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Zappa M, Verdecchia P, Andolina A, Spanevello A, Angeli F. Complications of SARS-CoV-2 Infection During Cardiac Rehabilitation: A Case Series. Cardiol Ther 2023; 12:533-538. [PMID: 37453974 PMCID: PMC10423178 DOI: 10.1007/s40119-023-00325-6] [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: 03/08/2023] [Accepted: 06/22/2023] [Indexed: 07/18/2023] Open
Abstract
INTRODUCTION Vaccination strongly reduces the risk of hospitalization and death due to coronavirus disease 2019 (COVID-19). However, the severity of the acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection and the degree of protection exerted over time by vaccination remains to be fully elucidated among hospitalized comorbid and vulnerable patients with SARS-CoV-2 infection. METHODS We report a case series of nine hospitalized vulnerable patients who developed a SARS-CoV-2 infection during a cardiac rehabilitation inpatient program. RESULTS Age ranged from 50 to 81 years. All but one patient had received at least three doses of anti-COVID-19 vaccine more than 4 months before the cardiac event. Indications for cardiac rehabilitation included acute coronary syndromes, congestive heart failure, heart valve surgery, and coronary artery bypass graft. After the confirmed diagnosis of SARS-CoV-2 infection, all patients developed symptoms. Eight patients developed at least one SARS-CoV-2-related complication, including a significant increase in high-sensitivity troponin I levels, new-onset hypoxemia, persistent atrial fibrillation, non-sustained ventricular tachycardia and recurrent sinus arrest, pericardial effusion, and a persistent increase in blood pressure. CONCLUSION Almost all patients developed complications which, however, did not evolve towards more severe expressions of the disease. These data suggest that even in this new phase of the pandemic, vaccination may exert a potential role to reduce the risk of progression towards more severe disease of SARS-CoV-2 infection in vulnerable patients with cardiovascular comorbidities.
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Affiliation(s)
- Martina Zappa
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Paolo Verdecchia
- Fondazione Umbra Cuore e Ipertensione-ONLUS and Division of Cardiology, Hospital S. Maria della Misericordia, Perugia, Italy
| | - Andrea Andolina
- Department of Medicine and Cardiopulmonary Rehabilitation, Istituti Clinici Scientifici Maugeri, IRCCS Tradate, Via Crotto Roncaccio 16, Tradate, VA, Italy
| | - Antonio Spanevello
- Department of Medicine and Cardiopulmonary Rehabilitation, Istituti Clinici Scientifici Maugeri, IRCCS Tradate, Via Crotto Roncaccio 16, Tradate, VA, Italy
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Fabio Angeli
- Department of Medicine and Technological Innovation (DiMIT), University of Insubria, Varese, Italy.
- Department of Medicine and Cardiopulmonary Rehabilitation, Istituti Clinici Scientifici Maugeri, IRCCS Tradate, Via Crotto Roncaccio 16, Tradate, VA, Italy.
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Angeli F. New Perspectives and Strategies for the Management of Hypertension. J Cardiovasc Dev Dis 2023; 10:346. [PMID: 37623359 PMCID: PMC10455940 DOI: 10.3390/jcdd10080346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 08/08/2023] [Indexed: 08/26/2023] Open
Abstract
Hypertension is the leading preventable risk factor for cardiovascular disease and all-cause mortality worldwide [...].
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Affiliation(s)
- Fabio Angeli
- Department of Medicine and Technological Innovation (DiMIT), University of Insubria, 21100 Varese, Italy;
- Department of Medicine and Cardiopulmonary Rehabilitation, Istituti Clinici Scientifici Maugeri IRCCS, 21049 Tradate, Italy
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Hamada S, Suzuki T, Tokuda Y, Taniguchi K, Shibuya K. Comparing clinical outcomes of ARB and ACEi in patients hospitalized for acute COVID-19. Sci Rep 2023; 13:11810. [PMID: 37479767 PMCID: PMC10361955 DOI: 10.1038/s41598-023-38838-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 07/16/2023] [Indexed: 07/23/2023] Open
Abstract
Continued receipt of Renin-Angiotensin-Aldosterone inhibitors in patients with COVID-19 has shown potential in producing better clinical outcomes. However, superiority between ACEi (angiotensin-converting enzyme inhibitors) and ARB (angiotensin II receptor blockers) regarding clinical outcomes in this setting remains unknown. We retrospectively collected data on patients hospitalized for acute COVID-19 using the nationwide administrative database (Diagnosis and Procedure Combinations, DPC). The DPC data covered around 25% of all acute care hospitals in Japan. Patient outcomes, with focus on inpatient mortality, were compared between patients previously prescribed ACEi and those prescribed ARB. Comparisons based on crude, multivariate and propensity-score adjusted analysis were conducted. We examined a total of 7613 patients (ARB group, 6903; ACEi group 710). The ARB group showed lower crude in-hospital mortality, compared to the ACEi group (5% vs 8%; odds ratio, 0.65; 95% CI 0.48-0.87), however not in the multivariate-adjusted model (odds ratio, 0.95; 95% CI 0.69-1.3) or propensity-score adjusted models (odds ratio, 0.86; 95% CI 0.63-1.2). ARB shows potential in reducing hospital stay duration over ACEi in patients admitted for COVID-19, but does not significantly reduce in-hospital mortality. Further prospective studies are needed to draw a definitive conclusion, but continuation of either of these medications is warranted to improve clinical outcomes.
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Affiliation(s)
| | | | - Yasuharu Tokuda
- The Tokyo Foundation for Policy Research, Minato-ku, Tokyo, Japan.
- Muribushi Okinawa Center for Teaching Hospitals, 3-42-8 Iso, Urasoe, Okinawa, 901-2132, Japan.
- University of Tsukuba School of Medicine, Tsukuba, Japan.
| | - Kiyosu Taniguchi
- National Hospital Organization Mie National Hospital, Tsu, Mie, Japan
| | - Kenji Shibuya
- The Tokyo Foundation for Policy Research, Minato-ku, Tokyo, Japan
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Swiderski J, Gadanec LK, Apostolopoulos V, Moore GJ, Kelaidonis K, Matsoukas JM, Zulli A. Role of Angiotensin II in Cardiovascular Diseases: Introducing Bisartans as a Novel Therapy for Coronavirus 2019. Biomolecules 2023; 13:787. [PMID: 37238657 PMCID: PMC10216788 DOI: 10.3390/biom13050787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 04/26/2023] [Accepted: 04/27/2023] [Indexed: 05/28/2023] Open
Abstract
Cardiovascular diseases (CVDs) are the main contributors to global morbidity and mortality. Major pathogenic phenotypes of CVDs include the development of endothelial dysfunction, oxidative stress, and hyper-inflammatory responses. These phenotypes have been found to overlap with the pathophysiological complications of coronavirus disease 2019 (COVID-19). CVDs have been identified as major risk factors for severe and fatal COVID-19 states. The renin-angiotensin system (RAS) is an important regulatory system in cardiovascular homeostasis. However, its dysregulation is observed in CVDs, where upregulation of angiotensin type 1 receptor (AT1R) signaling via angiotensin II (AngII) leads to the AngII-dependent pathogenic development of CVDs. Additionally, the interaction between the spike protein of severe acute respiratory syndrome coronavirus 2 with angiotensin-converting enzyme 2 leads to the downregulation of the latter, resulting in the dysregulation of the RAS. This dysregulation favors AngII/AT1R toxic signaling pathways, providing a mechanical link between cardiovascular pathology and COVID-19. Therefore, inhibiting AngII/AT1R signaling through angiotensin receptor blockers (ARBs) has been indicated as a promising therapeutic approach to the treatment of COVID-19. Herein, we review the role of AngII in CVDs and its upregulation in COVID-19. We also provide a future direction for the potential implication of a novel class of ARBs called bisartans, which are speculated to contain multifunctional targeting towards COVID-19.
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Affiliation(s)
- Jordan Swiderski
- Institute for Health and Sport, Victoria University, Melbourne, VIC 3030, Australia; (J.S.); (L.K.G.); (V.A.)
| | - Laura Kate Gadanec
- Institute for Health and Sport, Victoria University, Melbourne, VIC 3030, Australia; (J.S.); (L.K.G.); (V.A.)
| | - Vasso Apostolopoulos
- Institute for Health and Sport, Victoria University, Melbourne, VIC 3030, Australia; (J.S.); (L.K.G.); (V.A.)
- Immunology Program, Australian Institute for Musculoskeletal Science, Melbourne, VIC 3021, Australia
| | - Graham J. Moore
- Pepmetics Incorporated, 772 Murphy Place, Victoria, BC V8Y 3H4, Canada;
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada
| | | | - John M. Matsoukas
- Institute for Health and Sport, Victoria University, Melbourne, VIC 3030, Australia; (J.S.); (L.K.G.); (V.A.)
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada
- NewDrug PC, Patras Science Park, 26500 Patras, Greece;
- Department of Chemistry, University of Patras, 26504 Patras, Greece
| | - Anthony Zulli
- Institute for Health and Sport, Victoria University, Melbourne, VIC 3030, Australia; (J.S.); (L.K.G.); (V.A.)
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Angeli F, Zappa M, Reboldi G, Gentile G, Trapasso M, Spanevello A, Verdecchia P. The spike effect of acute respiratory syndrome coronavirus 2 and coronavirus disease 2019 vaccines on blood pressure. Eur J Intern Med 2023; 109:12-21. [PMID: 36528504 PMCID: PMC9744686 DOI: 10.1016/j.ejim.2022.12.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 12/07/2022] [Accepted: 12/12/2022] [Indexed: 12/14/2022]
Abstract
Among the various comorbidities potentially worsening the clinical outcome in patients hospitalized for the acute respiratory syndrome coronavirus-2 (SARS-CoV-2), hypertension is one of the most prevalent. However, the basic mechanisms underlying the development of severe forms of coronavirus disease 2019 (COVID-19) among hypertensive patients remain undefined and the direct association of hypertension with outcome in COVID-19 is still a field of debate. Experimental and clinical data suggest that SARS-CoV-2 infection promotes a rise in blood pressure (BP) during the acute phase of infection. Acute increase in BP and high in-hospital BP variability may be tied with acute organ damage and a worse outcome in patients hospitalized for COVID-19. In this context, the failure of the counter-regulatory renin-angiotensin-system (RAS) axis is a potentially relevant mechanism involved in the raise in BP. It is well recognized that the efficient binding of the Spike (S) protein to angiotensin converting enzyme 2 (ACE2) receptors mediates the virus entry into cells. Internalization of ACE2, downregulation and malfunction predominantly due to viral occupation, dysregulates the protective RAS axis with increased generation and activity of angiotensin (Ang) II and reduced formation of Ang1,7. Thus, the imbalance between Ang II and Ang1-7 can directly contribute to excessively rise BP in the acute phase of SARS-CoV-2 infection. A similar mechanism has been postulated to explain the raise in BP following COVID-19 vaccination ("Spike Effect" similar to that observed during the infection of SARS-CoV-2). S proteins produced upon vaccination have the native-like mimicry of SARS-CoV-2 S protein's receptor binding functionality and prefusion structure and free-floating S proteins released by the destroyed cells previously targeted by vaccines may interact with ACE2 of other cells, thereby promoting ACE2 internalization and degradation, and loss of ACE2 activities.
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Affiliation(s)
- Fabio Angeli
- Department of Medicine and Surgery, University of Insubria, Varese, 21100, Italy; Department of Medicine and Cardiopulmonary Rehabilitation, Maugeri Care and Research Institute, IRCCS Tradate, 21049, Italy.
| | - Martina Zappa
- Department of Medicine and Surgery, University of Insubria, Varese, 21100, Italy
| | - Gianpaolo Reboldi
- Department of Medicine, and Centro di Ricerca Clinica e Traslazionale (CERICLET), University of Perugia, Perugia, 06100, Italy
| | - Giorgio Gentile
- College of Medicine and Health. University of Exeter, Exeter, United Kingdom and Department of Nephrology, Royal Cornwall Hospitals NHS Trust, Truro, United Kingdom
| | - Monica Trapasso
- Dipartimento di Igiene e Prevenzione Sanitaria, PSAL, Sede Territoriale di Varese, ATS Insubria, Varese, 21100, Italy
| | - Antonio Spanevello
- Department of Medicine and Surgery, University of Insubria, Varese, 21100, Italy; Department of Medicine and Cardiopulmonary Rehabilitation, Maugeri Care and Research Institute, IRCCS Tradate, 21049, Italy
| | - Paolo Verdecchia
- Division of Cardiology, Hospital S. Maria della Misericordia, Perugia, and Fondazione Umbra Cuore e Ipertensione-ONLUS, Perugia, 06100, Italy
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mRNA Metabolism and Hypertension. Biomedicines 2023; 11:biomedicines11010118. [PMID: 36672629 PMCID: PMC9855994 DOI: 10.3390/biomedicines11010118] [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: 12/08/2022] [Revised: 12/28/2022] [Accepted: 12/28/2022] [Indexed: 01/05/2023] Open
Abstract
Hypertension is the most frequent cardiovascular risk factor all over the world. It remains a leading contributor to the risk of cardiovascular events and death. In the year 2015, about 1.5 billion of adult people worldwide had hypertension (as defined by office systolic blood pressure ≥ 140 mmHg or office diastolic blood pressure ≥ 90 mmHg). Moreover, the number of hypertensive patients with age ranging from 30 to 79 years doubled in the last 30 years (from 317 million men and 331 million women in the year 1990 to 652 million men and 626 million women in 2019) despite stable age-standardized prevalence worldwide. Despite such impressive growth, the proportion of controlled hypertension is very low. A better understanding of the pathogenesis of hypertension may contribute to the development of innovative therapeutic strategies. In this context, alterations of the messenger RNA metabolism have been recently evaluated as contributors to the pathogenesis of hypertension, and pharmacological modulation of RNA metabolism is under investigation as potential and novel therapeutic armamentarium in hypertension.
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Angeli F, Zappa M, Verdecchia P. Rethinking the Role of the Renin-Angiotensin System in the Pandemic Era of SARS-CoV-2. J Cardiovasc Dev Dis 2023; 10:jcdd10010014. [PMID: 36661909 PMCID: PMC9862389 DOI: 10.3390/jcdd10010014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 12/26/2022] [Accepted: 12/29/2022] [Indexed: 01/03/2023] Open
Abstract
After assessing the levels of spread and severity of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, academic literature focused on the pathophysiology of coronavirus disease 2019 (COVID-19) [...].
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Affiliation(s)
- Fabio Angeli
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy
- Department of Medicine and Cardiopulmonary Rehabilitation, Istituti Clinici Scientifici Maugeri IRCCS, 21049 Tradate, Italy
- Correspondence:
| | - Martina Zappa
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy
| | - Paolo Verdecchia
- Fondazione Umbra Cuore e Ipertensione-ONLUS, and Division of Cardiology, Hospital S. Maria della Misericordia, 06100 Perugia, Italy
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Endothelial Dysfunction in COVID-19: Potential Mechanisms and Possible Therapeutic Options. LIFE (BASEL, SWITZERLAND) 2022; 12:life12101605. [PMID: 36295042 PMCID: PMC9604693 DOI: 10.3390/life12101605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 09/29/2022] [Accepted: 10/12/2022] [Indexed: 11/06/2022]
Abstract
SARS-CoV-2, a novel coronavirus found in Wuhan (China) at the end of 2019, is the etiological agent of the current pandemic that is a heterogeneous disease, named coronavirus disease 2019 (COVID-19). SARS-CoV-2 affects primarily the lungs, but it can induce multi-organ involvement such as acute myocardial injury, myocarditis, thromboembolic eventsandrenal failure. Hypertension, chronic kidney disease, diabetes mellitus and obesity increase the risk of severe complications of COVID-19. There is no certain explanation for this systemic COVID-19 involvement, but it could be related to endothelial dysfunction, due to direct (endothelial cells are infected by the virus) and indirect damage (systemic inflammation) factors. Angiotensin-converting enzyme 2 (ACE2), expressed in human endothelium, has a fundamental role in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. In fact, ACE2 is used as a receptor by SARS-CoV-2, leading to the downregulation of these receptors on endothelial cells; once inside, this virus reduces the integrity of endothelial tissue, with exposure of prothrombotic molecules, platelet adhesion, activation of coagulation cascades and, consequently, vascular damage. Systemic microangiopathy and thromboembolism can lead to multi-organ failure with an elevated risk of death. Considering the crucial role of the immunological response and endothelial damage in developing the severe form of COVID-19, in this review, we will attempt to clarify the underlying pathophysiological mechanisms.
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Chu C, Schönbrunn A, Klemm K, von Baehr V, Krämer BK, Elitok S, Hocher B. Impact of hypertension on long-term humoral and cellular response to SARS-CoV-2 infection. Front Immunol 2022; 13:915001. [PMID: 36119050 PMCID: PMC9478933 DOI: 10.3389/fimmu.2022.915001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 08/15/2022] [Indexed: 12/15/2022] Open
Abstract
It was shown that hypertension delays SARS CoV-2 viral clearance and exacerbates airway hyperinflammation in the respiratory tract. However, it is unknown whether hypertension determines the long-term cellular and humoral response to SARS Cov2. Health care workers (HCWs) after an outbreak of SARS Cov-2 infections were analyzed. Infected HCWs were not vaccinated before blood collection. 5-14 months (median 7 months) after detection of SARS CoV-2 infection, blood was taken to analyze humoral response (S1 IgG and SARS CoV-2 neutralizing antibodies) and cellular (T cell responses to SARS-CoV-2 with Lymphocyte Transformation Test). To identify clinical factors that determine the immune response, a multivariate regression analysis was done considering age, BMI, sex, diabetes, hypertension, smoking, COPD, asthma and time between PCR positivity and blood collection as confounding factors. Infected hypertensive HCWs more often needed to be hospitalized than non-hypertensive HCWs, but were less likely to develop anosmia and myalgia. The long-term humoral and cellular immune response was significantly strengthened in hypertensive versus normotensive infected HCWs. Multivariate regression analysis revealed that hypertension was independently associated with the humoral response to SARS CoV-2 infection. Multivariate regression analysis using same confounding factors for the humoral response showed a clear trend for an association with the cellular response to SARS CoV-2 infection as well. In conclusion, SARS CoV-2 infection strengthened immune response to SARS CoV-2 infection in hypertensive HCWs independent of other risk factors.
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Affiliation(s)
- Chang Chu
- Fifth Department of Medicine (Nephrology/Endocrinology/Rheumatology/Pneumology), University Medical Centre Mannheim, University of Heidelberg, Heidelberg, Germany
- Department of Nephrology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Anne Schönbrunn
- Institute of Medical Diagnostics (IMD) Berlin-Potsdam, Berlin, Germany
| | - Kristin Klemm
- Fifth Department of Medicine (Nephrology/Endocrinology/Rheumatology/Pneumology), University Medical Centre Mannheim, University of Heidelberg, Heidelberg, Germany
- Department of Nephrology and Endocrinology, Ernst von Bergmann Hospital Potsdam, Potsdam, Germany
| | - Volker von Baehr
- Institute of Medical Diagnostics (IMD) Berlin-Potsdam, Berlin, Germany
| | - Bernhard K. Krämer
- Fifth Department of Medicine (Nephrology/Endocrinology/Rheumatology/Pneumology), University Medical Centre Mannheim, University of Heidelberg, Heidelberg, Germany
- European Center for Angioscience (ECAS), Faculty of Medicine of the University of Heidelberg, Mannheim, Germany
- Center for Preventive Medicine and Digital Health Baden-Württemberg, Center for Preventive Medicine and Digital Health Baden-Württemberg (CPDBW), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Mannheim Institute for Innate Immunoscience, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany
| | - Saban Elitok
- Fifth Department of Medicine (Nephrology/Endocrinology/Rheumatology/Pneumology), University Medical Centre Mannheim, University of Heidelberg, Heidelberg, Germany
- Department of Nephrology and Endocrinology, Ernst von Bergmann Hospital Potsdam, Potsdam, Germany
- *Correspondence: Berthold Hocher, ; Saban Elitok,
| | - Berthold Hocher
- Fifth Department of Medicine (Nephrology/Endocrinology/Rheumatology/Pneumology), University Medical Centre Mannheim, University of Heidelberg, Heidelberg, Germany
- Institute of Medical Diagnostics (IMD) Berlin-Potsdam, Berlin, Germany
- Key Laboratory of Study and Discovery of Small Targeted Molecules of Hunan Province, School of Medicine, Hunan Normal University, Changsha, China
- Reproductive and Genetic Hospital of China International Trust Investment Corporation (CITIC)-Xiangya, Changsha, China
- *Correspondence: Berthold Hocher, ; Saban Elitok,
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Angeli F, Reboldi G, Trapasso M, Zappa M, Spanevello A, Verdecchia P. COVID-19, vaccines and deficiency of ACE 2 and other angiotensinases. Closing the loop on the "Spike effect". Eur J Intern Med 2022; 103:23-28. [PMID: 35753869 PMCID: PMC9217159 DOI: 10.1016/j.ejim.2022.06.015] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 06/20/2022] [Indexed: 11/03/2022]
Abstract
The role of a dysregulated renin-angiotensin system (RAS) in the pathogenesis of COVID-19 is well recognized. The imbalance between angiotensin II (Ang II) and Angiotensin1-7 (Ang1,7) caused by the interaction between SARS-CoV-2 and the angiotensin converting enzyme 2 (ACE2) receptors exerts a pivotal role on the clinical picture and outcome of COVID-19. ACE2 receptors are not the exclusive angiotensinases in nature. Other angiotensinases (PRCP, and POP) have the potential to limit the detrimental effects of the interactions between ACE2 and the Spike proteins. In the cardiovascular disease continuum, ACE2 activity tends to decrease, and POP/PRCP activity to increase, from the health status to advanced deterioration of the cardiovascular system. The failure of the counter-regulatory RAS axis during the acute phase of COVID-19 is characterized by a decrease of ACE2 expression coupled to unchanged activity of other angiotensinases, therefore failing to limit the accumulation of Ang II. COVID-19 vaccines increase the endogenous synthesis of SARS-CoV-2 spike proteins. Once synthetized, the free-floating spike proteins circulate in the blood, interact with ACE2 receptors and resemble the pathological features of SARS-CoV-2 ("Spike effect" of COVID-19 vaccines). It has been noted that an increased catalytic activity of POP/PRCP is typical in elderly individuals with comorbidities or previous cardiovascular events, but not in younger people. Thus, the adverse reactions to COVID-19 vaccination associated with Ang II accumulation are generally more common in younger and healthy subjects. Understanding the relationships between different mechanisms of Ang II cleavage and accumulation offers the opportunity to close the pathophysiological loop between the risk of progression to severe forms of COVID-19 and the potential adverse events of vaccination.
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Affiliation(s)
- Fabio Angeli
- Department of Medicine and Surgery, University of Insubria, Varese, Italy; Department of Medicine and Cardiopulmonary Rehabilitation, Maugeri Care and Research Institute, IRCCS, Tradate, Italy.
| | - Gianpaolo Reboldi
- Department of Medicine, and Centro di Ricerca Clinica e Traslazionale (CERICLET), University of Perugia, Perugia, Italy
| | - Monica Trapasso
- Dipartimento di Igiene e Prevenzione Sanitaria, ATS Insubria, PSAL, Sede Territoriale di Varese, Varese, Italy
| | - Martina Zappa
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Antonio Spanevello
- Department of Medicine and Surgery, University of Insubria, Varese, Italy; Department of Medicine and Cardiopulmonary Rehabilitation, Maugeri Care and Research Institute, IRCCS, Tradate, Italy
| | - Paolo Verdecchia
- Division of Cardiology, Hospital S. Maria Della Misericordia, Perugia, Italy; Fondazione Umbra Cuore e Ipertensione-ONLUS, Perugia, Italy
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Sonaglioni A, Lombardo M, Albini A, Noonan DM, Re M, Cassandro R, Elia D, Caminati A, Nicolosi GL, Harari S. Charlson comorbidity index, neutrophil-to-lymphocyte ratio and undertreatment with renin-angiotensin-aldosterone system inhibitors predict in-hospital mortality of hospitalized COVID-19 patients during the omicron dominant period. Front Immunol 2022; 13:958418. [PMID: 36090992 PMCID: PMC9453812 DOI: 10.3389/fimmu.2022.958418] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 08/04/2022] [Indexed: 11/24/2022] Open
Abstract
Purpose To investigate the clinical predictors of in-hospital mortality in hospitalized patients with Coronavirus disease 2019 (COVID-19) infection during the Omicron period. Methods All consecutive hospitalized laboratory‐confirmed COVID-19 patients between January and May 2022 were retrospectively analyzed. All patients underwent accurate physical, laboratory, radiographic and echocardiographic examination. Primary endpoint was in-hospital mortality. Results 74 consecutive COVID-19 patients (80.0 ± 12.6 yrs, 45.9% males) were included. Patients who died during hospitalization (27%) and those who were discharged alive (73%) were separately analyzed. Compared to patients discharged alive, those who died were significantly older, with higher comorbidity burden and greater prevalence of laboratory, radiographic and echographic signs of pulmonary and systemic congestion. Charlson comorbidity index (CCI) (OR 1.76, 95%CI 1.07-2.92), neutrophil-to-lymphocyte ratio (NLR) (OR 1.24, 95%CI 1.10-1.39) and absence of angiotensin-converting enzyme inhibitors (ACEI)/angiotensin II receptor blockers (ARBs) therapy (OR 0.01, 95%CI 0.00-0.22) independently predicted the primary endpoint. CCI ≥7 and NLR ≥9 were the best cut-off values for predicting mortality. The mortality risk for patients with CCI ≥7, NLR ≥9 and not in ACEI/ARBs therapy was high (86%); for patients with CCI <7, NLR ≥9, with (16.6%) or without (25%) ACEI/ARBs therapy was intermediate; for patients with CCI <7, NLR <9 and in ACEI/ARBs therapy was of 0%. Conclusions High comorbidity burden, high levels of NLR and the undertreatment with ACEI/ARBs were the main prognostic indicators of in-hospital mortality. The risk stratification of COVID-19 patients at hospital admission would help the clinicians to take care of the high-risk patients and reduce the mortality.
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Affiliation(s)
- Andrea Sonaglioni
- Division of Cardiology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) MultiMedica, Milan, Italy
| | - Michele Lombardo
- Division of Cardiology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) MultiMedica, Milan, Italy
| | - Adriana Albini
- European Institute of Oncology (IEO) Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
- *Correspondence: Adriana Albini,
| | - Douglas M. Noonan
- Immunology and General Pathology Laboratory, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
- Unit of Molecular Pathology, Immunology and Biochemistry, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) MultiMedica, Milan, Italy
| | - Margherita Re
- Division of Internal Medicine, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) MultiMedica, Milan, Italy
| | - Roberto Cassandro
- Division of Pneumology, Semi Intensive Care Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) MultiMedica, Milan, Italy
| | - Davide Elia
- Division of Pneumology, Semi Intensive Care Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) MultiMedica, Milan, Italy
| | - Antonella Caminati
- Division of Pneumology, Semi Intensive Care Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) MultiMedica, Milan, Italy
| | | | - Sergio Harari
- Division of Pneumology, Semi Intensive Care Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) MultiMedica, Milan, Italy
- Department of Clinical Sciences and Community Health, Università Di Milano, Milan, Italy
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12
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Agirbasli M. The effects of antihypertensive medications on severity and outcomes of COVID19. J Hum Hypertens 2022; 36:875-879. [PMID: 35810205 PMCID: PMC9281571 DOI: 10.1038/s41371-022-00722-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 06/18/2022] [Accepted: 06/28/2022] [Indexed: 11/12/2022]
Affiliation(s)
- Mehmet Agirbasli
- Department of Cardiology, School of Medicine, Istanbul Medeniyet University, Goztepe Prof. Dr. Suleyman Yalcin City Hospital, Istanbul, Turkey.
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13
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Jeffery MM, Oliveira J E Silva L, Bellolio F, Garovic VD, Dempsey TM, Limper A, Cummins NW. Association of outpatient use of renin-angiotensin-aldosterone system blockers on outcomes of acute respiratory illness during the COVID-19 pandemic: a cohort study. BMJ Open 2022; 12:e060305. [PMID: 35793915 PMCID: PMC9260198 DOI: 10.1136/bmjopen-2021-060305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Evaluate the associations between patients taking ACE inhibitors and angiotensin receptor blockers (ARBs) and their clinical outcomes after an acute viral respiratory illness (AVRI) due to COVID-19. DESIGN Retrospective cohort. SETTING The USA; 2017-2018 influenza season, 2018-2019 influenza season, and 2019-2020 influenza/COVID-19 season. PARTICIPANTS People with hypertension (HTN) taking an ACEi, ARB or other HTN medications, and experiencing AVRI. MAIN OUTCOME MEASURES Change in hospital admission, intensive care unit (ICU) or coronary care unit (CCU), acute respiratory distress (ARD), ARD syndrome (ARDS) and all-cause mortality, comparing COVID-19 to pre-COVID-19 influenza seasons. RESULTS The cohort included 1 059 474 episodes of AVRI (653 797 filled an ACEi or ARB, and 405 677 other HTN medications). 58.6% were women and 72.9% with age ≥65. The ACEi/ARB cohort saw a larger increase in risk in the COVID-19 influenza season than the other HTN medication cohort for four out of five outcomes, with an additional 1.5 percentage point (pp) increase in risk of an inpatient stay (95% CI 1.2 to 1.9 pp) and of ICU/CCU use (95% CI 0.3 to 2.7 pp) as well as a 0.7 pp (0.1 to 1.2 pp) additional increase in risk of ARD and 0.9 pp (0.4 to 1.3 pp) additional increase in risk of ARDS. There was no statistically significant difference in the absolute risk of death (-0.2 pp, 95% CI -0.4 to 0.1 pp). However, the relative risk of death in 2019/2020 versus 2017/2018 for the ACEi/ARB group was larger (1.40 (1.36 to 1.44)) than for the other HTN medication cohort (1.24 (1.21 to 1.28)). CONCLUSIONS People with AVRI using ACEi/ARBs for HTN had a greater increase in poor outcomes during the COVID-19 pandemic than those using other medications to treat HTN. The small absolute magnitude of the differences likely does not support changes in clinical practice.
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Affiliation(s)
- Molly Moore Jeffery
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Visiting Fellow, OptumLabs, Eden Prairie, Minnesota, USA
| | | | | | - Vesna D Garovic
- Department of Medicine, Division of Nephrology & Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Timothy M Dempsey
- David Grant Medical Center, US Air Force, Travis Air Force Base, California, USA
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew Limper
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Nathan W Cummins
- Department of Medicine, Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota, USA
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14
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Angeli F, Reboldi G, Trapasso M, Santilli G, Zappa M, Verdecchia P. Blood Pressure Increase following COVID-19 Vaccination: A Systematic Overview and Meta-Analysis. J Cardiovasc Dev Dis 2022; 9:150. [PMID: 35621861 PMCID: PMC9147472 DOI: 10.3390/jcdd9050150] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 04/23/2022] [Accepted: 05/07/2022] [Indexed: 02/04/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) vaccines proved a strong clinical efficacy against symptomatic or moderate/severe COVID-19 and are considered the most promising approach for curbing the pandemic. However, some questions regarding the safety of COVID-19 vaccines have been recently raised. Among adverse events to vaccines and despite a lack of signal during phase III clinical trials, an increase in blood pressure (BP) after COVID-19 vaccination has been reported as a potential adverse reaction. We systematically analyze this topic and undertook a meta-analysis of available data to estimate the proportion of patients with abnormal BP or raise in BP after vaccination. Six studies entered the final analysis. Overall, studies accrued 357,387 subjects with 13,444 events of abnormal or increased BP. After exclusion of outlier studies, the pooled estimated proportion of abnormal/increased BP after vaccination was 3.20% (95% CI: 1.62-6.21). Proportions of cases of stage III hypertension or hypertensive urgencies and emergencies was 0.6% (95% CI: 0.1% to 5.1%). In conclusion, abnormal BP is not rare after COVID-19 vaccination, but the basic mechanisms of this phenomenon are still unclear and require further research.
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Affiliation(s)
- Fabio Angeli
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy;
- Department of Medicine and Cardiopulmonary Rehabilitation, Istituti Clinici Scientifici Maugeri IRCCS, 21049 Tradate, Italy
| | - Gianpaolo Reboldi
- Department of Medicine, and Centro di Ricerca Clinica e Traslazionale (CERICLET), University of Perugia, 06100 Perugia, Italy; (G.R.); (G.S.)
| | - Monica Trapasso
- Dipartimento di Igiene e Prevenzione Sanitaria, PSAL, Sede Territoriale di Varese, ATS Insubria, 21100 Varese, Italy;
| | - Gabriella Santilli
- Department of Medicine, and Centro di Ricerca Clinica e Traslazionale (CERICLET), University of Perugia, 06100 Perugia, Italy; (G.R.); (G.S.)
| | - Martina Zappa
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy;
| | - Paolo Verdecchia
- Fondazione Umbra Cuore e Ipertensione-ONLUS and Division of Cardiology, Hospital S. Maria della Misericordia, 06100 Perugia, Italy;
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15
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Ambrosino P, Calcaterra IL, Mosella M, Formisano R, D’Anna SE, Bachetti T, Marcuccio G, Galloway B, Mancini FP, Papa A, Motta A, Di Minno MND, Maniscalco M. Endothelial Dysfunction in COVID-19: A Unifying Mechanism and a Potential Therapeutic Target. Biomedicines 2022; 10:biomedicines10040812. [PMID: 35453563 PMCID: PMC9029464 DOI: 10.3390/biomedicines10040812] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 03/28/2022] [Accepted: 03/29/2022] [Indexed: 02/07/2023] Open
Abstract
The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) generated a worldwide emergency, until the declaration of the pandemic in March 2020. SARS-CoV-2 could be responsible for coronavirus disease 2019 (COVID-19), which goes from a flu-like illness to a potentially fatal condition that needs intensive care. Furthermore, the persistence of functional disability and long-term cardiovascular sequelae in COVID-19 survivors suggests that convalescent patients may suffer from post-acute COVID-19 syndrome, requiring long-term care and personalized rehabilitation. However, the pathophysiology of acute and post-acute manifestations of COVID-19 is still under study, as a better comprehension of these mechanisms would ensure more effective personalized therapies. To date, mounting evidence suggests a crucial endothelial contribution to the clinical manifestations of COVID-19, as endothelial cells appear to be a direct or indirect preferential target of the virus. Thus, the dysregulation of many of the homeostatic pathways of the endothelium has emerged as a hallmark of severity in COVID-19. The aim of this review is to summarize the pathophysiology of endothelial dysfunction in COVID-19, with a focus on personalized pharmacological and rehabilitation strategies targeting endothelial dysfunction as an attractive therapeutic option in this clinical setting.
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Affiliation(s)
- Pasquale Ambrosino
- Istituti Clinici Scientifici Maugeri IRCCS, Cardiac Rehabilitation Unit of Telese Terme Institute, 82037 Telese Terme, Italy; (R.F.); (F.P.M.); (A.P.)
- Correspondence: (P.A.); (M.M.)
| | | | - Marco Mosella
- Istituti Clinici Scientifici Maugeri IRCCS, Pulmonary Rehabilitation Unit of Telese Terme Institute, 82037 Telese Terme, Italy; (M.M.); (S.E.D.)
| | - Roberto Formisano
- Istituti Clinici Scientifici Maugeri IRCCS, Cardiac Rehabilitation Unit of Telese Terme Institute, 82037 Telese Terme, Italy; (R.F.); (F.P.M.); (A.P.)
| | - Silvestro Ennio D’Anna
- Istituti Clinici Scientifici Maugeri IRCCS, Pulmonary Rehabilitation Unit of Telese Terme Institute, 82037 Telese Terme, Italy; (M.M.); (S.E.D.)
| | - Tiziana Bachetti
- Istituti Clinici Scientifici Maugeri IRCCS, Scientific Direction, 27100 Pavia, Italy;
| | - Giuseppina Marcuccio
- Università della Campania Luigi Vanvitelli, 81100 Caserta, Italy; (G.M.); (B.G.)
| | - Brurya Galloway
- Università della Campania Luigi Vanvitelli, 81100 Caserta, Italy; (G.M.); (B.G.)
| | - Francesco Paolo Mancini
- Istituti Clinici Scientifici Maugeri IRCCS, Cardiac Rehabilitation Unit of Telese Terme Institute, 82037 Telese Terme, Italy; (R.F.); (F.P.M.); (A.P.)
- Department of Science and Technology, University of Sannio, 82100 Benevento, Italy
| | - Antimo Papa
- Istituti Clinici Scientifici Maugeri IRCCS, Cardiac Rehabilitation Unit of Telese Terme Institute, 82037 Telese Terme, Italy; (R.F.); (F.P.M.); (A.P.)
| | - Andrea Motta
- Institute of Biomolecular Chemistry, National Research Council, 80078 Pozzuoli, Italy;
| | | | - Mauro Maniscalco
- Istituti Clinici Scientifici Maugeri IRCCS, Pulmonary Rehabilitation Unit of Telese Terme Institute, 82037 Telese Terme, Italy; (M.M.); (S.E.D.)
- Correspondence: (P.A.); (M.M.)
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Alhaddad MJ, Almulaify MS, Alshabib AA, Alwesaibi AA, Alkhameys MA, Alsenan ZK, Alsheef HJ, Alsaghirat MA, Almomtan MS, Alshakhs MN. Relation Between Renin–Angiotensin–Aldosterone System Inhibitors and COVID-19 Severity. Cureus 2022; 14:e22903. [PMID: 35399441 PMCID: PMC8986521 DOI: 10.7759/cureus.22903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2022] [Indexed: 12/05/2022] Open
Abstract
Background: Angiotensin-converting enzyme 2 (ACE2) receptor serves as a receptor for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus causing COVID-19, to enter the lungs. Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) may increase the expression of ACE2, resulting in concerns that patients with COVID-19 who are receiving these agents may be at increased risk of severe disease. This study was conducted to further investigate the effects of ACEIs and ARBs on the severity of COVID-19 in hospitalized hypertensive patients. Methods: The study was a retrospective observational study. The medical records of all adult hypertensive patients who were hospitalized at Dammam Medical Complex (DMC) between March 1, 2020, and December 31, 2020, due to COVID-19 were reviewed. The hypertensive patients who were receiving ACEIs or ARBs were compared with the other hypertensive patients who were not on ACEIs or ARBs. Results: A total of 148 hypertensive patients were included in the analysis. They consisted of 106 male and 42 female patients (72% and 28%, respectively). Nearly half of the patients were Saudi (75 patients, 50%). A total of 81 patients were in the ACEI/ARB group, and 67 patients were in the control group. There were no differences between the two groups in age, diabetic status, history of chronic kidney disease, initial blood pressure measurements, and initial oxygen requirements, but the control group contained fewer female patients (18% versus 37%) and Saudi patients (36% versus 63%) than the ACEI/ARB group (p-values = 0.017 and 0.002, respectively). The use of ACEIs or ARBs was associated with significant reductions in ICU admission (9% versus 31%, p-value = 0.001), need for intubation (7% versus 28%, p-value = 0.002), and death (2% versus 24%, p-value = 0.000). A significant negative association between the use ACEIs or ARBs and mortality was also observed in the multivariate analysis after the adjustment for the possible confounders, with an odds ratio (OR) of 0.087 and a 95% confidence interval (CI) of 0.017-0.449. Conclusions: ACEIs and ARBs have no adverse effects on the clinical prognosis of COVID-19 patients with hypertension. Their use might be even beneficial and protective, but future larger studies are needed to confirm these effects. In the meanwhile, they should be continued in COVID-19 hypertensive patients unless their use is contraindicated for other reasons (e.g., hypotension, hyperkalemia, or acute kidney injury (AKI)).
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