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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.
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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
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2
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Treating COVID-19: Targeting the Host Response, Not the Virus. Life (Basel) 2023; 13:life13030712. [PMID: 36983871 PMCID: PMC10054780 DOI: 10.3390/life13030712] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/19/2023] [Accepted: 01/31/2023] [Indexed: 03/09/2023] Open
Abstract
In low- and middle-income countries (LMICs), inexpensive generic drugs like statins, ACE inhibitors, and ARBs, especially if used in combination, might be the only practical way to save the lives of patients with severe COVID-19. These drugs will already be available in all countries on the first pandemic day. Because they target the host response to infection instead of the virus, they could be used to save lives during any pandemic. Observational studies show that inpatient statin treatment reduces 28–30-day mortality but randomized controlled trials have failed to show this benefit. Combination treatment has been tested for antivirals and dexamethasone but, with the exception of one observational study in Belgium, not for inexpensive generic drugs. Future pandemic research must include testing combination generic drug treatments that could be used in LMICs.
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Spannella F, Giulietti F, Di Pentima C, Allevi M, Bordoni V, Filipponi A, Falzetti S, Garbuglia C, Scorcella S, Giordano P, Sarzani R. Renin-Angiotensin-System Inhibitors Are Associated With Lower In-hospital Mortality in COVID-19 Patients Aged 80 and Older. Front Cardiovasc Med 2022; 9:916509. [PMID: 35783862 PMCID: PMC9247386 DOI: 10.3389/fcvm.2022.916509] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 05/04/2022] [Indexed: 11/30/2022] Open
Abstract
Background Older adults are at higher risk of morbidity and mortality for coronavirus disease 2019 (COVID-19). Renin-angiotensin-system inhibitors (RASi) were found to have a neutral or protective effect against mortality in COVID-19 adult patients. Aims We investigated whether this association was confirmed also in COVID-19 older patients. Methods This is a prospective observational study on 337 hospitalized older adults (aged 80 years and older). We classified the study population according to usage of RASi before and during hospitalization. A propensity score analysis was also performed to confirm the findings. Results The mean age was 87.4 ± 6.1 years. Patients taking RASi at home were 147 (43.6%). During hospitalization, 38 patients (11.3% of the entire study population) discontinued RASi, while 57 patients (16.9% of the entire study population) started RASi. In-hospital mortality was 43.9%. Patients taking RASi during hospitalization (patients who maintained their home RASi therapy + patients who started RASi during hospitalization) had a significantly lower in-hospital mortality than untreated patients [HR 0.48 (95% CI: 0.34–0.67)], even after adjustment for required respiratory support, functional status, albumin, inflammation, and cardiac biomarkers. The analysis of the groups derived from the “propensity score matching” (58 patients in each group) confirmed these results [HR 0.46 (95% CI: 0.23–0.91)]. Discussion Despite the high risk of death in older COVID-19 patients, RASi therapy during hospitalization was associated with a clinically relevant lower in-hospital mortality, likely due to the benefit of RAS modulation on the cardiopulmonary system during the acute phase of the disease. Conclusion Our findings confirm the protective role of RASi even in COVID-19 patients aged 80 years and older.
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Affiliation(s)
- Francesco Spannella
- Internal Medicine and Geriatrics, IRCCS INRCA, Ancona, Italy
- Department of Clinical and Molecular Sciences, University “Politecnica delle Marche”, Ancona, Italy
| | - Federico Giulietti
- Internal Medicine and Geriatrics, IRCCS INRCA, Ancona, Italy
- Department of Clinical and Molecular Sciences, University “Politecnica delle Marche”, Ancona, Italy
| | - Chiara Di Pentima
- Internal Medicine and Geriatrics, IRCCS INRCA, Ancona, Italy
- Department of Clinical and Molecular Sciences, University “Politecnica delle Marche”, Ancona, Italy
| | - Massimiliano Allevi
- Internal Medicine and Geriatrics, IRCCS INRCA, Ancona, Italy
- Department of Clinical and Molecular Sciences, University “Politecnica delle Marche”, Ancona, Italy
| | - Valentina Bordoni
- Internal Medicine and Geriatrics, IRCCS INRCA, Ancona, Italy
- Department of Clinical and Molecular Sciences, University “Politecnica delle Marche”, Ancona, Italy
| | - Andrea Filipponi
- Internal Medicine and Geriatrics, IRCCS INRCA, Ancona, Italy
- Department of Clinical and Molecular Sciences, University “Politecnica delle Marche”, Ancona, Italy
| | - Sara Falzetti
- Internal Medicine and Geriatrics, IRCCS INRCA, Ancona, Italy
- Department of Clinical and Molecular Sciences, University “Politecnica delle Marche”, Ancona, Italy
| | - Caterina Garbuglia
- Internal Medicine and Geriatrics, IRCCS INRCA, Ancona, Italy
- Department of Clinical and Molecular Sciences, University “Politecnica delle Marche”, Ancona, Italy
| | - Samuele Scorcella
- Internal Medicine and Geriatrics, IRCCS INRCA, Ancona, Italy
- Department of Clinical and Molecular Sciences, University “Politecnica delle Marche”, Ancona, Italy
| | - Piero Giordano
- Internal Medicine and Geriatrics, IRCCS INRCA, Ancona, Italy
| | - Riccardo Sarzani
- Internal Medicine and Geriatrics, IRCCS INRCA, Ancona, Italy
- Department of Clinical and Molecular Sciences, University “Politecnica delle Marche”, Ancona, Italy
- *Correspondence: Riccardo Sarzani
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4
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Loader J, Taylor FC, Lampa E, Sundström J. Renin-Angiotensin Aldosterone System Inhibitors and COVID-19: A Systematic Review and Meta-Analysis Revealing Critical Bias Across a Body of Observational Research. J Am Heart Assoc 2022; 11:e025289. [PMID: 35624081 PMCID: PMC9238740 DOI: 10.1161/jaha.122.025289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background Renin‐angiotensin aldosterone system (RAAS) inhibitor—COVID‐19 studies, observational in design, appear to use biased methods that can distort the interaction between RAAS inhibitor use and COVID‐19 risk. This study assessed the extent of bias in that research and reevaluated RAAS inhibitor—COVID‐19 associations in studies without critical risk of bias. Methods and Results Searches were performed in MEDLINE, EMBASE, and CINAHL databases (December 1, 2019 to October 21, 2021) identifying studies that compared the risk of infection and/or severe COVID‐19 outcomes between those using or not using RAAS inhibitors (ie, angiotensin‐converting enzyme inhibitors or angiotensin II type‐I receptor blockers). Weighted hazard ratios (HR) and 95% CIs were extracted and pooled in fixed‐effects meta‐analyses, only from studies without critical risk of bias that assessed severe COVID‐19 outcomes. Of 169 relevant studies, 164 had critical risks of bias and were excluded. Ultimately, only two studies presented data relevant to the meta‐analysis. In 1 351 633 people with uncomplicated hypertension using a RAAS inhibitor, calcium channel blocker, or thiazide diuretic in monotherapy, the risk of hospitalization (angiotensin‐converting enzyme inhibitor: HR, 0.76; 95% CI, 0.66–0.87; P<0.001; angiotensin II type‐I receptor blockers: HR, 0.86; 95% CI, 0.77–0.97; P=0.015) and intubation or death (angiotensin‐converting enzyme inhibitor: HR, 0.64; 95% CI, 0.48–0.85; P=0.002; angiotensin II type‐I receptor blockers: HR, 0.74; 95% CI, 0.58–0.95; P=0.019) with COVID‐19 was lower in those using a RAAS inhibitor. However, these protective effects are probably not clinically relevant. Conclusions This study reveals the critical risk of bias that exists across almost an entire body of COVID‐19 research, raising an important question: Were research methods and/or peer‐review processes temporarily weakened during the surge of COVID‐19 research or is this lack of rigor a systemic problem that also exists outside pandemic‐based research? Registration URL: www.crd.york.ac.uk/prospero/; Unique identifier: CRD42021237859.
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Affiliation(s)
- Jordan Loader
- Department of Medical Sciences Uppsala University Uppsala Sweden.,Inserm U1300 - HP2 CHU Grenoble Alpes Grenoble France
| | - Frances C Taylor
- Baker Heart and Diabetes Institute Melbourne Victoria Australia.,Mary MacKillop Institute for Health Research, Australian Catholic University Melbourne Victoria Australia
| | - Erik Lampa
- Department of Medical Sciences Uppsala University Uppsala Sweden
| | - Johan Sundström
- Department of Medical Sciences Uppsala University Uppsala Sweden.,The George Institute for Global Health University of New South Wales Sydney Australia
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Smith SM, Desai RA, Walsh MG, Nilles EK, Shaw K, Smith M, Chamberlain AM, Derington CG, Bress AP, Chuang CH, Ford DE, Taylor BW, Chandaka S, Patel LP, McClay J, Priest E, Fuloria J, Doshi K, Ahmad FS, Viera AJ, Faulkner M, O'Brien EC, Pletcher MJ, Cooper-DeHoff RM. Angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and COVID-19-related outcomes: A patient-level analysis of the PCORnet blood pressure control lab. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 13:100112. [PMID: 35252907 PMCID: PMC8889730 DOI: 10.1016/j.ahjo.2022.100112] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 01/21/2022] [Accepted: 02/11/2022] [Indexed: 12/20/2022]
Abstract
SARS-CoV-2 accesses host cells via angiotensin-converting enzyme-2, which is also affected by commonly used angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), raising concerns that ACEI or ARB exposure may portend differential COVID-19 outcomes. In parallel cohort studies of outpatient and inpatient COVID-19-diagnosed adults with hypertension, we assessed associations between antihypertensive exposure (ACEI/ARB vs. non-ACEI/ARB antihypertensives, as well as between ACEI- vs. ARB) at the time of COVID-19 diagnosis, using electronic health record data from PCORnet health systems. The primary outcomes were all-cause hospitalization or death (outpatient cohort) or all-cause death (inpatient), analyzed via Cox regression weighted by inverse probability of treatment weights. From February 2020 through December 9, 2020, 11,246 patients (3477 person-years) and 2200 patients (777 person-years) were included from 17 health systems in outpatient and inpatient cohorts, respectively. There were 1015 all-cause hospitalization or deaths in the outpatient cohort (incidence, 29.2 events per 100 person-years), with no significant difference by ACEI/ARB use (adjusted HR 1.01; 95% CI 0.88, 1.15). In the inpatient cohort, there were 218 all-cause deaths (incidence, 28.1 per 100 person-years) and ACEI/ARB exposure was associated with reduced death (adjusted HR, 0.76; 95% CI, 0.57, 0.99). ACEI, versus ARB exposure, was associated with higher risk of hospitalization in the outpatient cohort, but no difference in all-cause death in either cohort. There was no evidence of effect modification across pre-specified baseline characteristics. Our results suggest ACEI and ARB exposure have no detrimental effect on hospitalizations and may reduce death among hypertensive patients diagnosed with COVID-19.
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Affiliation(s)
- Steven M Smith
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, United States of America
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, United States of America
| | - Raj A Desai
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, United States of America
| | - Marta G Walsh
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, United States of America
| | - Ester Kim Nilles
- Duke Clinical Research Institute, Duke University, Durham, NC, United States of America
| | - Katie Shaw
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL, United States of America
| | - Myra Smith
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL, United States of America
| | - Alanna M Chamberlain
- Departments of Quantitative Health Sciences and Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Catherine G Derington
- Department of Population Health Sciences, School of Medicine, University of Utah, Salt Lake City, UT, United States of America
| | - Adam P Bress
- Department of Population Health Sciences, School of Medicine, University of Utah, Salt Lake City, UT, United States of America
| | | | - Daniel E Ford
- Johns Hopkins University, Baltimore, MD, United States of America
| | - Bradley W Taylor
- Medical College of Wisconsin, Milwaukee, WI, United States of America
| | - Sravani Chandaka
- University of Kansas Medical Center, Kansas City, KS, United States of America
| | | | - James McClay
- University of Nebraska, Omaha, NE, United States of America
| | - Elisa Priest
- Baylor Scott & White Health, Dallas, TX, United States of America
| | - Jyotsna Fuloria
- School of Medicine, Louisiana State University, New Orleans, LA, United States of America
| | - Kruti Doshi
- Cook County Health, Chicago, IL, United States of America
| | - Faraz S Ahmad
- Departments of Medicine and Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States of America
| | - Anthony J Viera
- Department of Family Medicine and Community Health, School of Medicine, Duke University, Durham, NC, United States of America
| | - Madelaine Faulkner
- Department of Epidemiology & Biostatistics, School of Medicine, University of California San Francisco, San Francisco, CA, United States of America
| | - Emily C O'Brien
- Duke Clinical Research Institute, Duke University, Durham, NC, United States of America
| | - Mark J Pletcher
- Department of Epidemiology & Biostatistics, School of Medicine, University of California San Francisco, San Francisco, CA, United States of America
| | - Rhonda M Cooper-DeHoff
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, United States of America
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The Identikit of Patient at Risk for Severe COVID-19 and Death: The Dysregulation of Renin-Angiotensin System as the Common Theme. J Clin Med 2021; 10:jcm10245883. [PMID: 34945176 PMCID: PMC8704645 DOI: 10.3390/jcm10245883] [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: 11/19/2021] [Revised: 12/13/2021] [Accepted: 12/13/2021] [Indexed: 12/24/2022] Open
Abstract
Since the first months of the coronavirus disease 2019 (COVID-19) pandemic, several specific physiologic traits, such as male sex and older age, or health conditions, such as overweight/obesity, arterial hypertension, metabolic syndrome, and type 2 diabetes mellitus, have been found to be highly prevalent and associated with increased risk of adverse outcomes in hospitalized patients. All these cardiovascular morbidities are widespread in the population and often coexist, thus identifying a common patient phenotype, characterized by a hyper-activation of the “classic” renin-angiotensin system (RAS) and mediated by the binding of angiotensin II (Ang II) to the type 1-receptor. At the same time, the RAS imbalance was proved to be crucial in the genesis of lung injury after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, where angiotensin-converting-enzyme-2 (ACE2) is not only the receptor for SARS-CoV-2, but its down-regulation through internalization and shedding, caused by the virus binding, leads to a further dysregulation of RAS by reducing angiotensin 1-7 (Ang 1-7) production. This focused narrative review will discuss the main available evidence on the role played by cardiovascular and metabolic conditions in severe COVID-19, providing a possible pathophysiological link based on the disequilibrium between the two opposite arms of RAS.
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Camelo S, Latil M, Agus S, Dioh W, Veillet S, Lafont R, Dilda PJ. A comparison between virus- versus patients-centred therapeutic attempts to reduce COVID-19 mortality. Emerg Microbes Infect 2021; 10:2256-2263. [PMID: 34783636 PMCID: PMC8648031 DOI: 10.1080/22221751.2021.2006579] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 11/08/2021] [Accepted: 11/10/2021] [Indexed: 01/08/2023]
Abstract
Since December 2019, coronavirus disease 2019 (COVID-19), caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has changed our lives. Elderly and those with comorbidities represent the vast majority of patients hospitalized with severe COVID-19 symptoms, including acute respiratory disease syndrome and cardiac dysfunction. Despite a huge effort of the scientific community, improved treatment modalities limiting the severity and mortality of hospitalized COVID-19 patients are still required. Here, we compare the effectiveness of virus- and patients-centred strategies to reduce COVID-19 mortality. We also discuss the therapeutic options that might further reduce death rates associated with the disease in the future. Unexpectedly, extensive review of the literature suggests that SARS-CoV-2 viral load seems to be associated neither with the severity of symptoms nor with mortality of hospitalized patients with COVID-19. This may explain why, so far, virus-centred strategies using antivirals aiming to inhibit the viral replicative machinery have failed to reduce COVID-19 mortality in patients with respiratory failure. By contrast, anti-inflammatory treatments without antiviral capacities but centred on patients, such as dexamethasone or Tocilizumab®, reduce COVID-19 mortality. Finally, since the spike protein of SARS-CoV-2 binds to angiotensin converting enzyme 2 and inhibits its function, we explore the different treatment options focussing on rebalancing the renin-angiotensin system. This new therapeutic strategy could hopefully further reduce the severity of respiratory failure and limit COVID-19 mortality in elderly patients.
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Affiliation(s)
| | | | - Sam Agus
- Biophytis Inc., Cambridge, MA, USA
| | - Waly Dioh
- Biophytis, Sorbonne Université, Paris, France
| | | | - René Lafont
- Biophytis, Sorbonne Université, Paris, France
- CNRS – Institut de Biologie Paris Seine (BIOSIPE), Sorbonne Université, Paris, France
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Carro B. SARS-CoV-2 mechanisms of action and impact on human organism, risk factors and potential treatments. An exhaustive survey. ALL LIFE 2021. [DOI: 10.1080/26895293.2021.1977186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Belén Carro
- Department of Signal Theory and Communications, Universidad de Valladolid, Valladolid, Spain
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