1
|
Ge L, Meng Y, Ma W, Mu J. A retrospective prognostic evaluation using unsupervised learning in the treatment of COVID-19 patients with hypertension treated with ACEI/ARB drugs. PeerJ 2024; 12:e17340. [PMID: 38756444 PMCID: PMC11097962 DOI: 10.7717/peerj.17340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 04/15/2024] [Indexed: 05/18/2024] Open
Abstract
Introduction This study aimed to evaluate the prognosis of patients with COVID-19 and hypertension who were treated with angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor B (ARB) drugs and to identify key features affecting patient prognosis using an unsupervised learning method. Methods A large-scale clinical dataset, including patient information, medical history, and laboratory test results, was collected. Two hundred patients with COVID-19 and hypertension were included. After cluster analysis, patients were divided into good and poor prognosis groups. The unsupervised learning method was used to evaluate clinical characteristics and prognosis, and patients were divided into different prognosis groups. The improved wild dog optimization algorithm (IDOA) was used for feature selection and cluster analysis, followed by the IDOA-k-means algorithm. The impact of ACEI/ARB drugs on patient prognosis and key characteristics affecting patient prognosis were also analysed. Results Key features related to prognosis included baseline information and laboratory test results, while clinical symptoms and imaging results had low predictive power. The top six important features were age, hypertension grade, MuLBSTA, ACEI/ARB, NT-proBNP, and high-sensitivity troponin I. These features were consistent with the results of the unsupervised prediction model. A visualization system was developed based on these key features. Conclusion Using unsupervised learning and the improved k-means algorithm, this study accurately analysed the prognosis of patients with COVID-19 and hypertension. The use of ACEI/ARB drugs was found to be a protective factor for poor clinical prognosis. Unsupervised learning methods can be used to differentiate patient populations and assess treatment effects. This study identified important features affecting patient prognosis and developed a visualization system with clinical significance for prognosis assessment and treatment decision-making.
Collapse
Affiliation(s)
- Liye Ge
- Jiading District Central Hospital Affiliated Shanghai University of Medicine and Health Sciences, Shanghai, China
| | - Yongjun Meng
- Jiading District Central Hospital Affiliated Shanghai University of Medicine and Health Sciences, Shanghai, China
| | - Weina Ma
- Jiading District Central Hospital Affiliated Shanghai University of Medicine and Health Sciences, Shanghai, China
| | - Junyu Mu
- Nanjing Medical University, Nanjing, China
| |
Collapse
|
2
|
Felkle D, Zięba K, Kaleta K, Czaja J, Zyzdorf A, Sobocińska W, Jarczyński M, Bryniarski K, Nazimek K. Overreactive macrophages in SARS-CoV-2 infection: The effects of ACEI. Int Immunopharmacol 2023; 124:110858. [PMID: 37708705 DOI: 10.1016/j.intimp.2023.110858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 08/18/2023] [Accepted: 08/23/2023] [Indexed: 09/16/2023]
Abstract
Among various factors influencing the course of SARS-CoV-2 infection in humans, macrophage overactivation is considered the main cause of the cytokine storm that leads to severe complications of COVID-19. Moreover, the increased expression of angiotensin converting enzyme 2 (ACE2), an obligatory entry receptor of the coronavirus, caused by treatment with ACE inhibitors (ACEI) lowered overall confidence in the safety of these drugs. However, analysis of the course of coronavirus infection in patients treated with ACEI does not support these concerns. Instead, the beneficial effect of ACEI on macrophages has increasingly been emphasized. This includes their anti-inflammatory activation and the consequent reduction in the risk of severe disease and life-threatening complications. Herein, we summarize the current knowledge and understanding of the dual role of macrophages in SARS-CoV-2 infection, with a special focus on the postulated mechanisms underlying the beneficial effects of macrophage targeting by ACEI. These seem to involve the stimulation of macrophage angiotensin II type 2 and Mas receptors by angiotensin 1-7, intensively produced due to the up-regulation of ACE2 expression on macrophages, as well as the direct inhibition of macrophage hyper-responsiveness by ACEI. The impact of ACEI on macrophages may also lead to the activation of an effective antiviral response due to the increased expression of ACE2.
Collapse
Affiliation(s)
- Dominik Felkle
- Students' Scientific Group at the Department of Immunology, Jagiellonian University Medical College, Czysta 18, 31-121 Kraków, Poland
| | - Katarzyna Zięba
- Students' Scientific Group at the Department of Immunology, Jagiellonian University Medical College, Czysta 18, 31-121 Kraków, Poland
| | - Konrad Kaleta
- Students' Scientific Group at the Department of Immunology, Jagiellonian University Medical College, Czysta 18, 31-121 Kraków, Poland
| | - Julia Czaja
- Students' Scientific Group at the Department of Immunology, Jagiellonian University Medical College, Czysta 18, 31-121 Kraków, Poland
| | - Amanda Zyzdorf
- Students' Scientific Group at the Department of Immunology, Jagiellonian University Medical College, Czysta 18, 31-121 Kraków, Poland
| | - Wiktoria Sobocińska
- Students' Scientific Group at the Department of Immunology, Jagiellonian University Medical College, Czysta 18, 31-121 Kraków, Poland
| | - Mateusz Jarczyński
- Students' Scientific Group at the Department of Immunology, Jagiellonian University Medical College, Czysta 18, 31-121 Kraków, Poland
| | - Krzysztof Bryniarski
- Department of Immunology, Jagiellonian University Medical College, Czysta 18, 31-121 Kraków, Poland
| | - Katarzyna Nazimek
- Department of Immunology, Jagiellonian University Medical College, Czysta 18, 31-121 Kraków, Poland.
| |
Collapse
|
3
|
Chambergo-Michilot D, Runzer-Colmenares FM, Segura-Saldaña PA. Discontinuation of Antihypertensive Drug Use Compared to Continuation in COVID-19 Patients: A Systematic Review with Meta-analysis and Trial Sequential Analysis. High Blood Press Cardiovasc Prev 2023; 30:265-279. [PMID: 37171528 PMCID: PMC10177739 DOI: 10.1007/s40292-023-00579-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 05/04/2023] [Indexed: 05/13/2023] Open
Abstract
INTRODUCTION COVID-19 related mortality is about 2%, and it increases with comorbidities, like hypertension. Regarding management, there is debatable evidence about the benefits of continuation vs. discontinuation of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers (ACEI/ARB). AIM We performed a systematic review to assess the effects and safety of in-hospital discontinuation compared to continuation of ACEI/ARB in COVID-19 patients. METHODS We systematically searched on PubMed, Scopus, and EMBASE from inception to June 19, 2021. We included observational studies and trials that compared the effects and safety of continuing ACEI/ARB compared to discontinuing it in COVID-19 patients. Effects sizes for dichotomous variables were expressed as risk ratios (RR) and 95% confidence intervals. For continuous variables, effects were expressed as mean difference (MD). We used random effect models with the inverse variance method. We assessed certainty of evidence using the GRADE approach. RESULTS We included three open-label randomized controlled trials and five cohort studies. We found that the continuation group had lower risk of death compared with the discontinuation group only in the cohort group (RR: 0.46, 95% CI: 0.24-0.90), but not in the RCT group (RR: 1.22, 95% CI: 0.75-2.00). The ICU admission rate was significantly lower in the continuation group (RR: 0.46, 95% CI: 0.31-0.68) in the cohort group, but not in RCT group (RR: 1.03, 95% CI: 0.67-1.59). We did not find significant differences between groups regarding hospitalization length, hypotension, AKI needing renal replacement therapy, mechanical ventilation, new or worsening heart failure, myocarditis, renal replacement therapy, arrhythmias, thromboembolic events and SOFA AUC. The GRADE approach revealed that the certainty ranged from moderate to high level. CONCLUSIONS There is no significant difference in mortality and other outcomes between continuation and discontinuation groups.
Collapse
Affiliation(s)
- Diego Chambergo-Michilot
- Universidad Científica del Sur, Lima, Peru.
- CHANGE Research Working Group, Carrera de Medicina Humana, Universidad Científica del Sur, Lima, Peru.
| | | | - Pedro A Segura-Saldaña
- Department of Cardiology Research, Torres de Salud National Research Center, Lima, Peru
- Ingeniería Biomédica, Facultad de Ciencias y Filosofía, Universidad Peruana Cayetano Heredia, Lima, Peru
- Departamento de Cardiología, Hospital Nacional Edgardo Rebagliati Martins, Lima, Peru
| |
Collapse
|
4
|
Kurdi A, Mueller T, Weir N. An umbrella review and meta-analysis of renin-angiotensin system drugs use and COVID-19 outcomes. Eur J Clin Invest 2023; 53:e13888. [PMID: 36205627 PMCID: PMC9874890 DOI: 10.1111/eci.13888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 10/04/2022] [Accepted: 10/05/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND Despite the availability of extensive literature on the effect of angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin-receptor blockers (ARBs) on COVID-19 outcomes, the evidence is still controversial. We aimed to provide a comprehensive assessment of the effect of ACEIs/ARBs on COVID-19-related outcomes by summarising the currently available evidence. METHODS An umbrella review was conducted using Medline (OVID), Embase, Scopus, Cochrane library and medRxiv from inception to 1 February 2021. Systematic reviews with meta-analysis that evaluated the effect of ACEIs/ARBs on COVID-19-related clinical outcomes were eligible. Studies' quality was appraised using the AMSTAR 2 Critical Appraisal Tool. Data were analysed using the random-effects modelling including several subgroup analyses. Heterogenicity was assessed using I2 statistic. The study protocol was registered in PROSPERO (CRD42021233398) and reported using PRISMA guidelines. RESULTS Overall, 47 reviews were eligible for inclusion. Out of the nine COVID-19 outcomes evaluated, there was significant associations between ACEIs/ARBs use and each of death (OR = 0.80, 95%CI = 0.75-0.86; I2 = 51.9%), death/ICU admission as composite outcome (OR = 0.86, 95%CI = 0.80-0.92; I2 = 43.9%), severe COVID-19 (OR = 0.86, 95%CI = 0.78-0.95; I2 = 68%) and hospitalisation (OR = 1.23, 95%CI = 1.04-1.46; I2 = 76.4%). The significant reduction in death/ICU admission, however, was higher among studies which presented adjusted measure of effects (OR = 0.63, 95%CI = 0.47-0.84) and were of moderate quality (OR = 0.74, 95%CI = 0.63-0.85). CONCLUSIONS Collective evidence from observational studies indicate a good quality evidence on the significant association between ACEIs/ARBs use and reduction in death and death/ICU admission, but poor-quality evidence on both reducing severe COVID-19 and increasing hospitalisation. Our findings further support the current recommendations of not discontinuing ACEIs/ARBs therapy in patients with COVID-19.
Collapse
Affiliation(s)
- Amanj Kurdi
- Strathclyde Institute of Pharmacy and Biomedical Science, University of Strathclyde, Glasgow, Scotland, UK.,Department of Pharmacology and Toxicology, College of Pharmacy, Kurdistan Region Government, Hawler Medical University, Erbil, Iraq.,Division of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - Tanja Mueller
- Strathclyde Institute of Pharmacy and Biomedical Science, University of Strathclyde, Glasgow, Scotland, UK
| | - Natalie Weir
- Strathclyde Institute of Pharmacy and Biomedical Science, University of Strathclyde, Glasgow, Scotland, UK
| |
Collapse
|
5
|
Marozzi MS, Mancini F, Loponte L, Solimando AG, Vacca A, Cicco S. Block of the Angiotensin Pathways Affects Flow-Volume Spirometry in Patients with SARS-CoV-2 Infection. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2023; 1438:223-229. [PMID: 37845465 DOI: 10.1007/978-3-031-42003-0_35] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2023]
Abstract
BACKGROUND Angiotensin Converting Enzyme 2 (ACE2) is an endothelial cell receptor used by SARS-CoV- 2 virus to enter cells. Pulmonary function tests (PFTs), mainly spirometry, are the main diagnostic tools for most respiratory diseases. PFTs are mandatory for assessing the response to therapy. AIM We evaluated patients after the SARS-CoV-2 infection through flow-volume spirometry that evaluates the role of drugs inhibiting the ACE2 pathway. MATERIAL AND METHODS We evaluated 112 Caucasian patients 3-6 months after COVID-19 disease, i.e. after the date of negative molecular or antigenic nasopharyngeal swab. The series of patients showed a great variability due to a wide spectrum of age, the severity of disease manifestations, hospitalization, invasive/non-invasive ventilation, comorbidities, the presence/absence of a previous pneumological diagnosis and the variants of the virus. Patients were divided into those who were being treated with angiotensin receptor blocker (ARB) or ACE2 inhibitors (ACEi) (ARB/ACEi, group 1, 23 females and 12 males, aged 63.63 ± 10.40), and those who were not treated with these drugs (group 2, 38 females and 37 males, aged 55.12 ± 16.51). Distal airflow obstruction (DAO) was evaluate as forced expiratory flow (FEF) at 25%, 50% and 75% of total flow. RESULTS Group 1 presented lower peripheral oxygen saturation percentage vs group 2 (96.54 ± 3.06 vs 97.30 ± 1.19%, p < 0.05). Spirometry data were worst in group1: Forced expiratory volume at first minute (FEV1) (91.20 ± 17.09 vs 97.56 ± 16.40%, p < 0.05), Forced vital capacity (94.06 ± 17.48 vs 99.13 ± 17.71%, p < 0.05), and Tiffenau Index (0.78 ± 0.12 vs 0.84 ± 0.10, p < 0.05). There was a DAO in group1. In group 1, we found also a reduction in FEF 25 (73.97 ± 27.28 vs 86.89 ± 22.44%, p < 0.05), FEF 50 (74.69 ± 33.01 vs 85.67 ± 23.74%, p < 0.05), and FEF 25-75 (74.14 ± 35.03 vs 83.92 ± 25.38%, p < 0.05) but not in FEF 75 (73.06 ± 39.37 vs 82.27 ± 43.33%, p < 0.05). DISCUSSION In patients treated with ARB/ACEi the indexes of respiratory function were shifted towards the lower limits (albeit within normal limits). These parameters were significantly reduced compared to patients not treated with these drugs. This indicates that the COVID-19 disease is not only a pulmonary disease, but also a vascular one.
Collapse
Affiliation(s)
- Marialuisa Sveva Marozzi
- Unit of Internal Medicine "G. Baccelli" Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, A.O.U.C. Policlinico di Bari, Bari, Italy
| | - Francesca Mancini
- Unit of Internal Medicine "G. Baccelli" Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, A.O.U.C. Policlinico di Bari, Bari, Italy
| | - Luciana Loponte
- Unit of Internal Medicine "G. Baccelli" Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, A.O.U.C. Policlinico di Bari, Bari, Italy
| | - Antonio Giovanni Solimando
- Unit of Internal Medicine "G. Baccelli" Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, A.O.U.C. Policlinico di Bari, Bari, Italy
| | - Angelo Vacca
- Unit of Internal Medicine "G. Baccelli" Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, A.O.U.C. Policlinico di Bari, Bari, Italy
| | - Sebastiano Cicco
- Unit of Internal Medicine "G. Baccelli" Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, A.O.U.C. Policlinico di Bari, Bari, Italy
| |
Collapse
|
6
|
Filev R, Rostaing L, Lyubomirova M, Bogov B, Kalinov K, Svinarov D. Renin-angiotensin-aldosterone system blockers in Bulgarian COVID-19 patients with or without chronic kidney disease. Medicine (Baltimore) 2022; 101:e31988. [PMID: 36482641 PMCID: PMC9726321 DOI: 10.1097/md.0000000000031988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
When angiotensin-converting enzyme inhibitor/angiotensin receptor blocker-treated patients present with SARS-CoV-2 infection there is a debate to know whether renin-angiotensin-aldosterone (RAAS) blockers should be stopped or not. We conducted a prospective observational study in Bulgarian COVID-19-infected patients with or without chronic kidney disease (CKD) to assess whether maintenance RAAS blocker therapy has an impact on SARS-CoV-2 infection and its complications. We included 120 in-patient COVID-19 subjects, of whom 70 had CKD and 50 had normal renal function. A total of 30% of the patients (total number of 36 patients, 21 females) were receiving RAAS therapy at admission and it was maintained throughout hospitalization. The overall mortality was 19.2% (23 patients); there was no significant difference across the 2 groups (P-value = .21), except in RAAS blockers-treated hypertensive patients who had a significantly lower mortality as compared to non-RAAS-blockers-treated hypertensive patients (P = .04). Regarding subsequent intensive-care unit admission, there were 50% less patients in the RAAS group (4 out of 36, i.e., 11%) as compared to 19 out of 84 from the non-RAAS group, that is, 22.6% (P = .29). Overall, 37 patients developed acute kidney injury (any stage by KDIGO); of them 14 (37.8%) were receiving RAAS blockers. Acute kidney injury was not significantly associated with the use of RAAS blockers (P-value = .28). Likewise, both in non-CKD and in CKD patients the use of RAAS blockers did not have an impact on renal function recovery after SARS-CoV-2 infection. Finally, regarding RAAS blockers and the biological parameters outcome only D-dimers were significantly lower at the follow-up as compared to that in non-RAAS blocker treated patients. RAAS blockers benefited patients with hypertension by lowering mortality rate. Other than that, RAAS blocker therapy continuation during SARS-CoV-2 infection in CKD and non-CKD patients had no significant impact upon major outcomes.
Collapse
Affiliation(s)
- Rumen Filev
- Department of Nephrology, Internal disease Clinic, University Hospital “Saint Anna,” Sofia, Bulgaria
- Medical University Sofia, Bulgaria
| | - Lionel Rostaing
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, Grenoble University Hospital, Grenoble, France
- Grenoble Alpes University, Grenoble, France
- * Correspondence: Lionel Rostaing, Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, Grenoble University Hospital, Grenoble, France (e-mail: )
| | - Mila Lyubomirova
- Department of Nephrology, Internal disease Clinic, University Hospital “Saint Anna,” Sofia, Bulgaria
- Medical University Sofia, Bulgaria
| | - Boris Bogov
- Department of Nephrology, Internal disease Clinic, University Hospital “Saint Anna,” Sofia, Bulgaria
- Medical University Sofia, Bulgaria
| | | | - Dobrin Svinarov
- Medical University Sofia, Bulgaria
- Department of Clinical Laboratory, University Hospital “Alexandrovska,” Sofia, Bulgaria
| |
Collapse
|
7
|
Farhan HA, Yaseen IF, Alomar M, Lenihan D, Dent S, Lyon AR. Global pattern of cardiovascular disease management in patients with cancer and impact of COVID-19 on drug selection: IRAQ—IC-OS survey-based study. Front Cardiovasc Med 2022; 9:979631. [PMID: 36211547 PMCID: PMC9532627 DOI: 10.3389/fcvm.2022.979631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 08/12/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundRegional variations in cardiovascular disease (CVD) and CVD management are well known. However, there is limited information on geographical variations in the discipline of Cardio-Oncology, including both the nature of CVD in patients with cancer and its management. Furthermore, during the recent COVID-19 pandemic, CV care for patients was disrupted resulting in an unknown impact on cardio-oncology services.ObjectiveThe aim of this study was to identify the regional variations in the management of CVD among patients with cancer and the impact of the COVID-19 pandemic on the selection of cardiovascular drugs in cardio-oncology.MethodsAn online survey was conducted by the Iraq Chapter of the International Cardio-Oncology Society (IC-OS). The survey was shared with cardiologists and oncologists in all seven continents to identify whether regional variations exist in cardio-oncology daily practice.ResultsFrom April to July 2021, 140 participants responded to the survey, including cardiologists (72.9%) and oncologists (27.1%). Most of the respondents were from the Middle East (26.4%), North America (25%), Latin America and the Caribbean (25%), and Europe (20.7%). Baseline CV risk assessment in patients with cancer using the HFA/IC-OS score was reported in 75.7% of respondents (78.4% cardiologists and 68.4% oncologists). Hypertension was the most common CVD treated by the survey respondents globally (52.1%) unlike in Europe where heart failure was the most prominent CVD (51.7%). The blood pressure cutoff value to initiate hypertension management is >140/90 mmHg globally (72.9%), but in North America (48.6%) it was >130/80 mmHg. In the Middle East, 43.2% of respondents do not use cardioprotective medication. During the COVID-19 pandemic, 10.7% of respondents changed their practice, such as switching from prescribing ACEI to ARB. Apixaban is the main anticoagulant used in patients with cancer (32.9%); however, in cancer patients with COVID-19 infection, the majority used enoxaparin (31.4%).ConclusionMore than three-quarters of cardiologists and oncologists responding to the survey are using HFA/IC-OS proformas. The survey showed regional variations in the management of CVD on different continents. The use of cardioprotective agents was limited in some regions including the Middle East. COVID-19 pandemic impacted daily practice on the selection and switching of cardiovascular drugs including ACEI/ARB and the choice of anticoagulants.
Collapse
Affiliation(s)
- Hasan Ali Farhan
- Scientific Council of Cardiology, Iraqi Board for Medical Specializations, Baghdad, Iraq
- Baghdad Heart Center, Baghdad Teaching Hospital, Medical City, Baghdad, Iraq
| | - Israa Fadhil Yaseen
- Baghdad Heart Center, Baghdad Teaching Hospital, Medical City, Baghdad, Iraq
- *Correspondence: Israa Fadhil Yaseen
| | - Mohammed Alomar
- University of South Florida, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, United States
| | - Daniel Lenihan
- International Cardio-Oncology Society, Tampa, FL, United States
| | - Susan Dent
- Department of Medicine, Duke Cancer Institute, Duke University, Durham, NC, United States
| | - Alexander R. Lyon
- National Heart and Lung Institute, Imperial College, London, United Kingdom
- Cardio-Oncology Service, Royal Brompton Hospital, London, United Kingdom
| |
Collapse
|
8
|
Najafi N, Davoudi A, Izadyar H, Alishahi A, Mokhtariani A, Soleimanpourian B, Tabarrayi M, Moosazadeh M, Daftarian Z, Ahangarkani F. The effect of ACE inhibitors and ARBs on outcomes in hospitalized patients with COVID-19. Ir J Med Sci 2022:10.1007/s11845-022-03096-6. [PMID: 35854192 PMCID: PMC9296362 DOI: 10.1007/s11845-022-03096-6] [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: 06/01/2022] [Accepted: 07/05/2022] [Indexed: 02/03/2023]
Abstract
Background
Contradictory opinions exist regarding the use of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) in patients with hypertension, which is the most common comorbidity associated with COVID-19. Herein, the effects of ACEIs and ARBs on outcomes of COVID-19 patients were evaluated. Methods In this cross-sectional study, the outcomes of COVID-19 patients were compared between patients who received pretreatment ACEIs or ARBs and those who did not. Results The incidence of moderate and severe forms of COVID-19 was significantly higher in patients taking ACEI/ARB drugs (P-value = 0.012). Also, patients taking ACEI/ARB drugs (P-value = 0.034), patients with hypertension (P-value = 0.011), and patients with dyslipidemia (P-value = 0.011) experienced more severe forms of COVID-19. There was an association between increased length of hospital stay and dyslipidemia (P-value = 0.033) and the use of ACEI/ARB drugs (P-value = 0.041), while no correlation was found between other parameters in univariate linear regression analysis as well as multivariate linear regression. There was an association between increased mortality of patients with increasing age (P-value < 0.001), BMI greater than 30 kg/m2 (P-value = 0.02), asthma (P-value = 0.003), and dyslipidemia (P-value = 0.045). Conclusions ACEI/ARB drugs put COVID-19 patients at high risk for moderate to severe forms of COVID-19 and higher length of hospital stay. Although, it is notable that these drugs did not significantly affect specific adverse outcomes of COVID-19, such as the need for admission to the intensive care unit (ICU), length of ICU stay, ventilation, and mortality.
Collapse
Affiliation(s)
- Narges Najafi
- Antimicrobial Resistance Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Alireza Davoudi
- Antimicrobial Resistance Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Hamideh Izadyar
- Antimicrobial Resistance Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Abbas Alishahi
- Antimicrobial Resistance Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran.,Universal Scientific Education and Research Network (USERN), Tehran, Iran.,Student Research Committee, Mazandaran University of Medical Sciences, Sari, Iran
| | - Armaghan Mokhtariani
- Antimicrobial Resistance Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran.,Universal Scientific Education and Research Network (USERN), Tehran, Iran.,Student Research Committee, Mazandaran University of Medical Sciences, Sari, Iran
| | - Bahareh Soleimanpourian
- Antimicrobial Resistance Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran.,Universal Scientific Education and Research Network (USERN), Tehran, Iran.,Student Research Committee, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mina Tabarrayi
- Antimicrobial Resistance Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran.,Universal Scientific Education and Research Network (USERN), Tehran, Iran.,Student Research Committee, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mahmood Moosazadeh
- Gastrointestinal Cancer Research Center, Non-Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Zahra Daftarian
- Northbay Medical Center, Vacaville Center for Primary Care, Vacaville, CA, USA
| | - Fatemeh Ahangarkani
- Antimicrobial Resistance Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran.
| |
Collapse
|
9
|
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.
Collapse
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
| |
Collapse
|
10
|
The Effect of ACEI/ARB on the Outcomes of COVID-19 Hospitalized Patients. Nephrourol Mon 2022. [DOI: 10.5812/numonthly-121819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
: Considering that there are different reports about the effects of angiotensin II type-I receptor blockers (ARB) and angiotensin-converting enzyme inhibitors (ACEI) on the outcomes of the patients with COVID-19, we aimed to conduct this retrospective study on 138 hypertensive patients (81 ACEI/ARB users) to assess the patients’ outcomes by comparing ACEI/ARB and non-ACEI/ARB users. Multivariate adjusted cox regression model, by considering the effect of other variables, demonstrated that increased age (HR = 1.04, 95% CI = 1.01 -1.07, P =0.003) and non- ACEI/ARB users (HR = 2.12 95% CI = 1.12 - 4.13, P = 0.021) were associated with increased risk of in-hospital mortality in about one week follow-up. In conclusion, we found that in-hospital mortality was lower in ACEI/ARB users, showing the positive effect of these treatments on patients’ outcomes.
Collapse
|
11
|
Bandopadhyay A, Singh AK, Chaubey G. COVID-19: The Cause of the Manifested Cardiovascular Complications During the Pandemic. Front Cardiovasc Med 2021; 8:744482. [PMID: 34778405 PMCID: PMC8581218 DOI: 10.3389/fcvm.2021.744482] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 10/06/2021] [Indexed: 01/10/2023] Open
Abstract
In the course of human history, we encountered several devastating waves of pandemics, affecting millions of lives globally and now the rapid and progressive spread of the novel SARS-CoV-2, causing Coronavirus disease (COVID-19) has created a worldwide wave of crisis. Profoundly straining national health care systems, it also significantly impacted the global economic stability. With the introduction of COVID-19 measures, mainly driven by immunization drives, casualties due to the virus were reported to decrease considerably. But then comes into play the post-Covid morbidities, along with their short and long-term effects on the elderly and the co-morbid population. Moreover, the pediatric population and the otherwise healthy cohort of the young athletes were also reported being largely affected by the varying amount of post-recovery virus-induced Cardiac manifestations, in the subsequent waves of the pandemic. Therefore, here we thrived to find answers to the seemingly unending series of questions that popped up with the advent of the disease, nevertheless, there still lies a blind spot in understanding the impacts of the disease on the Cardiovascular Health of an individual, even after the clinical recovery. Thus, along with the current data related to the diverse cardiovascular complications due to SARS-COV-2 infection, we suggest long-term ‘Cardiac surveillance' for the COVID-19 recovered individuals.
Collapse
Affiliation(s)
- Audditiya Bandopadhyay
- Cytogenetics Laboratory, Department of Zoology, Banaras Hindu University, Varanasi, India
| | - Alok Kumar Singh
- M.D.D.M. (Cardiology), Senior Intervention Cardiologist, Lifeline Hospital, Varanasi, India
| | - Gyaneshwer Chaubey
- Cytogenetics Laboratory, Department of Zoology, Banaras Hindu University, Varanasi, India
| |
Collapse
|
12
|
Angeli F, Verdecchia P, Reboldi G. Pharmacotherapy for hypertensive urgency and emergency in COVID-19 patients. Expert Opin Pharmacother 2021; 23:235-242. [PMID: 34634987 PMCID: PMC8544668 DOI: 10.1080/14656566.2021.1990264] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Introduction Hypertension is a common chronic disorder in patients hospitalized for coronavirus disease 2019 (COVID-19). Furthermore, an exaggerated cardiovascular response with persistently raised blood pressure during hospitalization seems independently associated with in-hospital all-cause mortality, intensive care unit admission and heart failure. However, the real burden of elevated blood pressure during the acute phase of COVID-19 remains undefined. Areas covered The authors review the available evidence on the pharmacotherapy for the treatment of acute elevations in blood pressure (including hypertensive urgency and emergency) in COVID-19 patients. Expert opinion Acute elevations in blood pressure and unstable in-hospital blood pressure may be associated with organ damage and worse outcome in patients with COVID-19. In this setting, hypertensive emergencies require immediate reduction in blood pressure through intravenous treatment according to specific features and goals. Conversely, hypertensive urgencies usually require solely oral treatment. Diuretics, beta-blockers, renin-angiotensin-aldosterone system inhibitors, and calcium channel blockers may be of benefit in treating COVID-19 patients with elevated blood pressure values.
Collapse
Affiliation(s)
- Fabio Angeli
- Department of Medicine and Surgery, University of Insubria - Varese and Department of Medicine and Cardiopulmonary Rehabilitation, Maugeri Care and Research Institute, IRCCS, Tradat, Italy
| | - Paolo Verdecchia
- Fondazione Umbra Cuore E Ipertensione-ONLUS and Division of Cardiology, Hospital S. Maria Della Misericordia, Perugia, Italy
| | - Gianpaolo Reboldi
- Department of Medicine, and Centro Di Ricerca Clinica E Traslazionale (CERICLET), University of Perugia, Perugia, Italy
| |
Collapse
|
13
|
Sackin H. Hypothesis for renin-angiotensin inhibitor mitigation of COVID-19. Med Hypotheses 2021; 152:110609. [PMID: 34048987 PMCID: PMC8114589 DOI: 10.1016/j.mehy.2021.110609] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 04/11/2021] [Accepted: 05/09/2021] [Indexed: 11/30/2022]
Abstract
Preexisting hypertension is a known risk factor for severe COVID-19. Abnormal activation of RAS upregulates angiotensin II (Ang-II) and contributes to severe manifestations of COVID-19. Although RAS inhibitors (RASi) are a mainstay of antihypertensive therapy, they have been associated (in some animal studies) with an increase in angiotensin converting enzyme 2 (ACE2) receptors that facilitate cellular entry of the SARS-CoV-2 virus. Nonetheless, current medical practice does not recommend curtailing RASi to protect hypertensive patients from COVID. On the contrary, there is clinical evidence to support a beneficial effect of RASi for hypertensive patients in the midst of a COVID-19 pandemic, although the precise mechanism for this is unclear. In this paper, we hypothesize that RASi reduces the severity of COVID-19 by promoting ACE2-AT1R complex formation at the cell surface, where AT1R mediates the major vasopressor effects of Ang-II. Furthermore, we propose that the interaction between ACE2 and AT1R impedes binding of SARS-CoV-2 to ACE2, thereby allowing ACE2 to convert Ang-II to the more beneficial Ang(1–7), that has vasodilator and anti-inflammatory activity. Evidence for ACE2-AT1R complex formation during reduced Ang-II comes from receptor colocalization studies in isolated HEK293 cells, but this has not been confirmed in cells having endogenous expression of ACE2 and AT1R. Since the SARS-CoV-2 virus attacks the kidney, as well as the heart and lung, our hypothesis for the effect of RASi on COVID-19 could be tested in vitro using human proximal tubule cells (HK-2), having ACE2 and AT1 receptors. Specifically, colocalization of fluorescent labelled: SARS-CoV-2 spike protein, ACE2, and AT1R in HK-2 cells can be used to clarify the mechanism of RASi action in renal and lung epithelia, which could lead to protocols for reducing the severity of COVID-19 in both hypertensive and normotensive patients.
Collapse
Affiliation(s)
- Henry Sackin
- Department of Physiology and Biophysics & Center for Proteomics and Molecular Therapeutics, The Chicago Medical School, Rosalind Franklin University, North Chicago, IL, United States.
| |
Collapse
|
14
|
Kumar P, Kumar V, Murlidhar F, Fatima A, Jahangir M, Khalid D, Memon MK, Memon S, Kumar B. Comparison Between Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers for Incidence of Lung Cancer: A Retrospective Study. Cureus 2021; 13:e14788. [PMID: 34094750 PMCID: PMC8168993 DOI: 10.7759/cureus.14788] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2021] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Angiotensin-converting enzyme inhibitor (ACEI) and angiotensin II receptor blockers (ARBs) are taken as the first treatment option for hypertensive patients. The various global trials have suggested that ACEIs and ARBs may increase risk of lung cancer; however, the results are contradictory and there is no local study available. This study is conducted to compare the incidence of lung cancers in patients on ACEIs and ARBs. METHODS This retrospective study, conducted in a major cardiology unit of a tertiary care hospital in Pakistan, included patients diagnosed with hypertension, between 2005 and 2010, who were prescribed either ACEIs or ARBs. During the period of 2005 to 2010, 47,823 naïve hypertensive patients were reported in the outpatient department of the cardiology unit. Of which, 22,241 were prescribed ACEI and 25,582 were prescribed ARBs. After sorting patient data based on our inclusion criteria, n = 14,891 participants were included in the ACEI group and n = 19,112 participants were included in the ARB group. RESULTS The incidence of lung cancer in the ACEI and ARB group was n = 165 and n = 160, respectively. In this study, the overall incidence rates of lung cancer in the ACEI and ARB cohorts were 12.2 and 16.6 per 10,000 person-years, respectively. The hazard ratio was 1.32 (95% confidence interval: 1.06-1.64; p-value: 0.01). CONCLUSION In this study, the incidence of lung cancer was relatively more among people using ACEIs than ARBs. Hence, patients undergoing long-term treatment with ACEIs need regular follow-up and proper scanning to avoid grave complications.
Collapse
Affiliation(s)
- Pardeep Kumar
- Medicine, Jinnah Sindh Medical University, Karachi, PAK
| | - Vinod Kumar
- Internal Medicine, Cleveland Clinic Abu Dhabi, Abu Dhabi, ARE
| | - Fnu Murlidhar
- Internal Medicine, Chandka Medical College Hospital, Larkana, PAK
| | - Aliya Fatima
- Internal Medicine, Jinnah Postgraduate Medical Centre, Karachi, PAK
| | - Maha Jahangir
- Anesthesiology, Civil Hospital Karachi, Karachi, PAK
| | - Dua Khalid
- Internal Medicine, Jinnah Sindh Medical University, Karachi, PAK
| | - Muhammad Khizar Memon
- Internal Medicine, Liaquat University of Medical and Health Sciences, Hyderabad, PAK
| | - Sidra Memon
- Internal Medicine, Jinnah Sindh Medical University, Karachi, PAK
| | - Besham Kumar
- Internal Medicine, Jinnah Postgraduate Medical Centre, Karachi, PAK
| |
Collapse
|
15
|
Harky A, Chor CYT, Nixon H, Jeilani M. The controversy of using angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in COVID-19 patients. J Renin Angiotensin Aldosterone Syst 2021; 22:1470320320987118. [PMID: 33412991 PMCID: PMC7797594 DOI: 10.1177/1470320320987118] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest, Liverpool, UK.,Department of Congenital Cardiac Surgery, Alder Hey Children Hospital, Liverpool, UK.,Department of Integrative Biology, Faculty of Life Science, University of Liverpool, Liverpool, UK
| | | | - Henry Nixon
- Department of Medicine, St. George's Hospital Medical School, London, UK
| | - Milad Jeilani
- Maidstone Hospital, Maidstone and Tunbridge Wells NHS Trust, Kent, UK
| |
Collapse
|