLA Geffen School of Medicine, Los Angeles, CA, USA
| | - Hamid Moradi
- Research, Tibor Rubin VA Medical Center, VA Long Beach Healthcare System, 5901 East 7th Street, Long Beach, CA, 90822, USA.,Division of Nephrology and Hypertension, Harold Simmons Center for Kidney Disease Research and Epidemiology, School of Medicine, University of California Irvine, Orange, CA, USA
| | - Elani Streja
- Research, Tibor Rubin VA Medical Center, VA Long Beach Healthcare System, 5901 East 7th Street, Long Beach, CA, 90822, USA. .,Division of Nephrology and Hypertension, Harold Simmons Center for Kidney Disease Research and Epidemiology, School of Medicine, University of California Irvine, Orange, CA, USA.
| | - Amrita Ahluwalia
- Research, Tibor Rubin VA Medical Center, VA Long Beach Healthcare System, 5901 East 7th Street, Long Beach, CA, 90822, USA.
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Ortiz-Prado E, Fernandez Naranjo RP, Vasconez E, Simbaña-Rivera K, Correa-Sancho T, Lister A, Calvopiña M, Viscor G. Analysis of Excess Mortality Data at Different Altitudes During the COVID-19 Outbreak in Ecuador. High Alt Med Biol 2021; 22:406-416. [PMID: 34905395 DOI: 10.1089/ham.2021.0070] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Ortiz-Prado, Esteban, Raul Patricio Fernandez Naranjo, Eduardo Vasconez, Katherine Simbaña-Rivera, Trigomar Correa-Sancho, Alex Lister, Manuel Calvopiña, and Ginés Viscor. Analysis of excess mortality data at different altitudes during the COVID-19 outbreak in Ecuador. High Alt Med Biol. 22:406-416, 2021. Background: It has been speculated that living at high altitude confers some risk reduction in terms of SARS-CoV-2 infection, reduced transmissibility, and arguable lower COVID-19-related mortality. Objective: We aim to determine the number of excess deaths reported in Ecuador during the first year of the COVID-19 pandemic in relation to different altitude categories among 221 cantons in Ecuador, ranging from sea level to 4,300 m above. Methods: A descriptive ecological country-wide analysis of the excess mortality in Ecuador was performed since March 1, 2020, to March 1, 2021. Every canton was categorized as lower (for altitudes 2,500 m or less) or higher (for altitudes >2,500 m) in a first broad classification, as well as in two different classifications: The one proposed by Imray et al. in 2011 (low altitude <1,500 m, moderate altitude 1,500-2,500 m, high altitude 2,500-3,500 m, or very high altitude 3,500-5,500 m) and the one proposed by Bärtsch et al. in 2008 (near sea level 0-500 m, low altitude 500-2,000 m, moderate altitude 2,000-3,000 m, high altitude 3,000-5,500 m, and extreme altitude 5,500 m). A Poisson fitting analysis was used to identify trends on officially recorded all-caused deaths and those attributed to COVID-19. Results: In Ecuador, at least 120,573 deaths were recorded during the first year of the pandemic, from which 42,453 were catalogued as excessive when compared with the past 3 years of averages (2017-2019). The mortality rate at the lower altitude was 301/100,000 people, in comparison to 242/100,000 inhabitants in elevated cantons. Considering the four elevation categories, the highest excess deaths came from towns located at low altitude (324/100,000), in contrast to the moderate altitude (171/100,000), high-altitude (249/100,000), and very high-altitude (153/100,000) groups. Conclusions: This is the first report on COVID-19 excess mortality in a high-altitude range from 0 to 4,300 m above sea level. We found that absolute COVID-19-related excess mortality is lower both in time and in proportion in the cantons located at high and very high altitude when compared with those cantons located at low altitude.
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Affiliation(s)
- Esteban Ortiz-Prado
- One Health Research Group, Faculty of Medicine, Universidad de las Americas, Quito, Ecuador.,Department of Cell Biology, Physiology and Immunology of the Faculty of Biology, Universitat de Barcelona, Barcelona, Spain
| | | | - Eduardo Vasconez
- One Health Research Group, Faculty of Medicine, Universidad de las Americas, Quito, Ecuador
| | | | - Trigomar Correa-Sancho
- One Health Research Group, Faculty of Medicine, Universidad de las Americas, Quito, Ecuador
| | - Alex Lister
- University Hospital Southampton NHS FT, Southampton, United Kingdom
| | - Manuel Calvopiña
- One Health Research Group, Faculty of Medicine, Universidad de las Americas, Quito, Ecuador
| | - Ginés Viscor
- Department of Cell Biology, Physiology and Immunology of the Faculty of Biology, Universitat de Barcelona, Barcelona, Spain
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10
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Graham DJ, Izurieta HS, Muthuri SG, Zhang D, Sandhu AT, Lu Y, Zhao Y, Feng Y, Eworuke E, Lyu H, Gandotra C, Smith ER, Avagyan A, Wernecke M, Kelman JA, Forshee RA, MaCurdy TE. Risk of Covid-19-Related Hospitalization and More Severe Outcomes in Medicare Beneficiaries Treated with Renin-Angiotensin-Aldosterone System Inhibitors for Hypertension. J Gen Intern Med 2021; 36:3802-3809. [PMID: 34599472 PMCID: PMC8486159 DOI: 10.1007/s11606-021-07155-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 09/14/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND There are theoretical concerns that angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) could increase the risk of severe Covid-19. OBJECTIVE To determine if ACEIs and ARBs are associated with an increased risk of Covid-19 hospitalization overall, or hospitalization involving intensive care unit (ICU) admission, invasive mechanical ventilation, or death. DESIGN Observational case-control study. PARTICIPANTS Medicare beneficiaries aged ≥ 66 years with hypertension, treated with ACEIs, ARBs, calcium channel blockers (CCBs), or thiazide diuretics. MAIN MEASURES Adjusted odds ratios (OR) and 95% confidence intervals (CI) for the outcomes of Covid-19 hospitalization, or hospitalization involving ICU admission, invasive mechanical ventilation, or death. RESULTS A total of 35,300 cases of hospitalized Covid-19 were matched to 228,228 controls on calendar date and neighborhood of residence. The median age of cases was 79 years, 57.4% were female, and the median duration of hospitalization was 8 days (interquartile range 5-12). ACEIs and ARBs were associated with a slight reduction in Covid-19 hospitalization risk compared with treatment with other first-line antihypertensives (OR for ACEIs 0.95, 95% CI 0.92-0.98; OR for ARBs 0.94, 95% CI 0.90-0.97). Similar results were obtained for hospitalizations involving ICU admission, invasive mechanical ventilation, or death. There were no meaningful differences in risk for ACEIs compared with ARBs. In an analysis restricted to monotherapy with a first-line agent, CCBs were associated with a small increased risk of Covid-19 hospitalization compared with ACEIs (OR 1.09, 95% CI 1.04-1.14), ARBs (OR 1.10, 95% CI 1.05-1.15), or thiazide diuretics (OR 1.11, 95% CI 1.03-1.19). CONCLUSIONS ACEIs and ARBs were not associated with an increased risk of Covid-19 hospitalization or with hospitalization involving ICU admission, invasive mechanical ventilation, or death. The finding of a small increased risk of Covid-19 hospitalization with CCBs was unexpected and could be due to residual confounding.
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Affiliation(s)
- David J Graham
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, US Food and Drug Administration, 10903 New Hampshire Ave, Building 22, Room 4314, Silver Spring, MD, 20993, USA.
| | - Hector S Izurieta
- Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | | | - Di Zhang
- Office of Biostatistics, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Alexander T Sandhu
- Acumen LLC, Burlingame, CA, USA
- Division of Cardiology, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Yun Lu
- Office of Biostatistics and Epidemiology, Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Yueqin Zhao
- Office of Biostatistics, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | | | - Efe Eworuke
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, US Food and Drug Administration, 10903 New Hampshire Ave, Building 22, Room 4314, Silver Spring, MD, 20993, USA
| | - Hai Lyu
- Acumen LLC, Burlingame, CA, USA
| | - Charu Gandotra
- Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | | | | | | | | | - Richard A Forshee
- Office of Biostatistics and Epidemiology, Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Thomas E MaCurdy
- Acumen LLC, Burlingame, CA, USA
- Department of Economics, Stanford University, Stanford, CA, USA
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11
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Khan M, Singh GK, Abrar S, Ganeshan R, Morgan K, Harky A. Pharmacotherapeutic agents for the management of COVID-19 patients with preexisting cardiovascular disease. Expert Opin Pharmacother 2021; 22:2455-2474. [PMID: 34464223 PMCID: PMC8425433 DOI: 10.1080/14656566.2021.1960311] [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: 03/08/2021] [Accepted: 07/22/2021] [Indexed: 12/15/2022]
Abstract
INTRODUCTION The coronavirus disease 2019 (COVID-19) pandemic is the largest public health challenge of the twenty-first century. While COVID-19 primarily affects the respiratory system, manifesting as interstitial pneumonitis and severe acute respiratory distress syndrome (ARDS), it also has implications for the cardiovascular system. Moreover, those admitted to hospital with severe COVID-19 are more likely to have cardiovascular comorbidities such as hypertension and diabetes mellitus. The underlying pathophysiology of why COVID-19 onset can further decline cardiac pathologies as well as trigger acute onset of new cardiac complications is not yet well understood. AREAS COVERED In this review, the authors extensively review literature focused on the current understanding and approaches of managing patients who have underlying cardiovascular diseases and concomitant COVID-19 infection. Furthermore, the authors explore the possible cardiovascular implications of the suggested COVID-19 therapeutic agents that are used to treat this lethal disease. EXPERT OPINION Current evidence is evolving around the many trialed pharmacotherapeutic considerations for the management of coronavirus disease 2019 (COVID-19) in patients with cardiovascular disease. While we await such data, clinicians should advocate for careful consideration of all concomitant medications for those presenting with COVID-19 on a patient-by-patient basis.
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Affiliation(s)
- Maryam Khan
- School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
| | | | - Sakina Abrar
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | - Kara Morgan
- Department of Cardiology, Manchester Royal Infirmary, Manchester, UK
- Division of Pharmacy & Optometry, School of Health Sciences, Faculty of Biology, Medicine & Health, The University of Manchester, Manchester, UK
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest, Liverpool, UK
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12
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Ventura D, Carr AL, Davis RD, Silvestry S, Bogar L, Raval N, Gries C, Hayes JE, Oliveira E, Sniffen J, Allison SL, Herrera V, Jennings DL, Page RL, McDyer JF, Ensor CR. Renin Angiotensin Aldosterone System Antagonism in 2019 Novel Coronavirus Acute Lung Injury. Open Forum Infect Dis 2021; 8:ofab170. [PMID: 34642634 PMCID: PMC8083494 DOI: 10.1093/ofid/ofab170] [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: 12/17/2020] [Accepted: 03/31/2021] [Indexed: 01/08/2023] Open
Abstract
It has been established that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) uses angiotensin-converting enzyme 2 (ACE2), a membrane-bound regulatory peptide, for host cell entry. Renin-angiotensin-aldosterone system (RAAS) inhibitors have been reported to increase ACE2 in type 2 pneumocyte pulmonary tissue. Controversy exists for the continuation of ACE inhibitors, angiotensin II receptor blockers, and mineralocorticoid receptor antagonists in the current pandemic. ACE2 serves as a regulatory enzyme in maintaining homeostasis between proinflammatory angiotensin II and anti-inflammatory angiotensin 1,7 peptides. Derangements in these peptides are associated with cardiovascular disease and are implicated in the progression of acute respiratory distress syndrome. Augmentation of the ACE2/Ang 1,7 axis represents a critical target in the supportive management of coronavirus disease 2019–associated lung disease. Observational data describing the use of RAAS inhibitors in the setting of SARS-CoV-2 have not borne signals of harm to date. However, equipoise persists, requiring an analysis of novel agents including recombinant human-ACE2 and existing RAAS inhibitors while balancing ongoing controversies associated with increased coronavirus infectivity and virulence.
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Affiliation(s)
- Davide Ventura
- University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - Amy L Carr
- University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - R Duane Davis
- AdventHealth Transplant Institute, Orlando, Florida, USA
| | | | - Linda Bogar
- AdventHealth Transplant Institute, Orlando, Florida, USA
| | - Nirav Raval
- AdventHealth Transplant Institute, Orlando, Florida, USA
| | - Cynthia Gries
- AdventHealth Transplant Institute, Orlando, Florida, USA
| | - Jillian E Hayes
- Department of Pharmacy, AdventHealth Orlando, Orlando, Florida, USA.,University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - Eduardo Oliveira
- Department of Critical Care Medicine, AdventHealth Medical Group, Orlando, Florida, USA
| | - Jason Sniffen
- Infectious Diseases Consultants, Orlando, Florida, USA
| | - Steven L Allison
- Department of Pharmacy, AdventHealth Orlando, Orlando, Florida, USA.,University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - Victor Herrera
- Division of Infectious Diseases, Department of Internal Medicine, AdventHealth, Orlando, Florida, USA
| | - Douglas L Jennings
- Long Island University College of Pharmacy, Brooklyn, New York, USA.,Department of Pharmacy, Columbia University Medical Center, New York, New York, USA
| | - Robert L Page
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Anschutz Medical Campus, Aurora, Colorado, USA
| | - John F McDyer
- Department of Pulmonary Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Christopher R Ensor
- Department of Pharmacy, AdventHealth Orlando, Orlando, Florida, USA.,University of Florida College of Pharmacy, Gainesville, Florida, USA
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13
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Sandhu AT, Kohsaka S, Lin S, Woo CY, Goldstein MK, Heidenreich PA. Renin-angiotensin-aldosterone system inhibitors and SARS-CoV-2 infection: an analysis from the veteran's affairs healthcare system. Am Heart J 2021; 240:46-57. [PMID: 34126079 PMCID: PMC8196226 DOI: 10.1016/j.ahj.2021.06.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 06/07/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) are known to impact the functional receptor for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The association between chronic therapy with these medications and infection risk remains unclear. OBJECTIVES The objective was to determine the association between prior ACEI or ARB therapy and SARS-CoV-2 infection among patients with hypertension in the U.S. Veteran's Affairs health system. METHODS We compared the odds of SARS-CoV-2 infection among three groups: patients treated with ACEI, treated with ARB, or treated with alternate first-line anti-hypertensives without ACEI/ARB. We excluded patients with alternate indications for ACEI or ARB therapy. We performed an augmented inverse propensity weighted analysis with adjustment for demographics, region, comorbidities, vitals, and laboratory values. RESULTS Among 1,724,723 patients with treated hypertension, 659,180 were treated with ACEI, 310,651 with ARB, and 754,892 with neither. Before weighting, patients treated with ACEI or ARB were more likely to be diabetic and use more anti-hypertensives. There were 13,278 SARS-CoV-2 infections (0.8%) between February 12, 2020 and August 19, 2020. Patients treated with ACEI had lower odds of SARS-CoV-2 infection (odds ratio [OR] 0.93; 95% CI: 0.89-0.97) while those treated with ARB had similar odds (OR 1.02; 95% CI: 0.96-1.07) compared with patients treated with alternate first-line anti-hypertensives without ACEI/ARB. In falsification analyses, patients on ACEI did not have a difference in their odds of unrelated outcomes. CONCLUSIONS Our results suggest the safety of continuing ACEI and ARB therapy. The association between ACEI therapy and lower odds of SARS-CoV-2 infection requires further investigation.
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Affiliation(s)
- Alexander T Sandhu
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA.
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Shoutzu Lin
- Medical Service, VA Palo Alto Health Care System, Palo Alto, CA
| | | | - Mary K Goldstein
- Medical Service, VA Palo Alto Health Care System, Palo Alto, CA; Center for Health Policy and Primary Care and Outcomes Research, Department of Medicine, Stanford, CA
| | - Paul A Heidenreich
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA; Medical Service, VA Palo Alto Health Care System, Palo Alto, CA
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14
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Li S, Sarangarajan R, Jun T, Kao YH, Wang Z, Hao K, Schadt E, Kiebish MA, Granger E, Narain NR, Chen R, Schadt EE, Li L. In-hospital use of ACE inhibitors/angiotensin receptor blockers associates with COVID-19 outcomes in African American patients. J Clin Invest 2021; 131:e151418. [PMID: 34411004 DOI: 10.1172/jci151418] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 08/18/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUNDThe angiotensin-converting enzyme (ACE) D allele is more prevalent among African Americans compared with other races and ethnicities and has previously been associated with severe coronavirus disease 2019 (COVID-19) pathogenesis through excessive ACE1 activity. ACE inhibitors/angiotensin receptor blockers (ACE-I/ARB) may counteract this mechanism, but their association with COVID-19 outcomes has not been specifically tested in the African American population.METHODSWe identified 6218 patients who were admitted into Mount Sinai hospitals with COVID-19 between February 24 and May 31, 2020, in New York City. We evaluated whether the outpatient and in-hospital use of ACE-I/ARB is associated with COVID-19 in-hospital mortality in an African American compared with non-African American population.RESULTSOf the 6218 patients with COVID-19, 1138 (18.3%) were ACE-I/ARB users. In a multivariate logistic regression model, ACE-I/ARB use was independently associated with a reduced risk of in-hospital mortality in the entire population (OR, 0.655; 95% CI, 0.505-0.850; P = 0.001), African American population (OR, 0.44; 95% CI, 0.249-0.779; P = 0.005), and non-African American population (OR, 0.748, 95% CI, 0.553-1.012, P = 0.06). In the African American population, in-hospital use of ACE-I/ARB was associated with improved mortality (OR, 0.378; 95% CI, 0.188-0.766; P = 0.006), whereas outpatient use was not (OR, 0.889; 95% CI, 0.375-2.158; P = 0.812). When analyzing each medication class separately, ARB in-hospital use was significantly associated with reduced in-hospital mortality in the African American population (OR, 0.196; 95% CI, 0.074-0.516; P = 0.001), whereas ACE-I use was not associated with impact on mortality in any population.CONCLUSIONIn-hospital use of ARB was associated with a significant reduction in in-hospital mortality among COVID-19-positive African American patients.FUNDINGNone.
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Affiliation(s)
| | | | - Tomi Jun
- Sema4, Stamford, Connecticut, USA
| | | | | | - Ke Hao
- Sema4, Stamford, Connecticut, USA
| | | | | | | | | | - Rong Chen
- Sema4, Stamford, Connecticut, USA.,Department of Genetics and Genomic Sciences, the Icahn Institute for Genomics and Multiscale Biology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Eric E Schadt
- Sema4, Stamford, Connecticut, USA.,Department of Genetics and Genomic Sciences, the Icahn Institute for Genomics and Multiscale Biology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Li Li
- Sema4, Stamford, Connecticut, USA.,Department of Genetics and Genomic Sciences, the Icahn Institute for Genomics and Multiscale Biology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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15
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Effects of the Na +/H + Ion Exchanger on Susceptibility to COVID-19 and the Course of the Disease. JOURNAL OF THE RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM : JRAAS 2021. [PMID: 34285709 DOI: 10.1155/2021/4754440.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The Na+/H+ ion exchanger (NHE) pumps Na+ inward the cell and H+ ion outside the cell. NHE activity increases in response to a decrease in intracellular pH, and it maintains intracellular pH in a narrow range. Patients with obesity, diabetes, and hypertension and the elderly are prone to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. The angiotensin II (Ang II) level is high in chronic diseases such as diabetes, hypertension, and obesity. Ang II is the main stimulator of NHE, and an increased Ang II level causes prolonged NHE activation in these patients. The long-term increase in NHE activity causes H+ ions to leave the cell in patients with diabetes, hypertension, and obesity. Increasing H+ ions outside the cell lead to an increase in oxidative stress and reactive oxygen species. H+ ion flows into the cell due to the increased oxidative stress. This vicious circle causes intracellular pH to drop. Although NHE is activated when intracellular pH decreases, there is prolonged NHE activation in chronic diseases such as aforementioned. Novel coronavirus disease 2019 (COVID-19) progression may be more severe and mortal in these patients. SARS-CoV-2 readily invades the cell at low intracellular pH and causes infection. The renin-angiotensin system and NHE play a vital role in regulating intracellular pH. The reduction of NHE activity or its prolonged activation may cause susceptibility to SARS-CoV-2 infection by lowering intracellular pH in patients with diabetes, hypertension, and obesity. Prolonged NHE activation in these patients with COVID-19 may worsen the course of the disease. Scientists continue to investigate the mechanism of the disease and the factors that affect its clinical progression.
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16
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Bezabih YM, Bezabih A, Alamneh E, Peterson GM, Bezabhe W. Comparison of renin-angiotensin-aldosterone system inhibitors with other antihypertensives in association with coronavirus disease-19 clinical outcomes. BMC Infect Dis 2021; 21:527. [PMID: 34090358 PMCID: PMC8178664 DOI: 10.1186/s12879-021-06088-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 04/20/2021] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Reports on the effects of renin-angiotensin-aldosterone system (RAAS) inhibitors on the clinical outcomes of coronavirus disease-19 (COVID-19) have been conflicting. We performed this meta-analysis to find conclusive evidence. METHODS We searched published articles through PubMed, EMBASE and medRxiv from 5 January 2020 to 3 August 2020. Studies that reported clinical outcomes of patients with COVID-19, stratified by the class of antihypertensives, were included. Random and fixed-effects models were used to estimate pooled odds ratio (OR). RESULTS A total 36 studies involving 30,795 patients with COVID-19 were included. The overall risk of poor patient outcomes (severe COVID-19 or death) was lower in patients taking RAAS inhibitors (OR = 0.79, 95% CI: [0.67, 0.95]) compared with those receiving non-RAAS inhibitor antihypertensives. However, further sub-meta-analysis showed that specific RAAS inhibitors did not show a reduction of poor COVID-19 outcomes when compared with any class of antihypertensive except beta-blockers (BBs). For example, compared to calcium channel blockers (CCBs), neither angiotensin-I-converting enzyme inhibitors (ACEIs) (OR = 0.91, 95% CI: [0.67, 1.23]) nor angiotensin-II receptor blockers (ARBs) (OR = 0.90, 95% CI: [0.62, 1.33]) showed a reduction of poor COVID-19 outcomes. When compared with BBs, however, both ACEIs (OR = 0.85, 95% CI: [0.73, 0.99) and ARBs (OR = 0.72, 95% CI: [0.55, 0.94]) showed an apparent decrease in poor COVID-19 outcomes. CONCLUSIONS RAAS inhibitors did not increase the risk of mortality or severity of COVID-19. Differences in COVID-19 clinical outcomes between different class of antihypertensive drugs were likely due to the underlying comorbidities for which the antihypertensive drugs were prescribed, although adverse effects of drugs such as BBs could not be excluded.
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Affiliation(s)
- Yihienew M. Bezabih
- Arsi University College of Health Sciences, Arsi University, P. O. Box, 04, Assela, Ethiopia
| | - Alemayehu Bezabih
- École Nationale Vétérinaire, Agroalimentaire et de L’alimentation, Nantes-Atlantique, BIOEPAR (UMR1300 INRA/ONIRIS), Atlanpole-Chantrerie CS-40706 44307, Nantes Cedex 3, France
| | - Endalkachew Alamneh
- School of Pharmacy and Pharmacology, University of Tasmania, Private Bag 26, Hobart, TAS 7001 Australia
| | - Gregory M. Peterson
- School of Pharmacy and Pharmacology, University of Tasmania, Private Bag 26, Hobart, TAS 7001 Australia
| | - Woldesellassie Bezabhe
- School of Pharmacy and Pharmacology, University of Tasmania, Private Bag 26, Hobart, TAS 7001 Australia
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17
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Khera R, Mortazavi BJ, Sangha V, Warner F, Young HP, Ross JS, Shah ND, Theel ES, Jenkinson WG, Knepper C, Wang K, Peaper D, Martinello RA, Brandt CA, Lin Z, Ko AI, Krumholz HM, Pollock BD, Schulz WL. Accuracy of Computable Phenotyping Approaches for SARS-CoV-2 Infection and COVID-19 Hospitalizations from the Electronic Health Record. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2021. [PMID: 34013299 PMCID: PMC8132274 DOI: 10.1101/2021.03.16.21253770] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Objective: Real-world data have been critical for rapid-knowledge generation throughout the COVID-19 pandemic. To ensure high-quality results are delivered to guide clinical decision making and the public health response, as well as characterize the response to interventions, it is essential to establish the accuracy of COVID-19 case definitions derived from administrative data to identify infections and hospitalizations. Methods: Electronic Health Record (EHR) data were obtained from the clinical data warehouse of the Yale New Haven Health System (Yale, primary site) and 3 hospital systems of the Mayo Clinic (validation site). Detailed characteristics on demographics, diagnoses, and laboratory results were obtained for all patients with either a positive SARS-CoV-2 PCR or antigen test or ICD-10 diagnosis of COVID-19 (U07.1) between April 1, 2020 and March 1, 2021. Various computable phenotype definitions were evaluated for their accuracy to identify SARS-CoV-2 infection and COVID-19 hospitalizations. Results: Of the 69,423 individuals with either a diagnosis code or a laboratory diagnosis of a SARS-CoV-2 infection at Yale, 61,023 had a principal or a secondary diagnosis code for COVID-19 and 50,355 had a positive SARS-CoV-2 test. Among those with a positive laboratory test, 38,506 (76.5%) and 3449 (6.8%) had a principal and secondary diagnosis code of COVID-19, respectively, while 8400 (16.7%) had no COVID-19 diagnosis. Moreover, of the 61,023 patients with a COVID-19 diagnosis code, 19,068 (31.2%) did not have a positive laboratory test for SARS-CoV-2 in the EHR. Of the 20 cases randomly sampled from this latter group for manual review, all had a COVID-19 diagnosis code related to asymptomatic testing with negative subsequent test results. The positive predictive value (precision) and sensitivity (recall) of a COVID-19 diagnosis in the medical record for a documented positive SARS-CoV-2 test were 68.8% and 83.3%, respectively. Among 5,109 patients who were hospitalized with a principal diagnosis of COVID-19, 4843 (94.8%) had a positive SARS-CoV-2 test within the 2 weeks preceding hospital admission or during hospitalization. In addition, 789 hospitalizations had a secondary diagnosis of COVID-19, of which 446 (56.5%) had a principal diagnosis consistent with severe clinical manifestation of COVID-19 (e.g., sepsis or respiratory failure). Compared with the cohort that had a principal diagnosis of COVID-19, those with a secondary diagnosis had a more than 2-fold higher in-hospital mortality rate (13.2% vs 28.0%, P<0.001). In the validation sample at Mayo Clinic, diagnosis codes more consistently identified SARS-CoV-2 infection (precision of 95%) but had lower recall (63.5%) with substantial variation across the 3 Mayo Clinic sites. Similar to Yale, diagnosis codes consistently identified COVID-19 hospitalizations at Mayo, with hospitalizations defined by secondary diagnosis code with 2-fold higher in-hospital mortality compared to those with a primary diagnosis of COVID-19. Conclusions: COVID-19 diagnosis codes misclassified the SARS-CoV-2 infection status of many people, with implications for clinical research and epidemiological surveillance. Moreover, the codes had different performance across two academic health systems and identified groups with different risks of mortality. Real-world data from the EHR can be used to in conjunction with diagnosis codes to improve the identification of people infected with SARS-CoV-2.
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18
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Ren L, Yu S, Xu W, Overton JL, Chiamvimonvat N, Thai PN. Lack of association of antihypertensive drugs with the risk and severity of COVID-19: A meta-analysis. J Cardiol 2021; 77:482-491. [PMID: 33168337 PMCID: PMC7605745 DOI: 10.1016/j.jjcc.2020.10.015] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 09/08/2020] [Accepted: 10/23/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The association of antihypertensive drugs with the risk and severity of COVID-19 remains unknown. METHODS AND RESULTS We systematically searched PubMed, MEDLINE, The Cochrane Library, Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov, and medRxiv for publications before July 13, 2020. Cohort studies and case-control studies that contain information on the association of antihypertensive agents including angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), calcium-channel blockers (CCBs), β-blockers, and diuretics with the risk and severity of COVID-19 were selected. The random or fixed-effects models were used to pool the odds ratio (OR) with 95% confidence interval (CI) for the outcomes. The literature search yielded 53 studies that satisfied our inclusion criteria, which comprised 39 cohort studies and 14 case-control studies. These studies included a total of 2,100,587 participants. We observed no association between prior usage of antihypertensive medications including ACEIs/ARBs, CCBs, β-blockers, or diuretics and the risk and severity of COVID-19. Additionally, when only hypertensive patients were included, the severity and mortality were lower with prior usage of ACEIs/ARBs (overall OR of 0.81, 95% CI 0.66-0.99, p < 0.05 and overall OR of 0.77, 95% CI 0.66-0.91, p < 0.01). CONCLUSIONS Taken together, usage of antihypertensive drugs is not associated with the risk and severity of COVID-19. Based on the current available literature, it is not recommended to abstain from the usage of these drugs in COVID-19 patients. REGISTRATION The meta-analysis was registered on OSF (https://osf.io/ynd5g).
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Affiliation(s)
- Lu Ren
- Department of Internal Medicine, Cardiology, UC Davis, Davis, CA, USA
| | - Shandong Yu
- Department of Cardiology, Cardiovascular Center, Beijing Friendship Hospital, Capital Medical University, Beijing, PR China
| | - Wilson Xu
- Department of Internal Medicine, Cardiology, UC Davis, Davis, CA, USA
| | - James L Overton
- Department of Internal Medicine, Cardiology, UC Davis, Davis, CA, USA
| | - Nipavan Chiamvimonvat
- Department of Internal Medicine, Cardiology, UC Davis, Davis, CA, USA; Department of Veteran Affairs, Northern California Health Care System, 10535 Hospital Way, Mather, CA 95655, USA.
| | - Phung N Thai
- Department of Internal Medicine, Cardiology, UC Davis, Davis, CA, USA.
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19
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Lee HY, Ahn J, Park J, Kang CK, Won SH, Kim DW, Park JH, Chung KH, Joh JS, Bang JIH, Kang CH, Oh MD, Pyun WB. Different therapeutic associations of renin-angiotensin system inhibitors with coronavirus disease 2019 compared with usual pneumonia. Korean J Intern Med 2021; 36:617-628. [PMID: 33858123 PMCID: PMC8137390 DOI: 10.3904/kjim.2020.656] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 02/02/2021] [Accepted: 02/03/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND/AIMS Although it is near concluded that renin-angiotensin system inhibitors do not have a harmful effect on coronavirus disease 2019 (COVID-19), there is no report about whether angiotensin receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACEIs) offer any protective role. This study aimed to compare the association of ARBs and ACEIs with COVID-19-related mortality. METHODS All patients with COVID-19 in Korea between January 19 and April 16, 2020 were enrolled. The association of ARBs and ACEIs with mortality within 60 days were evaluated. A comparison of hazard ratio (HR) was performed between COVID-19 patients and a retrospective cohort of pneumonia patients hospitalized in 2019 in Korea. RESULTS Among 10,448 COVID-19 patients, ARBs and ACEIs were prescribed in 1,231 (11.7%) and 57 (0.6%) patients, respectively. After adjusting for age, sex, and history of comorbidities, the ARB group showed neutral association (HR, 1.034; 95% CI, 0.765 to 1.399; p = 0.8270) and the ACEI groups showed no significant associations likely owing to the small population size (HR, 0.736; 95% CI, 0.314 to 1.726; p = 0.4810). When comparing HR between COVID-19 patients and a retrospective cohort of patients hospitalized with pneumonia in 2019, the trend of ACEIs showed similar benefits, whereas the protective effect of ARBs observed in the retrospective cohort was absent in COVID-19 patients. Meta-analyses showed significant positive correlation with survival of ACEIs, whereas a neutral association between ARBs and mortality. CONCLUSION Although ARBs or ACEIs were not associated with fatal outcomes, potential beneficial effects of ARBs observed in pneumonia were attenuated in COVID-19.
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Affiliation(s)
- Hae-Young Lee
- Korean Society of Hypertension, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Juhee Ahn
- Department of Public Health Sciences, Seoul National University, Seoul, Korea
| | - Juhong Park
- Department of Public Health Sciences, Seoul National University, Seoul, Korea
| | - Chang Kyung Kang
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sung-Ho Won
- Department of Public Health Sciences, Seoul National University, Seoul, Korea
- Institute of Health and Environment, Seoul National University, Seoul, Korea
| | | | - Jong-Heon Park
- National Health Insurance Service, Wonju, Korea
- Department of Benefits Strategy, National Health Insurance Service, Wonju, Korea
| | - Ki-Hyun Chung
- National Medical Center, Seoul, Korea
- National Committee for Clinical Management of Emerging Infectious Diseases, Seoul, Korea
| | | | - JI Hwan Bang
- National Committee for Clinical Management of Emerging Infectious Diseases, Seoul, Korea
- The Central Infectious Disease Hospital, Seoul, Korea
| | | | - Myoung-don Oh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- National Committee for Clinical Management of Emerging Infectious Diseases, Seoul, Korea
| | - Wook Bum Pyun
- Korean Society of Hypertension, Seoul, Korea
- Division of Cardiology, Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - The Korean Society of Hypertension
- Korean Society of Hypertension, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Public Health Sciences, Seoul National University, Seoul, Korea
- Institute of Health and Environment, Seoul National University, Seoul, Korea
- National Health Insurance Service, Wonju, Korea
- Department of Benefits Strategy, National Health Insurance Service, Wonju, Korea
- National Medical Center, Seoul, Korea
- National Committee for Clinical Management of Emerging Infectious Diseases, Seoul, Korea
- The Central Infectious Disease Hospital, Seoul, Korea
- Division of Cardiology, Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - The National Committee for Clinical Management of Emerging Infectious Diseases
- Korean Society of Hypertension, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Public Health Sciences, Seoul National University, Seoul, Korea
- Institute of Health and Environment, Seoul National University, Seoul, Korea
- National Health Insurance Service, Wonju, Korea
- Department of Benefits Strategy, National Health Insurance Service, Wonju, Korea
- National Medical Center, Seoul, Korea
- National Committee for Clinical Management of Emerging Infectious Diseases, Seoul, Korea
- The Central Infectious Disease Hospital, Seoul, Korea
- Division of Cardiology, Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
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20
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Dai XC, An ZY, Wang ZY, Wang ZZ, Wang YR. Associations Between the Use of Renin-Angiotensin System Inhibitors and the Risks of Severe COVID-19 and Mortality in COVID-19 Patients With Hypertension: A Meta-Analysis of Observational Studies. Front Cardiovasc Med 2021; 8:609857. [PMID: 33981731 PMCID: PMC8107232 DOI: 10.3389/fcvm.2021.609857] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 02/22/2021] [Indexed: 01/10/2023] Open
Abstract
Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) share a target receptor with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The use of ACEIs/ARBs may cause angiotensin-converting enzyme 2 receptor upregulation, facilitating the entry of SARS-CoV-2 into host cells. There is concern that the use of ACEIs/ARBs could increase the risks of severe COVID-19 and mortality. The impact of discontinuing these drugs in patients with COVID-19 remains uncertain. We aimed to assess the association between the use of ACEIs/ARBs and the risks of mortality and severe disease in patients with COVID-19. A systematic search was performed in PubMed, EMBASE, Cochrane Library, and MedRxiv.org from December 1, 2019, to June 20, 2020. We also identified additional citations by manually searching the reference lists of eligible articles. Forty-two observational studies including 63,893 participants were included. We found that the use of ACEIs/ARBs was not significantly associated with a reduction in the relative risk of all-cause mortality [odds ratio (OR) = 0.87, 95% confidence interval (95% CI) = 0.75-1.00; I 2 = 57%, p = 0.05]. We found no significant reduction in the risk of severe disease in the ACEI subgroup (OR = 0.95, 95% CI = 0.88-1.02, I 2 = 50%, p = 0.18), the ARB subgroup (OR = 1.03, 95% CI = 0.94-1.13, I 2 = 62%, p = 0.48), or the ACEI/ARB subgroup (OR = 0.83, 95% CI = 0.65-1.08, I 2 = 67%, p = 0.16). Moreover, seven studies showed no significant difference in the duration of hospitalization between the two groups (mean difference = 0.33, 95% CI = -1.75 to 2.40, p = 0.76). In conclusion, the use of ACEIs/ARBs appears to not have a significant effect on mortality, disease severity, or duration of hospitalization in COVID-19 patients. On the basis of the findings of this meta-analysis, there is no support for the cessation of treatment with ACEIs or ARBs in patients with COVID-19.
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Affiliation(s)
- Xiao-Ce Dai
- Department of Cardiology, Affiliated Hospital of Jiaxing University, Zhejiang, China
| | - Zhuo-Yu An
- Peking University People's Hospital, Beijing, China
| | - Zi-Yang Wang
- Peking University People's Hospital, Beijing, China
| | | | - Yi-Ren Wang
- Peking University People's Hospital, Beijing, China
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21
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Singh S, Widrich C, Nap M, Schokker E, Zwinderman AH, Pinto‐Sietsma S. Antihypertensives and their relation to mortality by SARS-CoV-2 infection. J Med Virol 2021; 93:2467-2475. [PMID: 33404127 PMCID: PMC7986392 DOI: 10.1002/jmv.26775] [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: 10/13/2020] [Revised: 12/16/2020] [Accepted: 12/21/2020] [Indexed: 01/20/2023]
Abstract
The role of antihypertensives, especially Renin-Angiotensin-Aldosterone System inhibitors, is still debatable in COVID-19-related severity and outcome. Therefore, we search for a more global analysis of antihypertensive medication in relation to SAS-CoV-2 severity using prescription data worldwide. The association between the percentage use of different types of antihypertensive medications and mortality rates due to a SARS-CoV-2 infection during the first 3 weeks of the pandemic was analyzed using random effects linear regression models for 30 countries worldwide. Higher percentages of prescribed angiotensin receptor blockers (ARBs) (β, 95% confidence interval [CI]; -0.02 [-0.04 to -0.0012]; p = .042) and calcium channel blockers (CCBs) (β, 95% CI; -0.023 [-0.05 to -0.0028]; p = .0304) were associated with a lower first 3-week SARS-CoV-2-related death rate, whereas a higher percentage of prescribed angiotensin-converting enzyme inhibitors (ACEis) (β, 95% CI; 0.03 [0.0061-0.05]; p = .0103) was associated with a higher first 3-week death rate, even when adjusted for age and metformin use. There was no association between the amount of prescribed beta-blockers (BBs) and diuretics (Diu) and the first 3-week death rate. When analyzing the combination of drugs that is used by at least 50% of antihypertensive users, within the different countries, countries with the lowest first 3-week death rates had at least an angiotensin receptor blocker as one of the most often prescribed antihypertensive medications (ARBs/CCBs: [β, 95% CI; -0.02 [-0.03 to -0.004]; p = .009], ARBs/BBs: [β, 95% CI; -0.03 [-0.05 to -0.006]; p = .01]). Finally, countries prescribing high-potency ARBs had lower first 3-week ARBs. In conclusion, ARBs and CCB seem to have a protective effect against death from SARS-CoV-2 infection.
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Affiliation(s)
- Sandeep Singh
- Departments of Clinical Epidemiology, Biostatistics and Bio‐InformaticsAmsterdam University Medical Centre, Academic Medical CenterAmsterdamThe Netherlands
- Department of Vascular MedicineAmsterdam University Medical Centre, Academic Medical CenterAmsterdamThe Netherlands
| | - Christine Widrich
- Department of Analytics SolutionsIQVIA NederlandAmsterdamThe Netherlands
| | - Martijn Nap
- Department of Analytics and Technology SolutionsIQVIA NederlandAmsterdamThe Netherlands
| | | | - Aeilko H. Zwinderman
- Departments of Clinical Epidemiology, Biostatistics and Bio‐InformaticsAmsterdam University Medical Centre, Academic Medical CenterAmsterdamThe Netherlands
| | - Sara‐Joan Pinto‐Sietsma
- Departments of Clinical Epidemiology, Biostatistics and Bio‐InformaticsAmsterdam University Medical Centre, Academic Medical CenterAmsterdamThe Netherlands
- Department of Vascular MedicineAmsterdam University Medical Centre, Academic Medical CenterAmsterdamThe Netherlands
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22
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Rothlin RP, Duarte M, Pelorosso FG, Nicolosi L, Salgado MV, Vetulli HM, Spitzer E. Angiotensin Receptor Blockers for COVID-19: Pathophysiological and Pharmacological Considerations About Ongoing and Future Prospective Clinical Trials. Front Pharmacol 2021; 12:603736. [PMID: 33854432 PMCID: PMC8039444 DOI: 10.3389/fphar.2021.603736] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 02/02/2021] [Indexed: 12/12/2022] Open
Abstract
COVID-19 pandemic demands a swift response to find therapeutic tools that effectively reduce morbidity and mortality. Despite initial fears, evidence from retrospective observational studies supports the inhibition of the renin-angiotensin system as an emerging pathway to delay or moderate angiotensin II-driven lung inflammation. This has triggered several prospective clinical trials. In this commentary we provide an overview and analysis of current ongoing clinical trials aimed at evaluating the therapeutic efficacy of angiotensin receptor blocker (ARB) use in COVID-19. The relevance of the results of these trials will have to be interpreted depending on the stage and severity of the disease and in light of the start time of their prescription related to the time of diagnosis of COVID-19 as well as the administered doses.
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Affiliation(s)
- Rodolfo Pedro Rothlin
- Sociedad Argentina de Farmacología Clínica, Asociación Médica Argentina, Buenos Aires, Argentina
| | - Mariano Duarte
- Hospital de Clínicas ‘José de San Martín’, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina
| | | | | | - M. Victoria Salgado
- Hospital de Alta Complejidad El Calafate SAMIC, El Calafate, Provincia de Santa Cruz, Argentina
- Centro de Estudios de Estado y Sociedad, Buenos Aires, Argentina
| | - Héctor Miguel Vetulli
- Servicio de Electrofisiología Cardíaca, Arritmias y Marcapasos. Sanatorio Otamendi y Miroli, Buenos Aires, Argentina
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23
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Armstrong K, Soltoff A, Rieu-Werden M, Metlay J, Haas J. Use of angiotensin converting enzyme inhibitors and angiotensin receptor blockers associated with lower risk of COVID-19 in household contacts. PLoS One 2021; 16:e0247548. [PMID: 33651840 PMCID: PMC7924745 DOI: 10.1371/journal.pone.0247548] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 02/09/2021] [Indexed: 01/08/2023] Open
Abstract
Background Use of angiotensin converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) has been hypothesized to affect COVID-19 risk. Objective To examine the association between use of ACEI/ARB and household transmission of COVID-19. Methods We conducted a modified cohort study of household contacts of patients who tested positive for COVID-19 between March 4 and May 17, 2020 in a large Northeast US health system. Household members were identified by geocoding and full address matching with exclusion of addresses with >10 matched residents or known congregate living functions. Medication use, clinical conditions and sociodemographic characteristics were obtained from electronic medical record (EMR) data on cohort entry. Cohort members were followed for at least one month after exposure to determine who tested positive for SARS-CoV-2. Mixed effects logistic regression and propensity score analyses were used to assess adjusted associations between medication use and testing positive. Results 1,499 of the 9,101 household contacts were taking an ACEI or an ARB. Probability of COVID-19 diagnosis during the study period was slightly higher among ACEI/ARB users in unadjusted analyses. However, ACEI/ARB users were older and more likely to have clinical comorbidities so that use of ACEI/ARB was associated with a decreased risk of being diagnosed with COVID-19 in mixed effect models (OR 0.60, 95% CI 0.44–0.81) or propensity score analyses (predicted probability 18.6% in ACEI/ARB users vs. 24.5% in non-users, p = 0.03). These associations were similar within age and comorbidity subgroups, including patients with documented hypertension, diabetes or cardiovascular disease, as well as when including other medications in the models. Conclusions In this observational study of household transmission, use of ACEIs or ARBs was associated with a decreased risk of being diagnosed with COVID-19. While causality cannot be inferred from these observational data, our results support current recommendations to continue ACEI/ARB in individuals at risk of COVID-19 exposure.
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Affiliation(s)
- Katrina Armstrong
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- * E-mail:
| | - Alex Soltoff
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Meghan Rieu-Werden
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Joshua Metlay
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Jennifer Haas
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
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24
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Ng TSB, Leblanc K, Yeung DF, Tsang TSM. Medication use during COVID-19: Review of recent evidence. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2021; 67:171-179. [PMID: 33727376 PMCID: PMC7963004 DOI: 10.46747/cfp.6703171] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To keep health care providers, in response to the ongoing coronavirus disease 2019 (COVID-19) pandemic, informed about the medications that have been proposed to treat the disease and the evidence supporting their use. QUALITY OF EVIDENCE A narrative review of medications most widely used to treat COVID-19 was conducted, outlining the best available evidence for each pharmacologic treatment to date. Searches were performed in PubMed, EMBASE, and MEDLINE using key words COVID-19 and treatment, as well as related terms. Relevant research studies conducted in human populations and cases specific to patients with COVID-19 were included, as were relevant hand-searched papers and reviews. Only articles in English and Chinese were included. MAIN MESSAGE While current management of patients with COVID-19 largely involves supportive care, without a widely available vaccine, practitioners have also resorted to repurposing medications used for other indications. This has caused considerable controversy, as many of these treatments have limited clinical evidence supporting their use and therefore pose implications for patient safety, drug access, and public health. For instance, medications such as hydroxychloroquine and chloroquine, lopinavir-ritonavir, nonsteroidal anti-inflammatory drugs, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers gained widespread media attention owing to hype, misinformation, or misinterpretation of research evidence. CONCLUSION Given the severity of the pandemic and the potential broad effects of implementing safe and effective treatment, this article provides a narrative review of the current evidence behind the most widely used medications to treat COVID-19 in order to enable health care practitioners to make informed decisions in the care of patients with this life-threatening disease.
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Affiliation(s)
- T S Brandon Ng
- Medical student in the Faculty of Medicine at the University of British Columbia in Vancouver
| | - Kori Leblanc
- Assistant Professor in the Leslie Dan Faculty of Pharmacy at the University of Toronto in Ontario
| | - Darwin F Yeung
- Clinical Assistant Professor in the Faculty of Medicine at the University of British Columbia
| | - Teresa S M Tsang
- Director of Echocardiography at Vancouver General Hospital and the UBC Hospital, and Professor of Medicine in the Division of Cardiology and Associate Head of Research for the Department of Medicine at the University of British Columbia.
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25
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Ng TSB, Leblanc K, Yeung DF, Tsang TSM. Médicaments utilisés durant la COVID-19. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2021; 67:e69-e78. [PMID: 33727386 PMCID: PMC7963008 DOI: 10.46747/cfp.6703e69] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Objectif En réponse à la pandémie actuelle de maladie à coronavirus 2019 (COVID-19), garder les médecins au fait des médicaments qui ont été proposés pour combattre la maladie, et des données probantes à l’appui de leur utilisation. Sources d’information Une revue narrative des médicaments les plus fréquemment utilisés pour combattre la COVID-19 a été réalisée, afin de souligner les meilleures données probantes disponibles concernant chaque traitement pharmacologique jusqu’ici. Des recherches ont été effectuées sur PubMed, EMBASE et MEDLINE à l’aide des mots-clés anglais COVID-19 et treatment , ainsi que d’autres mots-clés connexes. Ont été inclus les études pertinentes menées auprès de populations humaines et des cas de patients atteints de la COVID-19, ainsi que les articles et revues relevés à la main. Seuls les articles rédigés en anglais et en chinois ont été retenus. Message principal Alors que la prise en charge actuelle des patients atteints de la COVID-19 consiste principalement en soins de soutien, sans accès aux vaccins, les praticiens se sont tournés vers des médicaments utilisés dans d’autres indications. Cela a causé une grande controverse, puisque des données cliniques limitées étayaient l’utilisation de beaucoup de ces traitements, et cela pouvait se répercuter sur la sécurité du patient, l’accès aux médicaments et la santé publique. Par exemple, les médicaments tels que l’hydroxychloroquine et la chloroquine, le lopinavir-ritonavir, les anti-inflammatoires non stéroïdiens, les inhibiteurs de l’enzyme de conversion de l’angiotensine et les antagonistes des récepteurs de l’angiotensine ont capté l’attention des médias en raison de la médiatisation, de la mésinformation ou de la mauvaise interprétation des données de recherche. Conclusion Vu la gravité de la pandémie et les vastes effets éventuels de l’adoption de traitements sûrs et efficaces, cet article se veut être une revue narrative des données probantes actuelles étayant les médicaments les plus utilisés pour le traitement de la COVID-19 afin de permettre aux professionnels de la santé de prendre des décisions éclairées en matière de soins pour les patients qui sont atteints de cette maladie potentiellement mortelle.
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Affiliation(s)
- T S Brandon Ng
- Étudiant en médecine à la faculté de médecine de l'Université de la Colombie-Britannique à Vancouver
| | - Kori Leblanc
- Professeure adjointe à la faculté de pharmacie Leslie Dan de l'Université de Toronto en Ontario
| | - Darwin F Yeung
- Professeur clinique adjoint à la faculté de médecine de l'Université de la Colombie-Britannique
| | - Teresa S M Tsang
- Directrice de l'échocardiographie à l'Hôpital Vancouver General Hospital et UBC Hospital, et elle est professeure de médecine à la division de cardiologie et directrice associée de recherche au département de médecine de l'Université de la Colombie-Britannique.
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26
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Khera R, Clark C, Lu Y, Guo Y, Ren S, Truax B, Spatz ES, Murugiah K, Lin Z, Omer SB, Vojta D, Krumholz HM. Association of Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers With the Risk of Hospitalization and Death in Hypertensive Patients With COVID-19. J Am Heart Assoc 2021; 10:e018086. [PMID: 33624516 PMCID: PMC8403305 DOI: 10.1161/jaha.120.018086] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background Despite its clinical significance, the risk of severe infection requiring hospitalization among outpatients with severe acute respiratory syndrome coronavirus 2 infection who receive angiotensin‐converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) remains uncertain. Methods and Results In a propensity score–matched outpatient cohort (January–May 2020) of 2263 Medicare Advantage and commercially insured individuals with hypertension and a positive outpatient SARS‐CoV‐2, we determined the association of ACE inhibitors and ARBs with COVID‐19 hospitalization. In a concurrent inpatient cohort of 7933 hospitalized with COVID‐19, we tested their association with in‐hospital mortality. The robustness of the observations was assessed in a contemporary cohort (May–August). In the outpatient study, neither ACE inhibitors (hazard ratio [HR], 0.77; 0.53–1.13, P=0.18) nor ARBs (HR, 0.88; 0.61–1.26, P=0.48) were associated with hospitalization risk. ACE inhibitors were associated with lower hospitalization risk in the older Medicare group (HR, 0.61; 0.41–0.93, P=0.02), but not the younger commercially insured group (HR, 2.14; 0.82–5.60, P=0.12; P‐interaction 0.09). Neither ACE inhibitors nor ARBs were associated with lower hospitalization risk in either population in the validation cohort. In the primary inpatient study cohort, neither ACE inhibitors (HR, 0.97; 0.81–1.16; P=0.74) nor ARBs (HR, 1.15; 0.95–1.38, P=0.15) were associated with in‐hospital mortality. These observations were consistent in the validation cohort. Conclusions ACE inhibitors and ARBs were not associated with COVID‐19 hospitalization or mortality. Despite early evidence for a potential association between ACE inhibitors and severe COVID‐19 prevention in older individuals, the inconsistency of this observation in recent data argues against a role for prophylaxis.
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Affiliation(s)
- Rohan Khera
- Section of Cardiovascular Medicine Department of Internal Medicine Yale School of Medicine New Haven CT.,Center for Outcomes Research and Evaluation Yale-New Haven Hospital New Haven CT
| | - Callahan Clark
- Research & Development at UnitedHealth Group Minnetonka MN UAS
| | - Yuan Lu
- Section of Cardiovascular Medicine Department of Internal Medicine Yale School of Medicine New Haven CT.,Center for Outcomes Research and Evaluation Yale-New Haven Hospital New Haven CT
| | - Yinglong Guo
- Research & Development at UnitedHealth Group Minnetonka MN UAS
| | - Sheng Ren
- Research & Development at UnitedHealth Group Minnetonka MN UAS
| | - Brandon Truax
- Research & Development at UnitedHealth Group Minnetonka MN UAS
| | - Erica S Spatz
- Section of Cardiovascular Medicine Department of Internal Medicine Yale School of Medicine New Haven CT.,Center for Outcomes Research and Evaluation Yale-New Haven Hospital New Haven CT
| | - Karthik Murugiah
- Section of Cardiovascular Medicine Department of Internal Medicine Yale School of Medicine New Haven CT.,Center for Outcomes Research and Evaluation Yale-New Haven Hospital New Haven CT
| | - Zhenqiu Lin
- Section of Cardiovascular Medicine Department of Internal Medicine Yale School of Medicine New Haven CT.,Center for Outcomes Research and Evaluation Yale-New Haven Hospital New Haven CT
| | - Saad B Omer
- Section of Infectious Diseases Department of Internal Medicine Yale School of Medicine New Haven CT.,Yale Institute for Global Health New Haven CT.,Department of Epidemiology of Microbial Diseases Yale School of Public Health New Haven CT
| | - Deneen Vojta
- Research & Development at UnitedHealth Group Minnetonka MN UAS
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine Department of Internal Medicine Yale School of Medicine New Haven CT.,Center for Outcomes Research and Evaluation Yale-New Haven Hospital New Haven CT.,Department of Health Policy and Management Yale School of Public Health New Haven CT
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27
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Franklin JM, Lin KJ, Gatto NM, Rassen JA, Glynn RJ, Schneeweiss S. Real-World Evidence for Assessing Pharmaceutical Treatments in the Context of COVID-19. Clin Pharmacol Ther 2021; 109:816-828. [PMID: 33529354 PMCID: PMC8014840 DOI: 10.1002/cpt.2185] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 01/19/2021] [Indexed: 12/15/2022]
Abstract
The emergence and global spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has resulted in an urgent need for evidence on medical interventions and outcomes of the resulting disease, coronavirus disease 2019 (COVID-19). Although many randomized controlled trials (RCTs) evaluating treatments and vaccines for COVID-19 are already in progress, the number of clinical questions of interest greatly outpaces the available resources to conduct RCTs. Therefore, there is growing interest in whether nonrandomized real-world evidence (RWE) can be used to supplement RCT evidence and aid in clinical decision making, but concerns about nonrandomized RWE have been highlighted by a proliferation of RWE studies on medications and COVID-19 outcomes with widely varying conclusions. The objective of this paper is to review some clinical questions of interest, potential data types, challenges, and merits of RWE in COVID-19, resulting in recommendations for nonrandomized RWE designs and analyses based on established RWE principles.
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Affiliation(s)
- Jessica M Franklin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nicolle M Gatto
- Aetion, Inc., New York, New York, USA.,Department of Epidemiology, Columbia University, New York, New York, USA
| | | | - Robert J Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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28
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Krishnamurthy S, Lockey RF, Kolliputi N. Soluble ACE2 as a potential therapy for COVID-19. Am J Physiol Cell Physiol 2021; 320:C279-C281. [PMID: 33502950 PMCID: PMC7938633 DOI: 10.1152/ajpcell.00478.2020] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Soluble angiotensin-converting enzyme 2 (sACE2) could be a therapeutic option to treat coronavirus disease 2019 (COVID-19) infection. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) utilizes ACE2 receptors on cell surfaces to gain intracellular entry, making them an ideal target for therapy. High-affinity variants of sACE2, engineered using high-throughput mutagenesis, are capable of neutralizing COVID-19 infection as decoy receptors. These variants compete with native ACE2 present on cells by binding with spike (S) protein of SARS-CoV-2, making native ACE2 on cell surfaces available to convert angiotensin II to angiotensin-1,7, thus alleviating the exaggerated inflammatory response associated with COVID-19 infection. This article explores the use of sACE2 as potential therapy for COVID-19 infection.
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Affiliation(s)
- Sudarshan Krishnamurthy
- Wake Forest School of Medicine, Bowman Gray Center for Medical Education, Winston-Salem, North Carolina
| | - Richard F Lockey
- Division of Allergy and Immunology, Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Narasaiah Kolliputi
- Division of Allergy and Immunology, Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, Florida
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An J, Wei R, Zhou H, Luong TQ, Gould MK, Mefford MT, Harrison TN, Creekmur B, Lee M, Sim JJ, Brettler JW, Martin JP, Ong‐Su AL, Reynolds K. Angiotensin-Converting Enzyme Inhibitors or Angiotensin Receptor Blockers Use and COVID-19 Infection Among 824 650 Patients With Hypertension From a US Integrated Healthcare System. J Am Heart Assoc 2021; 10:e019669. [PMID: 33307964 PMCID: PMC7955437 DOI: 10.1161/jaha.120.019669] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background Previous reports suggest that the use of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) may upregulate angiotensin-converting enzyme 2 receptors and increase severe acute respiratory syndrome coronavirus 2 infectivity. We evaluated the association between ACEI or ARB use and coronavirus disease 2019 (COVID-19) infection among patients with hypertension. Methods and Results We identified patients with hypertension as of March 1, 2020 (index date) from Kaiser Permanente Southern California. Patients who received ACEIs, ARBs, calcium channel blockers, beta blockers, thiazide diuretics (TD), or no therapy were identified using outpatient pharmacy data covering the index date. Outcome of interest was a positive reverse transcription polymerase chain reaction test for COVID-19 between March 1 and May 6, 2020. Patient sociodemographic and clinical characteristics were identified within 1 year preindex date. Among 824 650 patients with hypertension, 16 898 (2.0%) were tested for COVID-19. Of those tested, 1794 (10.6%) had a positive result. Overall, exposure to ACEIs or ARBs was not statistically significantly associated with COVID-19 infection after propensity score adjustment (odds ratio [OR], 1.06; 95% CI, 0.90-1.25) for ACEIs versus calcium channel blockers/beta blockers/TD; OR, 1.10; 95% CI, 0.91-1.31 for ARBs versus calcium channel blockers/beta blockers/TD). The associations between ACEI use and COVID-19 infection varied in different age groups (P-interaction=0.03). ACEI use was associated with lower odds of COVID-19 among those aged ≥85 years (OR, 0.30; 95% CI, 0.12-0.77). Use of no antihypertensive medication was significantly associated with increased odds of COVID-19 infection compared with calcium channel blockers/beta blockers/TD (OR, 1.32; 95% CI, 1.11-1.56). Conclusions Neither ACEI nor ARB use was associated with increased likelihood of COVID-19 infection. Decreased odds of COVID-19 infection among adults ≥85 years using ACEIs warrants further investigation.
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Affiliation(s)
- Jaejin An
- Research & EvaluationKaiser Permanente Southern CaliforniaPasadenaCA,Kaiser Permanente Bernard J. Tyson School of MedicinePasadenaCA
| | - Rong Wei
- Research & EvaluationKaiser Permanente Southern CaliforniaPasadenaCA
| | - Hui Zhou
- Research & EvaluationKaiser Permanente Southern CaliforniaPasadenaCA
| | - Tiffany Q. Luong
- Research & EvaluationKaiser Permanente Southern CaliforniaPasadenaCA
| | - Michael K. Gould
- Research & EvaluationKaiser Permanente Southern CaliforniaPasadenaCA,Kaiser Permanente Bernard J. Tyson School of MedicinePasadenaCA
| | | | | | - Beth Creekmur
- Research & EvaluationKaiser Permanente Southern CaliforniaPasadenaCA
| | - Ming‐Sum Lee
- Southern California Permanente Medical GroupPasadenaCA
| | - John J. Sim
- Southern California Permanente Medical GroupPasadenaCA
| | | | | | | | - Kristi Reynolds
- Research & EvaluationKaiser Permanente Southern CaliforniaPasadenaCA,Kaiser Permanente Bernard J. Tyson School of MedicinePasadenaCA
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Semenzato L, Botton J, Drouin J, Baricault B, Vabre C, Cuenot F, Penso L, Herlemont P, Sbidian E, Weill A, Dray-Spira R, Zureik M. Antihypertensive Drugs and COVID-19 Risk: A Cohort Study of 2 Million Hypertensive Patients. Hypertension 2021; 77:833-842. [PMID: 33423528 PMCID: PMC7884243 DOI: 10.1161/hypertensionaha.120.16314] [Citation(s) in RCA: 81] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Supplemental Digital Content is available in the text. After initially hypothesizing a positive relationship between use of renin-angiotensin-aldosterone system inhibitors and risk of coronavirus disease 2019 (COVID-19), more recent evidence suggests negative associations. We examined whether COVID-19 risk differs according to antihypertensive drug class in patients treated by ACE (angiotensin-converting enzyme) inhibitors and angiotensin receptor blockers (ARBs) compared with calcium channel blockers (CCBs). Three exclusive cohorts of prevalent ACE inhibitors, ARB and CCB users, aged 18 to 80 years, from the French National Health Insurance databases were followed from February 15, 2020 to June 7, 2020. We excluded patients with a history of diabetes, known cardiovascular disease, chronic renal failure, or chronic respiratory disease during the previous 5 years, to only consider patients treated for uncomplicated hypertension and to limit indication bias. The primary end point was time to hospitalization for COVID-19. The secondary end point was time to intubation/death during a hospital stay for COVID-19. In a population of almost 2 million hypertensive patients (ACE inhibitors: 566 023; ARB: 958 227; CCB: 358 306) followed for 16 weeks, 2338 were hospitalized and 526 died or were intubated for COVID-19. ACE inhibitors and ARBs were associated with a lower risk of COVID-19 hospitalization compared with CCBs (hazard ratio, 0.74 [95% CI, 0.65–0.83] and 0.84 [0.76–0.93], respectively) and a lower risk of intubation/death. Risks were slightly lower for ACE inhibitor users than for ARB users. This large observational study may suggest a lower COVID-19 risk in hypertensive patients treated over a long period with ACE inhibitors or ARBs compared with CCBs. These results, if confirmed, tend to contradict previous hypotheses and raise new hypotheses.
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Affiliation(s)
- Laura Semenzato
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products from the French National Agency for the Safety of Medicines and Health Products, Saint-Denis, France and the French National Health Insurance, Paris, France (L.S., J.B., B.B., C.V., J.D., F.C., L.P., P.H., E.S., A.W., R.D.-S., M.Z.)
| | - Jérémie Botton
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products from the French National Agency for the Safety of Medicines and Health Products, Saint-Denis, France and the French National Health Insurance, Paris, France (L.S., J.B., B.B., C.V., J.D., F.C., L.P., P.H., E.S., A.W., R.D.-S., M.Z.)
| | - Jérôme Drouin
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products from the French National Agency for the Safety of Medicines and Health Products, Saint-Denis, France and the French National Health Insurance, Paris, France (L.S., J.B., B.B., C.V., J.D., F.C., L.P., P.H., E.S., A.W., R.D.-S., M.Z.)
| | - Bérangère Baricault
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products from the French National Agency for the Safety of Medicines and Health Products, Saint-Denis, France and the French National Health Insurance, Paris, France (L.S., J.B., B.B., C.V., J.D., F.C., L.P., P.H., E.S., A.W., R.D.-S., M.Z.)
| | - Clémentine Vabre
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products from the French National Agency for the Safety of Medicines and Health Products, Saint-Denis, France and the French National Health Insurance, Paris, France (L.S., J.B., B.B., C.V., J.D., F.C., L.P., P.H., E.S., A.W., R.D.-S., M.Z.)
| | - François Cuenot
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products from the French National Agency for the Safety of Medicines and Health Products, Saint-Denis, France and the French National Health Insurance, Paris, France (L.S., J.B., B.B., C.V., J.D., F.C., L.P., P.H., E.S., A.W., R.D.-S., M.Z.)
| | - Laetitia Penso
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products from the French National Agency for the Safety of Medicines and Health Products, Saint-Denis, France and the French National Health Insurance, Paris, France (L.S., J.B., B.B., C.V., J.D., F.C., L.P., P.H., E.S., A.W., R.D.-S., M.Z.)
| | - Philippe Herlemont
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products from the French National Agency for the Safety of Medicines and Health Products, Saint-Denis, France and the French National Health Insurance, Paris, France (L.S., J.B., B.B., C.V., J.D., F.C., L.P., P.H., E.S., A.W., R.D.-S., M.Z.)
| | - Emilie Sbidian
- Epidemiology in Dermatology and Evaluation of Therapeutics Research Unit, University Paris-Est Créteil (E.S.)
| | - Alain Weill
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products from the French National Agency for the Safety of Medicines and Health Products, Saint-Denis, France and the French National Health Insurance, Paris, France (L.S., J.B., B.B., C.V., J.D., F.C., L.P., P.H., E.S., A.W., R.D.-S., M.Z.)
| | - Rosemary Dray-Spira
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products from the French National Agency for the Safety of Medicines and Health Products, Saint-Denis, France and the French National Health Insurance, Paris, France (L.S., J.B., B.B., C.V., J.D., F.C., L.P., P.H., E.S., A.W., R.D.-S., M.Z.)
| | - Mahmoud Zureik
- University Paris-Saclay, UVSQ, University Paris-Sud, Inserm, Anti-Infective Evasion and Pharmacoepidemiology, CESP, 78180, Montigny le Bretonneux, France (M.Z.)
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Cumhur Cure M, Cure E. Effects of the Na +/H + Ion Exchanger on Susceptibility to COVID-19 and the Course of the Disease. J Renin Angiotensin Aldosterone Syst 2021; 2021:4754440. [PMID: 34285709 PMCID: PMC8265032 DOI: 10.1155/2021/4754440] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 05/14/2021] [Accepted: 06/04/2021] [Indexed: 02/06/2023] Open
Abstract
The Na+/H+ ion exchanger (NHE) pumps Na+ inward the cell and H+ ion outside the cell. NHE activity increases in response to a decrease in intracellular pH, and it maintains intracellular pH in a narrow range. Patients with obesity, diabetes, and hypertension and the elderly are prone to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. The angiotensin II (Ang II) level is high in chronic diseases such as diabetes, hypertension, and obesity. Ang II is the main stimulator of NHE, and an increased Ang II level causes prolonged NHE activation in these patients. The long-term increase in NHE activity causes H+ ions to leave the cell in patients with diabetes, hypertension, and obesity. Increasing H+ ions outside the cell lead to an increase in oxidative stress and reactive oxygen species. H+ ion flows into the cell due to the increased oxidative stress. This vicious circle causes intracellular pH to drop. Although NHE is activated when intracellular pH decreases, there is prolonged NHE activation in chronic diseases such as aforementioned. Novel coronavirus disease 2019 (COVID-19) progression may be more severe and mortal in these patients. SARS-CoV-2 readily invades the cell at low intracellular pH and causes infection. The renin-angiotensin system and NHE play a vital role in regulating intracellular pH. The reduction of NHE activity or its prolonged activation may cause susceptibility to SARS-CoV-2 infection by lowering intracellular pH in patients with diabetes, hypertension, and obesity. Prolonged NHE activation in these patients with COVID-19 may worsen the course of the disease. Scientists continue to investigate the mechanism of the disease and the factors that affect its clinical progression.
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Affiliation(s)
- Medine Cumhur Cure
- 1Department of Biochemistry, Private Kucukcekmece Hospital, Istanbul, Turkey
| | - Erkan Cure
- 2Department of Internal Medicine, Ota&Jinemed Hospital, Istanbul, Turkey
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Renin-Angiotensin System Inhibitors and COVID-19: a Systematic Review and Meta-Analysis. Evidence for Significant Geographical Disparities. Curr Hypertens Rep 2020. [PMID: 32910274 DOI: 10.1007/s11906-020-01101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
PURPOSE OF REVIEW While the COVID-19 pandemic is constantly evolving, it remains unclear whether the use of angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) affects the clinical course of SARS-CoV-2 infection. For this meta-analysis, PubMed, CENTRAL, and grey literature were searched from their inception to 19 May 2020 for randomized, controlled trials or observational studies that evaluate the association between the use of either ACE inhibitors or ARBs and the risk for major clinical endpoints (infection, hospitalization, admission to ICU, death) in adult patients during the COVID-19 pandemic. In addition, a subgroup geographical analysis of outcomes was performed. Studies including less than 100 subjects were excluded from our analysis. RECENT FINDINGS In total, 25 observational studies were included. ACE inhibitors and ARBs were not associated with increased odds for SARS-CoV-2 infection, admission to hospital, severe or critical illness, admission to ICU, and SARS-CoV-2-related death. In Asian countries, the use of ACE inhibitors/ARBs decreased the odds for severe or critical illness and death (OR = 0.37, 95% CI 0.16-0.89, I2 = 83%, and OR = 0.62, 95% CI 0.39-0.99, I2 = 0%, respectively), whereas they increased the odds for ICU admission in North America and death in Europe (OR = 1.75, 95% CI 1.37-2.23, I2 = 0%, and OR = 1.68, 95% CI 1.05-2.70, I2 = 82%, respectively). ACE inhibitors might be marginally protective regarding SARS-CoV-2-related death compared with ARBs (OR = 0.86, 95% CI 0.74-1.00, I2 = 0%). Randomized controlled trials are needed to confirm the aforementioned associations between ACE inhibitors, ARBs, and SARS-CoV-2.
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African League Against Rheumatism (AFLAR) preliminary recommendations on the management of rheumatic diseases during the COVID-19 pandemic. Clin Rheumatol 2020; 40:3445-3454. [PMID: 32876786 PMCID: PMC7465880 DOI: 10.1007/s10067-020-05355-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/11/2020] [Accepted: 08/18/2020] [Indexed: 12/15/2022]
Abstract
Objectives To develop recommendations for the management of rheumatic and musculoskeletal diseases (RMDs) during the COVID-19 pandemic. Method A task force comprising of 25 rheumatologists from the 5 regions of the continent was formed and operated through a hub-and-spoke model with a central working committee (CWC) and 4 subgroups. The subgroups championed separate scopes of the clinical questions and formulated preliminary statements of recommendations which were processed centrally in the CWC. The CWC and each subgroup met by several virtual meetings, and two rounds of voting were conducted on the drafted statements of recommendations. Votes were online-delivered and recommendations were pruned down according to predefined criteria. Each statement was rated between 1 and 9 with 1–3, 4–6 and 7–9 representing disagreement, uncertainty and agreement, respectively. The levels of agreement on the statements were stratified as low, moderate or high according to the spread of votes. A statement was retired if it had a mean vote below 7 or a ‘low’ level of agreement. Results A total of 126 initial statements of recommendations were drafted, and these were reduced to 22 after the two rounds of voting. Conclusions The preliminary statements of recommendations will serve to guide the clinical practice of rheumatology across Africa amidst the changing practices and uncertainties in the current era of COVID-19. It is recognized that further updates to the recommendations will be needed as more evidence emerges.Key Points • AFLAR has developed preliminary recommendations for the management of RMDs in the face of the COVID-19 pandemic. • COVID-19 is an unprecedented experience which has brought new concerns regarding the use of some disease-modifying anti-rheumatic drugs (DMARDs), and these recommendations seek to provide guidelines to the African rheumatologists. • Hydroxychloroquine shortage has become rampart across Africa as the drug is being used as prophylaxis against COVID-19 and this may necessitate a review of treatment plan for some patients with RMDs. • Breastfeeding should continue for as long as possible if a woman is positive for SARS-CoV-2 as there is currently no evidence that the infection can be transmitted through breast milk. |
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