The association of COVID-19 occurrence and severity with the use of angiotensin converting enzyme inhibitors or angiotensin-II receptor blockers in patients with hypertension

The Comparative Effectiveness of Monotherapy and Combination Therapies: Impact of Angiotensin Receptor Blockers on the Onset of Alzheimer's Disease

Background

The criteria for use of Alzheimer's disease (AD) drug Leqembi recommended by the Department of Veterans Affairs (VA) include patients aged 65 years or older with mild cognitive impairment (MCI) or mild AD. Comorbidities that include hypertension, hyperlipidemia, and diabetes are common among these patients.

Objectives

Our objective is to investigate the comparative effectiveness of the administration of one, two, or three medications belonging to the categories of angiotensin receptor blockers (ARBs), angiotensin-converting enzyme inhibitors (ACEIs), Beta Blockers, Statins, and Metformin, for their potential to delay the clinical onset of AD and provide a window of opportunity for therapeutic intervention.

Design

Retrospective matched case-control study.

Setting

Data from the Department of Veterans Affairs national corporate data warehouse.

Participants

We conducted an analysis of 122,351 participants (13,611 with AD and 108,740 without AD), aged 65-89, who began at least one of the prescribed medication classes under investigation between October 1998 and April 2018.

Measurements

We utilized Cox proportional hazard regressions, both with and without propensity score weighting, to estimate hazard ratios (HR) associated with the use of different medication combinations for the pre-symptomatic survival time of AD onset. Additionally, we employed a supervised machine learning algorithm (random forest) to assess the relative importance of various therapies in predicting the occurrence of AD.

Result

Adding Metformin to the combination of ACEI+Beta Blocker (HR = 0.56, 95% CI (0.41, 0.77)) reduced the risk of AD onset compared to ACEI monotherapy alone (HR = 0.91, (0.85, 0.98)), Beta Blocker monotherapy (HR = 0.86, 95% CI (0.80, 0.92)), or combined ACEI+Beta Blocker (HR=0.85, 95%CI (0.77, 0.94)), when statin prescribers were used as a reference. Prescriptions of ARB alone or the combination of ARB with Beta Blocker showed an association with a lower risk of AD onset.

Conclusion

Selected medications for the treatment of multiple chronic conditions among elderly individuals with hypertension, hyperlipidemia, and diabetes as monotherapy or combination therapies lengthen the pre-symptomatic period before the onset of AD.

Intrahospital supervised exercise training improves survival rate among hypertensive patients with COVID-19

Among the people most affected by coronavirus disease 2019 (COVID-19) are those suffering from hypertension (HTN). However, pharmacological therapies for HTN are ineffective against COVID-19 progression and severity. It has been proposed that exercise training (EX) could be used as post-COVID treatment, which does not rule out the possible effects during hospitalization for COVID-19. Therefore, we aimed to determine the impact of supervised EX on HTN patients with COVID-19 during hospitalization. Among a total of 1,508 hospitalized patients with COVID-19 (confirmed by PCR), 439 subjects were classified as having HTN and were divided into two groups: EX (n = 201) and control (n = 238) groups. EX (3-4 times/wk during all hospitalizations) consisted of aerobic exercises (15-45 min; i.e., walking); breathing exercises (10-15 min) (i.e., diaphragmatic breathing, pursed-lip breathing, active abdominal contraction); and musculoskeletal exercises (8-10 sets of 12-15 repetitions/wk; lifting dumbbells, standing up and sitting, lumbar stabilization). Our data revealed that the EX (clinician: patient, 1:1 ratio) intervention was able to improve survival rates among controlled HTN patients with COVID-19 during their hospitalization when compared with the control group (chi-squared: 4.83; hazard ratio: 1.8; 95% CI: 1.117 to 2.899; P = 0.027). Multivariate logistic regression analysis revealed that EX was a prognostic marker (odds ratio: 0.449; 95% CI: 0.230-0.874; P = 0.018) along with sex and invasive and noninvasive mechanical ventilation. Our data showed that an intrahospital supervised EX program reduced the mortality rate among patients with HTN suffering from COVID-19 during their hospitalization.NEW & NOTEWORTHY In the present study, we found that exercise training improves the survival rate in hypertensive patients with COVID-19 during their hospitalization period. Our results provide strong evidence for the therapeutic efficacy of exercise training as a feasible approach to improving the outcomes of patients with COVID-19 who suffer from hypertension during their hospitalization.

Counter-regulatory renin-angiotensin system in hypertension: Review and update in the era of COVID-19 pandemic

Cardiovascular disease is the major cause of mortality and disability, with hypertension being the most prevalent risk factor. Excessive activation of the renin-angiotensin system (RAS) under pathological conditions, leading to vascular remodeling and inflammation, is closely related to cardiovascular dysfunction. The counter-regulatory axis of the RAS consists of angiotensin-converting enzyme 2 (ACE2), angiotensin (1-7), angiotensin (1-9), alamandine, proto-oncogene Mas receptor, angiotensin II type-2 receptor and Mas-related G protein-coupled receptor member D. Each of these components has been shown to counteract the effects of the overactivated RAS. In this review, we summarize the latest insights into the complexity and interplay of the counter-regulatory RAS axis in hypertension, highlight the pathophysiological functions of ACE2, a multifunctional molecule linking hypertension and COVID-19, and discuss the function and therapeutic potential of targeting this counter-regulatory RAS axis to prevent and treat hypertension in the context of the current COVID-19 pandemic.

Protective effect of ursodeoxycholic acid on COVID-19 in patients with chronic liver disease

Objective

Ursodeoxycholic acid (UDCA) may reduce susceptibility to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection by downregulating angiotensin-converting enzyme 2 (ACE2), based on recent experimental investigation. This study aimed to determine the potential protective effect of UDCA against SARS-CoV-2 infection in patients with chronic liver disease.

Methods

Patients with chronic liver disease receiving UDCA (taking UDCA ≥1 month) at Beijing Ditan Hospital between January 2022 and December 2022 were consecutively enrolled. These patients were matched in a 1:1 ratio to those with liver disease not receiving UDCA during the same period by using a propensity score matching analysis with nearest neighbor matching algorithm. We conducted a phone survey of coronavirus disease 2019 (COVID-19) infection during the early phase of the pandemic liberation (from 15 December 2022 to 15 January 2023). The risk of COVID-19 was compared in two matched cohorts of 225 UDCA users and 225 non-UDCA users based on patient self-report.

Results

In the adjusted analysis, the control group was superior to the UDCA group in COVID-19 vaccination rates and liver function indicators, including γ-glutamyl transpeptidase and alkaline phosphatase (p < 0.05). UDCA was associated with a lower incidence of SARS-CoV-2 infection (UDCA 85.3% vs. control 94.2%, p = 0.002), more mild cases (80.0% vs. 72.0%, p = 0.047), and shorter median time from infection to recovery (5 vs. 7 days, p < 0.001). Logistic regression analysis showed that UDCA was a significant protective factor against COVID-19 infection (OR: 0.32, 95%CI: 0.16-0.64, p = 0.001). Furthermore, diabetes mellitus (OR: 2.48, 95%CI: 1.11-5.54, p = 0.027) and moderate/severe infection (OR: 8.94, 95%CI: 1.07-74.61, p = 0.043) were more likely to prolong the time from infection to recovery.

Conclusion

UDCA therapy may be beneficial in reducing COVID-19 infection risk, alleviating symptoms, and shortening the recovery time in patients with chronic liver disease. However, it should be emphasized that the conclusions were based on patient self-report rather than classical COVID-19 detection by experimental investigations. Further large clinical and experimental studies are needed to validate these findings.

The effect of renin-angiotensin-aldosterone system inhibitors in patients with hypertension and COVID-19: A meta-analysis of randomized controlled trials and propensity score-matched studies

Background

High-quality evidence for whether the use of renin-angiotensin-aldosterone system (RAAS) inhibitors worsens clinical outcomes for patients with coronavirus disease 2019 (COVID-19) is lacking. The present study aimed to evaluate the effect of RAAS inhibitors on disease severity and mortality in patients with hypertension and COVID-19 using randomized controlled trials (RCTs) and propensity score-matched (PSM) studies.

Methods

A literature search was conducted with PubMed, Embase, and Scopus databases from 31 December 2019 to 10 January 2022. We included RCTs and PSM studies comparing the risk of severe illness or mortality in patients with hypertension and COVID-19 treated or not treated with RAAS inhibitors. Individual trial data were combined to estimate the pooled odds ratio (OR) with a random-effects model.

Results

A total of 17 studies (4 RCTs and 13 PSM studies) were included in the meta-analysis. The use of RAAS inhibitors was not associated with an increased risk of severe illness (OR=1.00, 95% confidence interval [CI]: 0.88-1.14, I²=28%) or mortality (OR=0.96, 95% CI: 0.83-1.11, I²=16%) for patients with hypertension and COVID-19. Furthermore, there was no significant difference in the severity of COVID-19 when patients continued or discontinued treatment with RAAS inhibitors (OR=1.01, 95% CI: 0.78-1.29, I²=0%).

Conclusions

This study suggests that there was no association between treatment with RAAS inhibitors and worsened COVID-19 disease outcomes. Our findings support the current guidelines that RAAS inhibitors should be continued in the setting of the COVID-19 pandemic. However, the benefit of RAAS inhibitor medications for COVID-19 patients should be further validated with more RCTs.

Renin-Angiotensin-Aldosterone Inhibitors and COVID-19 Infection

Purpose of Review

This review summarises the literature data and provides an overview of the role and impact of the use of renin–angiotensin–aldosterone system (RAAS) inhibitors in patients with coronavirus disease 2019 (COVID-19) infection.

Recent Findings

The angiotensin-converting enzyme 2 (ACE2) has a key role in the regulation of the RAAS pathway, downregulating angiotensin II and attenuating inflammation, vasoconstriction and oxidative stress. Additionally, it plays an instrumental part in COVID-19 infection as it facilitates the cell entry of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and enables its replication. The use and role of RAAS inhibitors therefore during the COVID-19 pandemic have been intensively investigated.

Summary

Although it was initially assumed that RAAS inhibitors may relate to worse clinical outcomes and severe disease, data from large studies and meta-analyses demonstrated that they do not have an adverse impact on clinical outcomes or prognosis. On the contrary, some experimental and retrospective observational cohort studies showed a potential protective mechanism, although this effect remains to be seen in large clinical trials.

Renin-Angiotensin Aldosterone System Inhibitors and COVID-19: A Systematic Review and Meta-Analysis Revealing Critical Bias Across a Body of Observational Research

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.

Clinical outcomes of COVID-19 infection among patients with Alzheimer's disease or mild cognitive impairment

INTRODUCTION

Alzheimer's disease (AD) and COVID-19 share common risk factors including hypertension. Angiotensin converting enzyme inhibitors (ACEI) and angiotensin II receptor blockers (ARB) are frequently prescribed antihypertension medications.

METHODS

This study analyzed 436,823 veterans tested for SARS-CoV-2 infection. We conducted both classical and propensity score weighted logistic models to compare COVID-19 outcomes between patients with AD or mild cognitive impairment (MCI) to those without cognitive impairment, and examined effect of ACEI/ARB prescription.

RESULTS

There was a statistically significant association between AD and increased odds of infection and mortality. MCI was not found to be a risk factor for infection. Subjects with MCI exhibited poor clinical outcomes. Prescribing ARBs but not ACEIs was significantly associated with a lower risk of COVID-19 occurrence among AD and MCI patients.

DISCUSSION

Exploring beneficial effects of existing medications to reduce the impact of COVID-19 on patients with AD or MCI is highly significant.

HIGHLIGHTS

There is significant association between Alzheimer's disease (AD) and increased risk of COVID-19 infection and odds of mortality. Subjects with mild cognitive impairment (MCI) defined by claims data exhibit poor clinical outcomes, but MCI was not found to be a risk factor for severe acute respiratory syndrome coronavirus 2 infection. Prescribing angiotensin II receptor blockers was significantly associated with a lower risk of COVID-19 occurrence among AD/MCI patients.

Safety of ACEi and ARB in COVID-19 management: A retrospective analysis

Background & Aims

Severe acute respiratory syndrome coronavirus 2 (SARS‐CoV2)is a highly contagious virus that has infected 260 million individuals since December 2019. The severity of coronavirus disease 2019 (COVID‐19) depends upon the complex interplay between viral factors and the host's inflammatory response, which can trigger a cascadeeventually leading to multiorgan failure. There is contradictory evidence that angiotensin‐converting enzyme (ACEi) or angiotensin receptor blockers (ARBs) may affect mortality in patients with severe COVID‐19, theoretically due to interaction with the bradykinin pathway. Therefore, we aim to explore the association between ACEi and ARB use and mortality in severe SARS‐CoV2 infection.Severe acute respiratory yndrome with coronavirus (SARS‐CoV2) is a highly contagious virus that has infected 260 million individuals since December 2019. The severity of COVID‐19 depends upon the complex interplay between viral factors and the host's inflammatory response, which can trigger a cascadeeventually leading to multiorgan failure. There is contradictory evidence that angiotensin‐converting enzyme (ACEi) or angiotensin receptor blockers (ARBs) may affect mortality in patients with severe COVID‐19, theoretically due to interaction with the bradykinin pathway. Therefore, we aim to explore the association between ACEi and ARB use and mortality in severe SARS‐CoV2 infection.

Materials & Methodology

This multicenter retrospective observational study enrolled 2935 COVID‐19 patients admitted at six hospitals in Southern California, USA, between March 2020 and August 2021. Our primary outcome was the association of pre‐hospital use of ACEi and ARB on in‐hospital mortality in COVID‐19 patients. First, relevant deidentified patient data were extracted using an SQL program from the electronic medical record. Then, a bivariate analysis of the relationship between ACEi and ARB use and different study variables using χ² and t test was done. Finally, we did a backward selection Cox multivariate regression analysis using mortality as a dependent variable.

Results

Of the 2935 patients in the study, hypertension was present in 40.6%, and congestive heart failure in 13.8%. ACEi and ARB were used by 17.5% and 11.3% of patients, respectively, with 28.8% of patients on either medication. After adjusting for confounding variables in the multivariate analysis, the use of ACEi (HR: 1.226, 95% CI: 0.989–1.520) or ARB (HR: 0.923, 95% CI: 0.701–1.216) was not independently associated with increased mortality.

Conclusion

Our results are consistent with the clinical guidelines and position statements per the International Society of Hypertension, that there is no indication to stop the use of ACEi/ARB in COVID‐19 patients.

Neutralizing antibody responses over time in demographically and clinically diverse individuals recovered from SARS-CoV-2 infection in the United States and Peru: A cohort study

BACKGROUND

People infected with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) experience a wide range of clinical manifestations, from asymptomatic and mild illness to severe illness and death, influenced by age and a variety of comorbidities. Neutralizing antibodies (nAbs) are thought to be a primary immune defense against the virus. Large, diverse, well-characterized cohorts of convalescent individuals provide standardized values to benchmark nAb responses to past SARS-CoV-2 infection and define potentially protective levels of immunity.

METHODS AND FINDINGS

This analysis comprises an observational cohort of 329 HIV-seronegative adults in the United States (n = 167) and Peru (n = 162) convalescing from SARS-CoV-2 infection from May through October 2020. The mean age was 48 years (range 18 to 86), 54% of the cohort overall was Hispanic, and 34% identified as White. nAb titers were measured in serum by SARS-CoV-2.D614G Spike-pseudotyped virus infection of 293T/ACE2 cells. Multiple linear regression was applied to define associations between nAb titers and demographic variables, disease severity and time from infection or disease onset, and comorbidities within and across US and Peruvian cohorts over time. nAb titers peaked 28 to 42 days post-diagnosis and were higher in participants with a history of severe Coronavirus Disease 2019 (COVID-19) (p < 0.001). Diabetes, age >55 years, male sex assigned at birth, and, in some cases, body mass index were also independently associated with higher nAb titers, whereas hypertension was independently associated with lower nAb titers. nAb titers did not differ by race, underlying pulmonary disease or smoking. Two months post-enrollment, nAb ID50 (ID80) titers declined 3.5 (2.8)-fold overall. Study limitations in this observational, convalescent cohort include survivorship bias and missing early viral loads and acute immune responses to correlate with the convalescent responses we observed.

CONCLUSIONS

In summary, in our cohort, nAb titers after SARS-CoV-2 infection peaked approximately 1 month post-diagnosis and varied by age, sex assigned at birth, disease severity, and underlying comorbidities. Our data show great heterogeneity in nAb responses among people with recent COVID-19, highlighting the challenges of interpreting natural history studies and gauging responses to vaccines and therapeutics among people with recent infection. Our observations illuminate potential correlations of demographic and clinical characteristics with nAb responses, a key element for protection from COVID-19, thus informing development and implementation of preventative and therapeutic strategies globally.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04403880.

Coronavirus Disease (COVID-19) Control between Drug Repurposing and Vaccination: A Comprehensive Overview

Respiratory viruses represent a major public health concern, as they are highly mutated, resulting in new strains emerging with high pathogenicity. Currently, the world is suffering from the newly evolving severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This virus is the cause of coronavirus disease 2019 (COVID-19), a mild-to-severe respiratory tract infection with frequent ability to give rise to fatal pneumonia in humans. The overwhelming outbreak of SARS-CoV-2 continues to unfold all over the world, urging scientists to put an end to this global pandemic through biological and pharmaceutical interventions. Currently, there is no specific treatment option that is capable of COVID-19 pandemic eradication, so several repurposed drugs and newly conditionally approved vaccines are in use and heavily applied to control the COVID-19 pandemic. The emergence of new variants of the virus that partially or totally escape from the immune response elicited by the approved vaccines requires continuous monitoring of the emerging variants to update the content of the developed vaccines or modify them totally to match the new variants. Herein, we discuss the potential therapeutic and prophylactic interventions including repurposed drugs and the newly developed/approved vaccines, highlighting the impact of virus evolution on the immune evasion of the virus from currently licensed vaccines for COVID-19.