Clinical Outcomes of Renin-Angiotensin Aldosterone Blockade in Patients with Advanced Chronic Kidney Disease: A Systematic Review and Meta-Analysis

BACKGROUND

The cardiovascular and renal benefits of renin-angiotensin aldosterone system (RAAS) blockade are not well-established in patients with advanced CKD. We conducted a systematic review and meta-analysis to identify potential risks and benefits from RAAS blockade in patients with CKD stage 4-5.

METHODS

A Medline search from inception to November 2022 was conducted to identify randomized controlled trials (RCTs) in patients with CKD stage 4-5 (estimated GFR ≤ 30 mL/min/1.73m2) comparing RAAS blockade against placebo or alternative antihypertensive therapy. Different intervention strategies were assessed (RAAS use vs non-use, initiation vs placebo/alternative therapy or discontinuation vs continuation). The primary outcome was progression to end-stage kidney disease (ESKD). Secondary outcomes were all-cause mortality and major adverse cardiovascular events (MACE). The risk ratio (RR) was estimated using a random-effects model.

RESULTS

Nine RCTs (1,150 patients) were included. In RCTs, RAAS blockade was associated with a significant reduction in progression to ESKD: RR 0.84 (95% confidence interval [CI] 0.74 - 0.96; p = 0.01). There was no benefit from RAAS blockade on all-cause mortality or MACE: RR 1.02 (95% CI 0.63 - 1.65; p = 0.93) and RR 0.87 (95% CI 0.49- 1.57; p = 0.65), respectively.

CONCLUSIONS

RAAS blockade may be considered in selected patients with CKD stage 4-5 to delay progression to ESKD.

Stevens-Johnson Syndrome From Combined Allopurinol and Angiotensin-Converting Enzyme Inhibitors: A Narrative Review

Stevens-Johnson syndrome (SJS) is a severe and potentially debilitating skin reaction frequently related to medication use. Allopurinol and angiotensin-converting enzyme (ACE) inhibitors are commonly prescribed medications for prevalent health conditions worldwide, and their interaction associated with SJS warrants further investigation. A comprehensive literature search was performed to investigate cases as studies related to SJS occurring in patients with concomitant use of allopurinol and ACE inhibitors. We identified case reports and studies detailing hypersensitivity reactions, including SJS, attributed to a combination of allopurinol and ACE inhibitors. Despite the drug-drug interactions or lack thereof seen in patient populations, there is no definitive evidence of a pharmacokinetic interaction between allopurinol and ACE inhibitors. We were only able to find one case report specifically detailing SJS in a patient on combined ACE inhibitors and allopurinol. While the exact mechanism of the interaction is unclear, those reported cases of severe hypersensitivity reactions suggest a previous history of impaired renal function as a predisposing factor in the development of SJS. The potential risk of SJS with coadministration of ACE inhibitors and allopurinol is a drug-drug interaction that physicians should be aware of. This topic requires additional attention to determine if this drug combination should be avoided entirely in certain patients.

Pharmacogenomic knowledge and awareness among diverse patients treated with angiotensin converting enzyme inhibitors

We developed novel electronic phenotyping algorithms for the BioMe biobank data, which accurately identified angiotensin converting enzyme inhibitor (ACEi)-induced angioedema cases and controls. A survey was mailed to all 1075 patients and 91 were returned. Over a third reported that prescribing physicians had not discussed with them the concepts of interindividual drug response variability or adverse event risk, and 73% of patients were previously unaware of pharmacogenomics; however, most patients were interested in having pharmacogenomic testing. Moreover, 67% of patients indicated that pharmacogenomic testing would positively influence their medication compliance. In addition to identifying an innovative approach to define biobank cohorts for pharmacogenomic studies, these results indicate that patients are interested in pharmacogenomic testing, which could translate to improved adherence.

Life-threatening bronchospasm induced by an angiotensin-converting enzyme inhibitor in a chronically ventilated patient: Diagnostic pitfalls and literature review

Cough- and asthma-like symptoms are common adverse reactions to angiotensin-converting enzyme inhibitors (ACEi). However, attributing these symptoms to the use of ACEi might be masked by clinical confounders. We report a 68-year-old female residing in a long-term acute-care facility for patients requiring prolonged invasive mechanical ventilation treated for years with ACEi. Daily reversible bouts of life-threatening severe bronchospasm gradually developed over 6 weeks and abruptly resolved following the cessation of ACEi treatment. The late appearance of bronchospasm and the unique clinical setup of chronic invasive ventilation in a patient with smoking-related chronic obstructive lung disease are among the principal confounders that delay the identification of the causative association between ACEi and respiratory compromise. Chronic positive pressure ventilation may also conceal small airway reactivity and obstruction, similar to auto-positive end-expiratory pressure (auto-PEEP). Conceivably, angiotensin receptor blockers should be preferred over ACEi in such patients.

A strategy to improve adherence to guideline-directed medical therapy (GDMT) and the role of the multidisciplinary team in a heart-failure programme

BACKGROUND

Heart failure (HF) patients place a heavy burden on the healthcare system because of their frequent need for in-patient treatment, emergency room visits and subsequent hospital stays. To provide proper care and effective therapy, practitioners have streamlined delivery techniques such as clinical pathways, checklists and pocket manuals. However, a description of the establishment of a disease-management programme, including a multidisciplinary team of physicians, clinical pharmacists and nurse specialists is required. The aim of this study was to highlight the role of the multidisciplinary team in a heart-failure programme by assessing the improvement in adherence to guideline-directed medical therapy.

METHODS

A retrospective, observational research was undertaken on patients with HF at a cardiac centre in Riyadh, to observe the HF patients' management before (January to December 2014) and after (January to December 2015) the establishment of a programme.

RESULTS

The use of angiotensin converting enzyme inhibitors and angiotensin receptor blockers was 75.59% in 2014 at discharge and 81.17% in 2015 (p = 0.249). Beta-blockers use at release increased from 87.83% in 2014 to 94.53% in 2015 (p = 0.021). The flu vaccine was given to 48.24% of patients in 2014 and 75.13% of the patients in 2015 (p < 0.001). The pneumococcal vaccine was administered to 44.22% of patients in 2014 and 75.13% of patients in 2015 (p < 0.001). The ejection fraction improved from 30.21% in the first month to 39.56% in the 12th month (p = 0.001) in patients managed in 2015.

CONCLUSION

The multidisciplinary heart-failure programme resulted in a positive effect, in the form of improved patient care after including the clinical pharmacist and nurse specialist.

Cutaneous microcirculation reactivity in patients with arterial hypertension, taking into account intake of anti-hypertensive drugs

OBJECTIVE

The aim of the study was to assess the reactivity of the cutaneous microcirculation in patients with arterial hypertension (AH), taking into account the intake of anti-hypertensive drugs, using laser doppler flowometry (LDF) and the post-occlusive reactive hyperaemia (PORH) test.

MATERIAL AND METHODS

The analysis included 44 patients with well-controlled AH, and 22 subjectively healthy volunteers aged 23 - 74 years, matched with the study group. During the study period, 22 patients in the study group were taking ACEI drugs, also in combination with other drug groups in terms of gender and age. 19 patients were taking other groups of drugs, including: ARB, beta-blockers, alpha-blockers, CCB, diuretics, also in combination, while 3 patients were not taking medication for AH; they were recommended non-pharmacological treatment. Blood biochemical tests, ambulatory blood pressure monitoring (ABPM) and PORH test using LDF were performed.

RESULTS

The study showed that the PORH flow parameters were not differ statistically significantly between the study and control groups (p> 0.05). Statistically significant differences were shown in the PORH maximum level (ML) on the skin forearm between the study group not taking ACEI drugs and the control group. No statistically significant differences were shown between the study group taking ACEI and the control group.

CONCLUSIONS

The pathogenesis of AH is multifactorial and depends, inter alia, on disturbances at the level of microcirculation. Proper treatment, especially with the use of ACEI, can improve the microcirculation in AH patients.

Covid 19: Acing the Treatment

ACE 2 is the functional receptor that SARS-Cov-2 virus requires to enter cells and cause dysregulated inflammatory conditions that contribute towards acute lung injuries. The RAAS with its physiological surveillance and regulation system can be implicated in both harm and therapeutic benefit. The initial observational studies suggesting the discontinuation of ACE-I and ARBs have been firmly rebutted by international societies. On the contrary, these therapeutics may confer a survival benefit in Covid 19 infections. Understanding the biological plausibility of this pathway alongside the emerging therapeutic evidence may yield new modes of treatment. Such developments appear fundamentally important in the battle against the inevitable emergence of new variants and their potential to drive future waves of Covid 19 pandemics.

Profile of serious angioedema requiring an urgent advice from a national reference call center

Angioedema (AE) is a reason for emergency care when it is severe. Care is difficult when the diagnostic is not known before the attack: mast cell (MC) or bradykinin (BK) mediated. One is very common but often benign, the other rare but potentially fatal. The French national reference center of angioedema (CREAK) provides emergency physicians with a hotline and a guideline to help them manage their patients. This study aimed to describe the clinical features of AE episodes prompting a call on the CREAK hotline and classify patients depending on the suspected cause of the AE. This is a retrospective study between March and August 2019. Each physician calling on the CREAK hotline was asked to fill a clinical description form for the AE emergency. Known patients of CREAK was excluded. Eighty four patients were included. Forty one (48.8%) in the angiotensin converting enzyme inhibitors induced acquired angioedema (ACEi-AAE), 39 (46.4%) in the mast cell induced angioedema, and 4 (4.8%) in the Bradykinin mediated angioedema. The mast cell induced angioedema patients have more history of hives (29.3%) than ACEi-AAE (2.4%, P = .0004). ACEi-AAE mainly affected the tongue (58.5% vs 25.6%, P = .003) and larynx (29.3% vs 13%, P = .001). In 65.5% of cases, the etiological diagnosis was not mentioned by the appellant, but made by the hotline. In 31% of cases, the hotline suggested the administration of a specific treatment not previously provided by the caller. All the doctors who called the hotline appreciate this tele-expertise especially in case of ACEi-AAE presumptions. In addition to providing rapid AE expertise, this service also allows to educate physicians in the management of AE irrespective of its origin.

Use of renin angiotensin aldosterone system inhibitors in children with lupus and time to glucocorticoid discontinuation

There is little data to inform use of renin angiotensin aldosterone system (RAAS) inhibitors in pediatric patients with systemic lupus erythematosus (SLE). Here, we sought to characterize RAAS inhibitor use in pediatric SLE, and determine whether early RAAS inhibitor initiation among children with incident lupus nephritis is associated with decreased duration of chronic glucocorticoid exposure. A retrospective cohort study was performed of children (ages 5-18) with SLE and/or lupus nephritis in the Truven MarketScan^ΤΜ Medicaid and Commercial databases (2013-2018) and estimated RAAS inhibitor use. Among incident nephritis cases, we used competing risk hazard models with inverse probability of treatment weighting to estimate the association between RAAS inhibitor initiation less than 180 days after diagnosis and time to glucocorticoid discontinuation with kidney failure as a competing event. Among 592 children with nephritis and 1407 children with non-kidney SLE, 67% and 15% ever received RAAS inhibitors, respectively. Median duration of RAAS inhibitor use among 323 incident users was 14 and 9 months in children with and without nephritis, respectively. Medicaid enrollment was independently associated with greater likelihood of RAAS inhibitor use, irrespective of nephritis. Among 158 incident nephritis cases, early RAAS inhibitor initiation was significantly associated with a faster rate of glucocorticoid discontinuation (adjusted sub-distribution hazard ratio 1.81, 95% confidence interval [1.09 - 3.00]). Thus, early initiation of RAAS inhibitors may have a role in children newly diagnosed with lupus nephritis; not only those with refractory proteinuria after induction therapy. Hence, integrated health systems data could be leveraged to confirm these findings and optimize adjunctive therapies in pediatric lupus.

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.

Cardiovascular Medication Use and Risk of Acute Exacerbation in Patients With Asthma-COPD Overlap (CVACO Study)

PURPOSE

Current clinical guidelines are unclear regarding the association of cardiovascular medication with the risk of acute exacerbation (AE) in patients with asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO).

METHODS

We conducted a retrospective cohort study by interrogating the claims database of Taipei Veterans General Hospital. Patients with coexistent fixed airflow limitation and asthma were enrolled as an ACO cohort between 2009 and 2017. Exposure to cardiovascular medications, including angiotensin converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), non-selective beta-blockers, cardioselective beta-blockers, dihydropyridine (DHP) calcium channel blockers (CCBs), and non-DHP CCBs, in 3-month period each served as time-dependent covariates. Patients receiving a cardiovascular medication ≥ 28 cumulative daily doses were defined as respective cardiovascular medication users. Patients were followed up until December 31, 2018. The primary endpoint was severe AE, defined as hospitalization or emergency department visit for either asthma, COPD, or respiratory failure. The secondary outcome was moderate AE.

RESULTS

The final study cohort consisted of 582 ACO subjects, with a mean follow-up period of 2.98 years. After adjustment, ARB (hazard ratio [HR], 0.64, 95% confidence interval [CI], 0.44-0.93, P = 0.019), cardioselective beta-blocker (HR, 0.29, 95% CI, 0.11-0.72, P = 0.008) and DHP CCB (HR, 0.66, 95% CI, 0.45-0.97, P = 0.035) therapies were associated with lower risks of severe AE. ARB (HR, 0.42, 95% CI, 0.30-0.62, P < 0.001) and DHP CCB (HR, 0.55, 95% CI, 0.38-0.80, P = 0.002) therapies were associated with lower risks of moderate AE. Cardioselective beta-blockers, ARBs, and DHP CCBs were associated with lower risks of severe AE in frequent exacerbators. ACEI, non-selective beta-blocker, or non-DHP CCB use did not change the risk of severe AE.

CONCLUSIONS

ARB, cardioselective beta-blocker, and DHP CCB therapies may lower the risk of AE in patients with ACO.

Sex Differences in Therapies for Heart Failure

Heart failure (HF) is a common cause of morbimortality with different etiopathogenesis and prognosis between men and women. This review provides a brief overview of gender-based differences in response to pharmacological therapies of heart failure with or without reduced ejection fraction (EF). It focuses on the differences in therapy outcomes with angiotensin-converting enzyme inhibitors (ACEi), angiotensin receptor blockers (ARBs), angiotensin neprilysin inhibitors (ARNI), beta-adrenergic blockers, mineralocorticoid/aldosterone receptor antagonists, diuretics, ivabradine and digoxin. The baseline data originates from randomised controlled trials (RCTs) and large registries. We conclude that current guidelines recommending similar therapeutic approaches for both men and women are appropriate, while additional consideration should be given for different approaches regarding the use of ARBs, ACEi, and digoxin. Based on the available data, the ARBs might be considered a first-line therapy of HR for women instead of ACEi. Moreover, female patients should have stricter digoxin monitoring due to higher sensitivity and increased risk of complications. Finally, women are underrepresented in current clinical trials, and therefore future trials should aim to balance the gender recruitment disparity allowing sub-group analysis and comparisons between genders to guide individualised therapeutic strategies and appropriately targeted preventative steps.

Immunomodulatory Activity of the Most Commonly Used Antihypertensive Drugs-Angiotensin Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers

This review article is focused on antihypertensive drugs, namely angiotensin converting enzyme inhibitors (ACEI) and angiotensin II receptor blockers (ARB), and their immunomodulatory properties reported in hypertensive patients as well as in experimental settings involving studies on animal models and cell lines. The immune regulatory action of ACEI and ARB is mainly connected with the inhibition of proinflammatory cytokine secretion, diminished expression of adhesion molecules, and normalization of CRP concentration in the blood plasma. The topic has significant importance in future medical practice in the therapy of patients with comorbidities with underlying chronic inflammatory responses. Thus, this additional effect of immune regulatory action of ACEI and ARB may also benefit the treatment of patients with metabolic syndrome, allergies, or autoimmune disorders.

Patient-Reported Barriers to Adherence Among ACEI/ARB Users from a Motivational Interviewing Telephonic Intervention

PURPOSE

Hypertension is a common comorbidity among type 2 diabetes mellitus (T2DM) patients, which increases the risk of cardiovascular diseases. Despite the proven benefit of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) in this population, poor medication adherence is prevalent, resulting in higher complications and mortality rate. Motivational interviewing (MoI) has demonstrated effectiveness in improving medication adherence and identifying barriers. This study aimed to assess and identify patient-reported barriers to adherence to ACEI/ARB from an MoI telephonic intervention conducted by student pharmacist interns.

PATIENTS AND METHODS

This retrospective study was conducted within an MoI intervention customized by past ACEI/ARB adherence trajectories for nonadherent patients with T2DM and hypertension enrolled in a Medicare Advantage Plan. Adherence barriers were extracted from the interviewers' notes by two independent researchers. Descriptive analysis was performed to summarize the overall frequency of barriers as well as across trajectory groups, identified from the initial and follow-up calls.

RESULTS

In total, 247 patients received the initial MoI call from which 41% did not communicate any barrier for ACEI/ARB use despite having low adherence. About 59% of the patients reported at least one barrier during the initial call. The most common barriers included forgetfulness, discontinuation by physicians, side effects, multiple comorbidities, polypharmacy, lack of knowledge about disease/medication, and cost issues. The follow-up calls helped with uncovering at least one new barrier for 28 patients who previously communicated a different issue with their medication during the first call. Additionally, 18 patients with initial denial for having any barrier to adherence reported at least one barrier throughout the follow-up calls.

CONCLUSION

This study summarized patient-reported barriers to ACEI/ARB adherence from an MoI telephonic intervention performed among nonadherent patients. Identifying specific barriers for patients may help to further design tailored interventions that address the barriers and improve adherence.

Pharmacotherapy for Essential Hypertension: A Brief Review

Hypertension is one of the leading causes of disability-adjusted life years and mortality, with approximately 15% prevalence worldwide. Most patients with hypertension from low- to high-income countries do not receive treatment. Among those who receive treatment, the majority remain undertreated and do not achieve their blood pressure goals. Therefore, new hypertension guidelines introduce more conscientious treatment strategies to maximize the probability of achieving the new strict blood pressure goals compared with the previous guidelines. Who should receive treatment for hypertension? Which antihypertensive medications have the strongest supporting data? Are generic and more affordable medications as effective as expensive brand medications? What are the different treatment strategies to maximize success in controlling blood pressure? Here, we briefly review pharmacotherapy for hypertension and provide answers to these questions as well as some other common questions regarding treatment of hypertension.

Antihypertensive medications and COVID-19 diagnosis and mortality: Population-based case-control analysis in the United Kingdom

AIMS

Antihypertensive drugs have been implicated in coronavirus disease 2019 (COVID-19) susceptibility and severity, but estimated associations may be susceptible to bias. We aimed to evaluate antihypertensive medications and COVID-19 diagnosis and mortality, accounting for healthcare-seeking behaviour.

METHODS

A population-based case-control study was conducted including 16 866 COVID-19 cases and 70 137 matched controls from the UK Clinical Practice Research Datalink. We evaluated all-cause mortality among COVID-19 cases. Exposures were angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), beta-blockers (B), calcium-channel blockers (C), thiazide diuretics (D) and other antihypertensive drugs (O). Analyses were adjusted for covariates and consultation frequency.

RESULTS

ACEIs were associated with lower odds of COVID-19 diagnosis (adjusted odds ratio [AOR] 0.82, 95% confidence interval [CI] 0.77-0.88) as were ARBs (AOR 0.87, 95% CI 0.80-0.95) with little attenuation from adjustment for consultation frequency. C and D were also associated with lower odds of COVID-19 diagnosis. Increased odds of COVID-19 for B (AOR 1.19, 95% CI 1.12-1.26) were attenuated after adjustment for consultation frequency (AOR 1.01, 95% CI 0.95-1.08). Patients treated with ACEIs or ARBs had similar odds of mortality (AOR 1.00, 95% CI 0.83-1.20) to patients treated with classes B, C, D or O or patients receiving no antihypertensive therapy (AOR 0.99, 95% CI 0.83-1.18).

CONCLUSIONS

There was no evidence that antihypertensive therapy is associated with increased risk of COVID-19 diagnosis or mortality; most classes of antihypertensive therapy showed negative associations with COVID-19 diagnosis.

Angiotensin converting enzyme inhibitors and angiotensin II receptor blockers and outcomes in patients with acute decompensated heart failure: a systematic review and meta-analysis

BACKGROUND

Angiotensin-converting enzyme inhibitor (ACEi) and angiotensin-receptor blocker (ARB) are cornerstones in the treatment of heart failure with reduced ejection (HFrEF). However, there are limited data on their risk-benefit profile in patients with acute heart failure requiring hospitalizations.

METHODS

We did a meta-analysis pooling data from all studies examining the use of ACEi/ARB in patients hospitalized for heart failure compared to patients without ACEi/ARB use. We calculated pooled hazard ratios (HR) and their 95% confidence intervals (CI) using a random-effects model.

RESULTS

Twenty-five studies were included in the meta-analysis. Continued use of ACEi/ARBs in hospitalized patients with HFrEF was associated with lower 1-year mortality risk (pooled HR 0.68 [0.60-0.77] p < 0.001) and with lower 1-6-year mortality risk in those with heart failure preserved ejection fraction (HFpEF) (pooled HR 0.86 [0.78-0.94] p = 0.002). There were significant reductions in 1-year HF readmissions among hospitalized HFrEF patients (pooled HR 0.83 [0.73-0.95] p = 0.005).

CONCLUSION

Maintaining or initiating patients with HFrEF hospitalized for acute decompensated heart failure (ADHF) on ACEi/ARB is associated with a reduce risk of mortality and 1-year admissions, but the effect size is lower among those with HFpEF with more heterogeneous outcomes.

[Effect of renin-angiotensin-aldosterone system inhibitors on functional activity of the spinal cord and nerve roots in patients with degenerative lumbar spine diseases]

High neuroprotective activity of renin-angiotensin-aldosterone system (RAAS) inhibitors in patients with vascular diseases of the brain and spinal cord has been confirmed.

OBJECTIVE

To evaluate the effect of renin-angiotensin-aldosterone system inhibitors on functional activity of the spinal cord and nerve roots in patients with degenerative lumbar spine diseases.

MATERIAL AND METHODS

A retrospective observational cohort study was performed. We evaluated clinical and radiological parameters (gender, age of patients, type of antihypertensive drug, concomitant diseases, ODI (6) and SF-36 (7) scores of patient quality of life), functional recovery, increase of signal intensity and its area in T2WIs, localization and maximum spinal canal stenosis, as well as maximum spinal cord and nerve root compression.

RESULTS

The study included 117 medical records of respondents (88 men and 29 women aged 56.9±13.2 years) who underwent lumbar spine surgery for degenerative diseases. Arterial hypertension was verified in 68 (58.1%) patients, diabetes mellitus in 22 (18.8%) respondents. Age (p=0.002), diabetes mellitus (p=0.007), arterial hypertension (p=0.015) and antihypertensive therapy (p=0.023) were significantly associated with worse clinical and neurological status of patients. Binary logistic regression model demonstrated that only arterial hypertension was significantly associated with low preoperative quality of life (p=0.002).

CONCLUSION

Intake of AT II-1 receptor blockers and angiotensin converting enzyme inhibitors for arterial hypertension is a significant predictor of decrease in signal intensity of the spinal cord and its roots according to T2WIs.

A Case Report of Delayed Post-operative Angioedema Associated With Angiotensin-Converting Enzyme Inhibitor Use

Angiotensin-converting enzyme inhibitors are known to precipitate angioedema. Drug-induced angioedema is rare in the perioperative setting. Even fewer cases described hours following a minor procedure. In this case report, we present a 45-year-old female who developed drug-induced angioedema hours following an obstetric procedure.

Tranexamic Acid for the Emergency Treatment of Angiotensin-Converting Enzyme Inhibitor-Induced Angioedema

INTRODUCTION

Angioedema is a rare but potentially life-threatening adverse effect associated with the use of angiotensin-converting enzyme (ACE) inhibitors. Various therapies, including ecallantide, icatibant, complement-1 esterase inhibitors, and fresh frozen plasma, have been used for treatment with inconsistent results and significant adverse effects. Tranexamic acid (TXA) is used as an alternative for the treatment of hereditary angioedema and it may be an attractive option for the treatment of ACE inhibitor-induced angioedema (ACEi-AE) in the emergency department (ED). The purpose of this study was to evaluate the impact of TXA administration on rates of intubation in patients presenting to the ED with suspected ACEi-AE.

METHODS

This was an institutional review board-approved, retrospective cohort study conducted at a single-site ED. All patients who received TXA for ACEi-AE in the ED between January 1, 2019 and March 31, 2021 were eligible for inclusion. The primary outcome was the proportion of patients who required intubation for suspected ACEi-AE.

RESULTS

A total of 16 patients received TXA in the ED for suspected ACEi-AE during the study timeframe. Of these, two patients were intubated prior to administration of TXA. The remaining 14 patients did not require intubation following TXA administration.

CONCLUSION

Administration of TXA was associated with a low rate of adverse effects and did not contribute to further morbidity when added to standard care in patients presenting to the ED with suspected ACEi-AE.

Well-Known and Novel Players in Endothelial Dysfunction: Updates on a Notch(ed) Landscape

Endothelial dysfunction characterizes every aspect of the so-called cardiovascular continuum, a series of events ranging from hypertension to the development of atherosclerosis and, finally, to coronary heart disease, thrombus formation, myocardial infarction, and heart failure. Endothelial dysfunction is the main prognostic factor for the progression of vascular disorders, which responds to drug intervention and lifestyle changes. Virtually all of the drugs used to prevent cardiovascular disorders, such as long-used and new antilipidemic agents and inhibitors of angiotensin enzyme (ACEi), exert an important effect on the endothelium. Endothelial dysfunction is a central feature of coronavirus disease -19 (COVID-19), and it is now clear that life-risk complications of the disease are prompted by alterations of the endothelium induced by viral infection. As a consequence, the progression of COVID-19 is worse in the subjects in whom endothelial dysfunction is already present, such as elderly, diabetic, obese, and hypertensive patients. Importantly, circulating biomarkers of endothelial activation and injury predict the severity and mortality of the disease and can be used to evaluate the efficacy of treatments. The purpose of this review is to provide updates on endothelial function by discussing its clinical relevance in the cardiovascular continuum, the latest insights from molecular and cellular biology, and their implications for clinical practice, with a focus on new actors, such as the Notch signaling and emerging therapies for cardiovascular disease.

Association between early worsening of kidney function and poor outcomes in patients treated with renin angiotensin system inhibitors: A meta-analysis

AIM

As renin angiotensin system inhibitors (RASi) are widely used in the clinic, early worsening of kidney function (EWKF) after RASi therapy deserves attention, as its clinical significance is unknown. The aim was to evaluate the relationship between EWKF and long-term outcomes including all-cause mortality, kidney and cardiovascular events, in all the patients treated with RASi.

METHODS

We searched PubMed, Embase, and the Cochrane databases for controlled trials that compared the outcomes of patients with and without EWKF after RASi treatment. Our primary outcome was all-cause mortality, and secondary outcomes were kidney and cardiovascular events. We pooled data using a random effects model.

RESULTS

A total of ten studies were enrolled, of which eight were randomized trials (including 33 454 patients) and two were observational studies (including 148 144 patients). Of the eight randomized trials, 4996 patients with type 2 diabetes, 19 118 with heart failure (HF), and 9340 with atherosclerotic vascular disease and diabetes with end-organ damage. Both observational studies investigated all kinds of patients with initial RASi treatment. In patients with RASi, the EWKF group had a higher risk of all-cause mortality than the no-EWKF group in the randomized studies (n =  13 581; RR, 1.22; 95% CI, 1.04-1.42; P = .02) and in observational studies (n = 148 144; OR, 1.70; 95% CI, 1.43-2.01; P < .00001). In patients who experienced EWKF, no statistically significant difference was found between the efficacy of RASi and placebo in all-cause mortality (n = 1762; RR, 0.85; 95% CI, 0.68-1.06; P = .14).

CONCLUSION

RASi treatment led to an increased incidence of EWKF which was associated with poorer long-term outcomes. As the benefit of RAS blockade to patients with EWKF was limited, we suggest clinicians use RASi with caution when EWKF occurs.

Blood-Brain Barrier Crossing Renin-Angiotensin Drugs and Cognition in the Elderly: A Meta-Analysis

[Figure: see text].

Angiotensin converting enzyme inhibitors and risk of lung cancer: A systematic review and meta-analysis

BACKGROUND

We performed a meta-analysis to determine whether a consistent relationship exists between the use of angiotensin converting enzyme inhibitors (ACEIs) and the risk of lung cancer. Accordingly, we summarized and reviewed previously published quantitative studies.

METHODS

Eligible studies with reference lists published before June 1st, 2019 were obtained from searching several databases. Random effects' models were used to summarize the overall estimate of the multivariate adjusted odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

Thirteen observational studies involving 458,686 ACEI users were included in the analysis, Overall, pooled risk ratios indicate that ACEIs use was not a risk factor for lung cancer (RR 0.982, 95% C.I. 0.873 - 1.104; P = .76). There was significant heterogeneity between the studies (Q = 52.54; P < .001; I2 = 86.07). There was no significant association between ACEIs use and lung cancer in studies with over five years of ACEIs exposure (RR 0.95, 95% C.I. 0.75 - 1.20; P = .70); and ≤ 5years of exposure to ACEIs (RR 0.98, 95% C.I. 0.83 - 1.15; P = .77). There were no statistically significant differences in the pooled risk ratio obtained according to the study design (Q = 0.65; P = .723) and the comparator regimen (Q = 3.37; P = .19).

CONCLUSIONS

The use of ACEIs was not associated with an increased risk of lung cancer. Nevertheless, well-designed observational studies with different ethnic populations are still needed to evaluate the long-term (over 10 years) association between ACEIs use and lung cancer.

Associations Between the Use of Renin-Angiotensin System Inhibitors and the Risks of Severe COVID-19 and Mortality in COVID-19 Patients With Hypertension: A Meta-Analysis of Observational Studies

Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) share a target receptor with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The use of ACEIs/ARBs may cause angiotensin-converting enzyme 2 receptor upregulation, facilitating the entry of SARS-CoV-2 into host cells. There is concern that the use of ACEIs/ARBs could increase the risks of severe COVID-19 and mortality. The impact of discontinuing these drugs in patients with COVID-19 remains uncertain. We aimed to assess the association between the use of ACEIs/ARBs and the risks of mortality and severe disease in patients with COVID-19. A systematic search was performed in PubMed, EMBASE, Cochrane Library, and MedRxiv.org from December 1, 2019, to June 20, 2020. We also identified additional citations by manually searching the reference lists of eligible articles. Forty-two observational studies including 63,893 participants were included. We found that the use of ACEIs/ARBs was not significantly associated with a reduction in the relative risk of all-cause mortality [odds ratio (OR) = 0.87, 95% confidence interval (95% CI) = 0.75-1.00; I 2 = 57%, p = 0.05]. We found no significant reduction in the risk of severe disease in the ACEI subgroup (OR = 0.95, 95% CI = 0.88-1.02, I 2 = 50%, p = 0.18), the ARB subgroup (OR = 1.03, 95% CI = 0.94-1.13, I 2 = 62%, p = 0.48), or the ACEI/ARB subgroup (OR = 0.83, 95% CI = 0.65-1.08, I 2 = 67%, p = 0.16). Moreover, seven studies showed no significant difference in the duration of hospitalization between the two groups (mean difference = 0.33, 95% CI = -1.75 to 2.40, p = 0.76). In conclusion, the use of ACEIs/ARBs appears to not have a significant effect on mortality, disease severity, or duration of hospitalization in COVID-19 patients. On the basis of the findings of this meta-analysis, there is no support for the cessation of treatment with ACEIs or ARBs in patients with COVID-19.

Does taking an angiotensin inhibitor increase the risk for COVID-19? - a systematic review and meta-analysis

Because SARS-COV2 entry into cells is dependent on angiotensin converting enzyme 2 (ACE2) and angiotensin converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) increase ACE2 activity, the safety of ACEI/ARB usage during the coronavirus disease 2019 (COVID-19) pandemic is a controversial topic. To address that issue, we performed a meta-analysis following The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Searches of the Embase, MEDLINE, PubMed, and Cochrane Library databases identified 16 case-control studies examining the effect of ACEI/ARB on the incidence of COVID-19 and its severity. ACEI/ARB usage was associated with an increased risk of COVID-19 morbidity (odds ratio (OR) 1.20, 95% confidence interval (CI) 1.07-1.33, P=0.001) among the general population but not in a hypertensive population (OR 1.05, 95% CI 0.90-1.21, P=0.553). ACEI/ARB usage was not associated with an increased risk of COVID-19 morbidity (coefficient 1.00, 95% CI 1.00-1.00, P=0.660) when we adjusted for hypertension in the general population. ACEI/ARB usage was also not associated with an increased risk of severe illness (OR 0.90, 95%CI 0.55-1.47, P=0.664) or mortality (OR 1.43, 95%CI 0.97-2.10, P=0.070) in COVID-19 patients. Our meta-analysis revealed that ACEI/ARB usage was not associated with either the increased risk of SARS-COV2 infection or the adverse outcomes in COVID-19 patients.

Effects of antihypertensive medication and high-intensity interval training in hypertensive metabolic syndrome individuals

Pharmacological and non-pharmacological therapies are simultaneously prescribed when treating hypertensive individuals with elevated cardiovascular risk (ie, metabolic syndrome individuals). However, it is unknown if the interactions between antihypertensive medication (AHM) and lifestyle interventions (ie, exercise training) may result in a better ambulatory blood pressure (ABP) control. To test this hypothesis, 36 hypertensive individuals with metabolic syndrome (MetS) under long-term prescription with AHM targeting the renin-angiotensin-aldosterone system (RAAS) were recruited. Before and after 4 months of high-intensity interval training (HIIT), participants completed two trials in a double-blind, randomized order: (a) placebo trial consisting of AHM withdrawal for 3 days and (b) AHM trial where individuals held their habitual dose of AHM. In each trial, 24-h mean arterial pressure (MAP) was monitored and considered the primary study outcome. Secondary outcomes included plasma renin activity (PRA) and aldosterone concentration to confirm withdrawal effects on RAAS, along with the analysis of urine albumin-to-creatinine ratio (UACR) to assess kidney function. The results showed main effects from AHM and HIIT reducing 24-h MAP (-5.7 mmHg, p < 0.001 and -2.3 mmHg, p = 0.007, respectively). However, there was not interaction between AHM and HIIT on 24-h MAP (p = 0.240). There was a main effect of AHM increasing PRA (p < 0.001) but no effect on plasma aldosterone concentration (p = 0.368). HIIT did not significantly improve RAAS hormones or the UACR. In conclusion, AHM and HIIT have independent and additive effects in lowering ABP. These findings support the combination of habitual AHM with exercise training with the goal to reduce ABP in hypertensive MetS individuals.

Controversial Roles of the Renin Angiotensin System and Its Modulators During the COVID-19 Pandemic

Since December 2019, the coronavirus 2019 (COVID-19) pandemic has rapidly spread and overwhelmed healthcare systems worldwide, urging physicians to understand how to manage this novel infection. Early in the pandemic, more severe forms of COVID-19 have been observed in patients with cardiovascular comorbidities, who are often treated with renin-angiotensin aldosterone system (RAAS)-blockers, such as angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs), but whether these are indeed independent risk factors is unknown. The cellular receptor for the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the membrane-bound angiotensin converting enzyme 2 (ACE2), as for SARS-CoV(-1). Experimental data suggest that expression of ACE2 may be increased by RAAS-blockers, raising concerns that these drugs may facilitate viral cell entry. On the other hand, ACE2 is a key counter-regulator of the RAAS, by degrading angiotensin II into angiotensin (1-7), and may thereby mediate beneficial effects in COVID-19. These considerations have raised concerns about the management of these drugs, and early comments shed vivid controversy among physicians. This review will describe the homeostatic balance between ACE-angiotensin II and ACE2-angiotensin (1-7) and summarize the pathophysiological rationale underlying the debated role of the RAAS and its modulators in the context of the pandemic. In addition, we will review available evidence investigating the impact of RAAS blockers on the course and prognosis of COVID-19 and discuss why retrospective observational studies should be interpreted with caution. These considerations highlight the importance of solid evidence-based data in order to guide physicians in the management of RAAS-interfering drugs in the general population as well as in patients with more or less severe forms of SARS-CoV-2 infection.

Dual-enzyme hydrolysis for preparation of ACE-inhibitory peptides from sesame seed protein: Optimization, separation, and identification

To prepare and identify ACE-inhibitory peptides originated from sesame seed protein, peptides with strong ACE-inhibitory activities were obtained via the optimization of protease and hydrolysis conditions, and these peptides were purified and identified by membrane separation, gel filtration, and liquid chromatography-mass spectrometry. Results showed that the dual-enzyme comprised alcalase and trypsin with the enzyme activity ratio of 3:7 was suitable to produce ACE-inhibitory peptides. The highest ACE-inhibitory activity of 98.10 ± 0.26% was obtained at the following parameters, pH 8.35, E/S ratio of 6,145 U/g, and hydrolysis time of 4.4 hr. ISGAQPSLR and VVISAPSK ranked the first and second ACE-inhibitory activity among 15 identified ACE-inhibitory peptides. Both peptides influenced ACE via binding with the S1 pocket, S2 pocket, and Zn²⁺ ion. ISGAQPSLR even impacted the S1' pocket. ISGAQPSLR and VVISAPSK acted as a competitive and noncompetitive inhibitor, respectively. ACE-inhibitory peptides derivated from sesame seed protein have potential applications in functional food. PRACTICAL APPLICATIONS: Although sesame seed protein is proven as the precursor of ACE-inhibitory peptide, preparing ACE-inhibitory peptide from sesame seed protein is still suffering from insufficient information on hydrolysis condition and the peptide sequence. Therefore, the performance of the typical protease on preparing ACE-inhibitory peptide from sesame seed protein has been evaluated, the effect of the amino acid composition of sesame seed protein and cleavage specificity of protease on the generation of ACE-inhibitory peptide has been investigated, hydrolysis conditions have been optimized, the peptide sequence has been identified to illuminate the effect of sesame seed protein fraction on the formation of ACE-inhibitory peptide and discuss the structural characteristics. ACE-inhibitory peptides originating from sesame seed protein could apply in functional food. It is promising for dual-enzyme hydrolysis to utilize in preparation of high-value bioactive peptides.

Alport Syndrome: a comprehensive review on genetics, pathophysiology, histology, clinical, and therapeutic perspectives

BACKGROUND

Alport syndrome (AS) is a disease caused by mutations in COL4A3, COL4A4 or COL4A5, the genes that encode distinct chains of type IV collagen. The vast majority of cases presents as an inherited disorder, although de novo mutations are present in around 10% of the cases.

METHODS

This non-systematic review summarizes recent evidence on AS. We discuss the genetic and pathophysiology of AS, clinical manifestations, histopathology, diagnostic protocols, conventional treatment and prognostic markers of the disease. In addition, we summarize experimental findings with novel therapeutic perspectives for AS.

RESULTS

The deficient synthesis of collagen heterotrimers throughout the organism leads to impaired basement membranes (BM) in several organs. As a result, the disease manifests in a wide range of conditions, particularly renal, ocular and auricular alterations. Moreover, leiomyomatosis and vascular abnormalities may also be present as atypical presentations. In this framework, diagnosis can be performed based on clinical evaluation, skin or renal biopsy and genetic screening, the latter being the gold standard. There are no formally approved treatments for AS, even though therapeutic options have been described to delay disease progression and increase life expectancy. Novel therapeutic targets under pre-clinical investigation included paricalcitol, sodium-glucose co-transporter-2 inhibitors, bardoxolone methyl, anti-microRNA-21 oligonucleotides, recombinant human pentraxin-2, lysyl oxidase-like-2 blockers, hydroxypropyl-b-cyclodextrin, sodium 4- phenylbutyrate and stem cell therapy.

CONCLUSION

AS is still a greatly under and misdiagnosed disorder. The pathophysiology is still not fully unnderstand and genetics of the disease have also some gaps. Up to know, there is no specific and effective treatment for AS. Further studies are necessary to establish novel and effective therapeutic protocols.

Changes in systolic blood pressure in dogs with pituitary dependent hyperadrenocorticism during the first year of trilostane treatment

Background

Systemic hypertension (SH) is common in dogs and humans with hypercortisolism and can persist after treatment.

Objectives

To evaluate changes in prevalence of SH and systolic blood pressure (SBP) in dogs with pituitary‐dependent hyperadrenocorticism (PDH) during the first year of trilostane treatment, its relationship with disease control and selected laboratory variables, and their response to antihypertensive treatment.

Animals

Fifty‐one dogs with PDH treated with trilostane Q12h.

Methods

Prospective case series study. Dogs were evaluated at diagnosis (T0) and 1, 3, 6, and 12 months (T12). Dogs were classified as nonhypertensive (SBP < 160 mm Hg) or hypertensive (SBP≥160 mm Hg) and subclassified according to target organ damage (TOD) risk. Hypertensive dogs were treated with benazepril and, if control of SH was not achieved, amlodipine was added.

Results

Prevalence of SH decreased from T0 (36/51) to T12 (17/37; P = .01). Changes in SBP during the study were influenced by the risk of TOD at T0. In severely hypertensive (SBP ≥ 180 mm Hg) dogs, the decrease in SBP was more pronounced whereas in normotensive (SBP < 140 mm Hg) dogs SBP increased slightly (P = .00). Blood pressure was not associated with disease control. Antihypertensive treatment was needed in 31/51 dogs, and in 13/31 dogs additional SH control with amlodipine was required. One third of nonhypertensive dogs at T0 required treatment with benazepril because SH developed during follow‐up.

Conclusions and Clinical Importance

In dogs with PDH, SBP should be measured at every visit, regardless of disease control or SBP at diagnosis. More than 1 drug may be necessary to manage SH in affected dogs.

Angiotensin axis antagonists increase the incidence of haemodynamic instability in dihydropyridine calcium channel blocker poisoning

CONTEXT

Amlodipine, a dihydropyridine calcium channel blocker (CCB), is the leading cause of cardiovascular drug-related overdose deaths in the USA. In contrast, angiotensin-II receptor blockers (ARBs) and angiotensin converting enzyme inhibitors (ACEIs) cause minimal toxicity in overdose. ACEIs/ARBs are often combined with dihydropyridines in hypertension treatment. Co-ingested ARBs/ACEIs may significantly contribute to the toxicity of dihydropyridine, but this has not been investigated.

OBJECTIVE

To investigate the clinical outcomes from dihydropyridine overdoses with ARBs/ACEIs versus dihydropyridine overdoses alone.

METHODS

This was a retrospective study of patients reported to the New South Wales Poisons Information Centre (NSW PIC) and 3 toxicology units (Jan 2016 to Jun 2019) in Australia. Patients >14 years who took an overdose of dihydropyridines (amlodipine, felodipine, lercanidipine, nifedipine) were included. Concurrent overdoses with non-dihydropyridine CCBs, alpha-blockers and beta-blockers were excluded. Patient demographics, drugs exposure details, serial vital signs, treatments and outcome were collected.

RESULTS

There were 100 patients. 68 took mixed overdoses of dihydropyridines with ARBs/ACEIs and 32 took single overdoses of dihydropyridines without ARBs/ACEIs. The mixed group had lower median nadir mean arterial pressures (62 vs 75 mmHg, p < 0.001), more frequently had hypotension (OR 4.5, 95%CI: 1.7-11.9) or bradycardia (OR 8.8, 95%CI: 1.1-70). Multivariable analysis indicated the mixed overdoses had an 11.5 mmHg (95%CI: 4.9-18.1) lower minimum systolic blood pressure (SBP) compared with the single group; other factors associated with a lower minimum SBP were higher doses [2.3 mmHg (95%CI: 1.1-3.5) lower per 10 defined daily doses] and younger age [2.2 mmHg (95%CI: 0.3-4.2) higher per decade]. A larger proportion of the mixed ingestion group received intravenous fluids (OR 5.7, 95%CI: 1.8-18.6) and antidotes and/or vasopressors (OR 2.9, 95%CI: 1.004-8.6).

CONCLUSION

Combined overdoses of dihydropyridines with ARBs/ACEIs caused more significant hypotension and required more haemodynamic support than overdoses of dihydropyridines alone.

Associations Between Antihypertensive Medications and Severe Hyponatremia: A Swedish Population-Based Case-Control Study

BACKGROUND

Calcium channel blockers (CCBs), beta-receptor blockers (BBs), angiotensin-converting enzyme inhibitors (ACEIs), and angiotensin II receptor blockers (ARBs) have occasionally been reported to cause severe hyponatremia. The aim was to explore the association between CCBs, BBs, ACEIs, and ARBs and hospitalization due to hyponatremia.

METHODS

Patients hospitalized with a principal diagnosis of hyponatremia (n = 11 213) were compared with matched controls (n = 44 801). Linkage of national population-based registers was used to acquire data. Multivariable logistic regression adjusting for co-medications, diseases, previous hospitalizations, and socioeconomic factors was used to explore the association between hospitalization for severe hyponatremia and the use of different CCBs, BBs, ACEIs, and ARBs. Furthermore, newly initiated (≤90 days) and ongoing use were examined separately.

RESULTS

Adjusted odds ratios (aORs) (95% confidence interval) for the investigated 4 drug classes ranged from 0.86 (0.81-0.92) for CCBs to 1.15 (1.07-1.23) for ARBs. For newly initiated drugs, aORs spanned from 1.64 (1.35-1.98) for CCBs to 2.24 (1.87-2.68) for ACEIs. In contrast, the corresponding associations for ongoing therapy were not elevated, ranging from 0.81 (0.75-0.86) for CCBs to 1.08 (1.00-1.16) for ARBs. In the CCBs subgroups, aOR for newly initiated vascular CCBs was 1.95 (1.62-2.34) whereas aOR for ongoing treatment was 0.82 (0.77-0.88).

CONCLUSIONS

For newly initiated CCBs, BBs, ACEIs, and ARBs, the risk of hospitalization due to hyponatremia was moderately elevated. In contrast, there was no evidence that ongoing treatment with investigated antihypertensive drugs increased the risk for hospitalization due to hyponatremia.

Mortality and Pre-Hospitalization use of Renin-Angiotensin System Inhibitors in Hypertensive COVID-19 Patients

Background

There has been significant controversy regarding the effects of pre‐hospitalization use of renin‐angiotensin system (RAS) inhibitors on the prognosis of hypertensive COVID‐19 patients.

Methods and Results

We retrospectively assessed 2,297 hospitalized COVID‐19 patients at Tongji Hospital in Wuhan, China, from January 10^th to March 30^th, 2020; and identified 1,182 patients with known hypertension on pre‐hospitalization therapy. We compared the baseline characteristics and in‐hospital mortality between hypertensive patients taking RAS inhibitors (N=355) versus non‐RAS inhibitors (N=827). Of the 1,182 hypertensive patients (median age 68 years, 49.1% male), 12/355 (3.4%) patients died in the RAS inhibitors group vs. 95/827 (11.5%) patients in the non‐RAS inhibitors group (p<0.0001). Adjusted hazard ratio for mortality was 0.28 (95% CI 0.15‐0.52, p<0.0001) at 45 days in the RAS inhibitors group compared with non‐RAS inhibitors group. Similar findings were observed when patients taking angiotensin receptor blockers (N=289) or angiotensin converting enzyme inhibitors (N=66) were separately compared with non‐RAS inhibitors group. The RAS inhibitors group compared with non‐RAS inhibitors group had lower levels of C‐reactive protein (median 13.5 vs. 24.4 pg/mL; p=0.007) and interleukin‐6 (median 6.0 vs. 8.5 pg/mL; p=0.026) on admission. The protective effect of RAS inhibitors on mortality was confirmed in a meta‐analysis of published data when our data were added to previous studies (odd ratio 0.44, 95% CI 0.29–0.65, p<0.0001).

Conclusions

In a large single center retrospective analysis we observed a protective effect of pre‐hospitalization use of RAS inhibitors on mortality in hypertensive COVID‐19 patients; which might be associated with reduced inflammatory response.

Effect of angiotensin converting enzyme inhibitors on the development of chronic subdural haematoma

AIMS

Angiotensin converting enzyme inhibitors (ACEI) have been recently discussed in connection with the medical treatment of chronic subdural haematoma (CSDH). They may improve the treatment results. The objective of our study was to evaluate the impact of ACEI on the development of CSDH. The first question was to assess the impact of ACEI on postoperative CSDH healing. The second was to assess the impact of ACEI on the development of CSDH as such.

PATIENTS AND METHODS

The study recruited patients treated surgically for CSDH at our department in the 2013-2018 period. Based on medical records, we retrospectively evaluated the clinical condition of the patients, their history (mainly pharmacological - the use of ACEI) and the course of treatment focussing on the reoccurrence of disease necessitating further therapeutic interventions. For the purpose of evaluating the impact of ACEI on postoperative CSDH healing, the patients were divided into two groups: those using ACEI and those without this medication. The results were compared. We also compared the prevalence of ACEI use in patients with CSDH with the prevalence of ACEI in the comparable population. The difference of the rates allowed us to evaluate the impact of ACEI on the development of CSDH itself.

RESULTS

Of the 217 patients after surgery for CSDH, 79 continued the use of ACEI; the remaining 138 patients did not use this medication. Patients using ACEI after the surgery experienced a recurrence in 24 (30.4%) cases; patients without ACEI in 37 (26.8%) cases. A negligibly higher number of recurrences was recorded in patients with postoperative use of ACEI, but this difference was not statistically significant (P=0.574). Of a total of 230 patients who underwent surgery for CSDH, 81 were using ACEI chronically (35.2%). In the control group of 100 patients, 38 (38.0%) patients used ACEI. The difference was not statistically significant (P=0.629), so it is not possible to assume that ACEIs influence the development of CSDH as such.

CONCLUSION

The initial high hopes for a positive ACEI effect on the healing of CSDH are now waived after the publication of several recent studies. According to our present knowledge, the development of CSDH does not appear to be influenced by ACEI use.

The presence of underlying asthma should be investigated in patients diagnosed with ACE inhibitor induced cough

INTRODUCTION

Why do only some of patients who are prescribed angiotensin converting enzyme inhibitors (ACE-I) develop cough? The pathogenesis of ACE-I-induced cough remains controversial and requires further studies.

OBJECTIVE

We aim to investigate whether asthma is a contributing cause of ACE-I-induced cough.

METHODS

Patients attending a cardiology clinic between March 2016 and March 2017 who were diagnosed with ACE-I induced cough were included in this study. ACE-I-induced cough was defined as cough which developed within 4 weeks after initiation of ACE-I therapy and which improved within 4 weeks after discontinuation of the ACE-I. Patients who had received ACE-I treatment for at least 6 months without side effects were included in the study as a control group. Face-to-face questionnaires, pulmonary function tests (PFT) and skin prick tests were applied to all the patients. If there was discordance between asthma history and PFT results, a methacholine bronchial provocation test (BPT) was performed.

RESULTS

A total of 43 patients with ACE-I induce cough were compared with 50 controls. Bronchial hyperreactivity (BHR), rhinitis, atopy and family history of asthma were more frequent in patients with ACE-I induced cough (P < .001). Patients with ACE-I-induced cough had significantly higher incidence of diagnosed asthma [OR = 8.28 (95%CI: 3.26-21.03) P < .001].

CONCLUSIONS

Asthma and an atopic background constitute a substantial risk factor for ACE-I induced cough. The presence of underlying asthma should be investigated in patients diagnosed with ACE inhibitor induced cough. However, the fact that most asthma patients tolerate ACE-I therapy, indicates that other cofactors are likely involved.

Frequency of Intraoperative Hypotension After the Induction of Anesthesia in Hypertensive Patients with Preoperative Angiotensin-converting Enzyme Inhibitors

Introduction

The renin-angiotensin-aldosterone system (RAAS) is an important target in the treatment of hypertension. Angiotensin-converting enzyme (ACE) inhibitors block the conversion of angiotensin I to angiotensin II. ACE inhibitors not only treat hypertension but also decrease morbidity and mortality in heart failure patients and in patients with acute myocardial infarction. The discontinuation of ACE inhibitors before the surgery is still controversial. To assess the current magnitude of the problem in our population, we aimed to conduct this study, which evaluated the frequency of intraoperative hypotension after the induction of anesthesia in controlled hypertensive patients with preoperative ACE inhibitors.

Material and methods

This descriptive case series study was conducted at a tertiary hospital in a developing country after approval from the Ethics Review Committee. A total of 115 adult patients, from 16 to 60 years of age, who have undergone elective surgery, have controlled hypertension on the desired drugs for at least six months, have no history of any cardiac event, and have taken the drug on the morning of the surgery, were included in the study after written consent. The demographic data of the patients were entered into the proforma. Preoperative systolic, diastolic, and mean arterial pressure were recorded by the researcher or an assignee in the preoperative holding area. The patients were followed in the recovery room by the team conducting the study until 10 minutes after the arrival of the patient in the recovery room. All statistical analyses were performed using Statistical Packages for the Social Sciences version 19 (SPSS Inc., Chicago, IL). p-value ≤0.05 was considered significant.

Results

Of the 115 patients, 56 (48.7%) patients were in the age group between 51 and 60 years of age; 38 patients were between the ages of 41 and 50 years and only 21 patients were 40 years or less. On gender, 68 patients were female and 47 were male. According to body mass index (BMI), the majority of the patients were in the overweight group, amounting to 53 (46%), and 86 (74.78%) patients were known diabetics. Overall, 77 (66.96%) of the patients developed intraoperative hypotension with 41 (35.65%) patients requiring the use of vasopressors in order to correct the hypotension. No statistically significant difference was found between demographic and clinical variables.

Conclusion

Intraoperative hypotension is more frequent in patients with controlled hypertension on ACE inhibitors although more studies need to be conducted on a larger population in order to determine a more definitive result.

Membranous nephropathy associated with profound hypothyroidism

Membranous nephropathy can be primary or secondary. Although common causes of secondary MN are malignancy and lupus, hypothyroidism was rarely reported. Providers should check thyroid function tests in patients with unexplained nephrotic proteinuria.

Group-Based Trajectory Modeling to Identify Patterns of Adherence and Its Predictors Among Older Adults on Angiotensin-Converting Enzyme Inhibitors (ACEIs)/Angiotensin Receptor Blockers (ARBs)

PURPOSE

Commonly prescribed medications among patients with comorbid diabetes mellitus and hypertension include ARBs and ACEIs. However, these medications are associated with suboptimal adherence leading to inadequately controlled blood pressure. Unlike traditional single estimates of proportion of days covered (PDC), group-based trajectory modeling (GBTM) can graphically display the dynamic nature of adherence. The objective of this study was to evaluate adherence using GBTMs among patients prescribed ACEI/ARBs and identify predictors associated with each adherence trajectory.

PATIENTS AND METHODS

Patients with an ACEI/ARBs prescription were identified between July 2017 and December 2017 using a Medicare Advantage dataset. PDC was used to measure monthly patient adherence during the one-year follow-up period. The monthly PDC was added to a logistic group-based trajectory model to provide distinct patterns of adherence. Further, a multinomial logistic regression was conducted to determine predictors of each identified adherence trajectory. Predictors included various socio-demographic and clinical patient characteristics.

RESULTS

A total of 22,774 patients were included in the analysis and categorized into 4 distinct adherence trajectories: rapid decline (12.6%); adherent (58.5%); gaps in adherence (12.2%), and gradual decline (16.6%). Significant predictors associated with all lower adherence trajectories included 90 days refill, >2 number of other medications, ≥1 hospitalizations, and prevalent users. Significant predictors associated with the rapid decline trajectory included male sex, comorbidities, and increased CMS risk score. Further, significant predictors associated with the gaps in adherence trajectory included increasing age, and comorbidities. Lastly, significant predictors associated with the gradual decline trajectory included increasing age, no health plan subsidy, comorbidities, and increasing CMS risk score.

CONCLUSION

Identifying various patient characteristics associated with non-adherent trajectories can guide the development of tailored interventions to enhance adherence to ACEI/ARBs.

Drug Therapies for Patients with IgA Nephropathy: A Network Meta-analysis of Randomized Clinical Trials

BACKGROUND

Several drugs are used for treating IgA nephropathy (IgAN). We carried out a network meta-analysis evaluating these drugs.

METHODS

Electronic databases were searched for appropriate randomized clinical trials carried out in patients with IgAN. The primary outcome was proteinuria remission rates and there were several other secondary outcome measures. The risk of bias was assessed. Mixed treatment comparison estimates were modelled from direct and indirect comparison estimates. Grading of the evidence for key comparisons was carried out.

RESULTS

Fifty-seven clinical trials were included in the systematic review and 51 in the metaanalysis. Polyunsaturated fatty acids, corticosteroids/angiotensin receptor blockers (ARB), ARB, angiotensin converting enzyme inhibitors (ACEI), ARB/ACEI, corticosteroids/ACEI and hypolipidemics/ ARB were observed with significantly higher rates of proteinuria remission than the standard of care. Several benefits were observed with other drugs on the secondary outcome measures. A very low grade was observed for the interventions.

CONCLUSION

We observed a few interventions to perform better in the management of IgAN. The results of this study will aid in further evaluation of such drugs that may assist in saving the resources and time. However, the readers should interpret the findings with great caution as the results might change with the advent of future head-to-head clinical trials.

Probable Enalapril Hepatotoxicity in a 13-Year-Old Male Western Lowland Gorilla: Pharmacologic Risks and Vigilance

A 13-year-old male Western lowland gorilla presented acutely with a precipitous decline in health status from liver disease. Through diagnostic assessment, including serum chemistries and advanced imaging, it was diagnosed with probable hepatotoxicity resulting from its prescribed medication, enalapril. As one of several angiotensin converting enzyme inhibitors (ACE-I) available to zoo veterinarians, enalapril had been administered for treatment of mild ventricular hypertrophy diagnosed during routine examination 2.5 years prior to the presentation. The gorilla made a complete recovery with discontinuation of this medication, and provision of hepatoprotectants. Hepatotoxicity has been documented in humans receiving this product as an adverse drug reaction and is considered both rare and unpredictable in occurrence. In this event, an association was suspected with indulgent consumption of mulberry browse (Morus sp.) offered as nutritional enrichment immediately prior to clinical presentation and had potential impact on hepatic cytochrome P450 metabolism of the enalapril. Although ACE-I are important medications in this taxon due to its predisposition to cardiac disease, this event underscores the need for vigilance on the part of veterinarians and managers whenever pharmaceuticals are administered. Most drugs are modeled in a limited number of species but utilized in a wide variety, and unintended results are possible.

Discontinuation of Angiotensin Converting Enzyme Inhibitors and Angiotensin Receptor Blockers in Chronic Kidney Disease

OBJECTIVE

To assess the patterns of angiotensin converting enzyme inhibitors and angiotensin receptor blockers (ACE-I/ARB) discontinuation in the setting of chronic kidney disease (CKD) progression in real-world clinical practice.

PATIENTS AND METHODS

We identified incident ACE-I/ARB users with a baseline estimated glomerular filtration rate (eGFR) ≥15 mL/min/1.73 m2 and without end-stage renal disease in the Geisinger Health System between January 1, 2004, and December 31, 2015. We investigated the associations of CKD stage, hospitalizations with and without acute kidney injury (AKI), serum potassium, bicarbonate level, thiazide, and loop diuretic use with ACE-I/ARB discontinuation.

RESULTS

Among the 53,912 ACE-I/ARB users, the mean age was 59.9 years, and 50.6% were female. More than half of users discontinued ACE-I/ARB within 5 years of therapy initiation. The risk of ACE-I/ARB discontinuation increased with more advanced CKD stage. For example, patients who initiated ACE-I/ARB with CKD stage G4 (eGFR: 15-29 mL/min/1.73 m2) were 2.09-fold (95% CI, 1.87-2.34) more likely to discontinue therapy than those with eGFR ≥ 90 mL/min/1.73 m2. Potassium level greater than 5.3 mEq/L, systolic blood pressure ≤ 90 mm Hg, bicarbonate level < 22 mmol/L, and intervening hospitalization-particularly AKI-related-were also strong risk factors for ACE-I/ARB discontinuation. Thiazide diuretic use was associated with lower risk, whereas loop diuretic use was associated with higher risk of discontinuation.

CONCLUSION

In a real-world cohort, discontinuation of ACE-I/ARB was common, particularly in patients with lower eGFR. Hyperkalemia, hypotension, low bicarbonate level, and hospitalization (AKI-related, in particular) were associated with a higher risk of ACE-I/ARB discontinuation. Additional studies are needed to evaluate the risk-benefit balance of discontinuing ACE-I/ARB in the setting of CKD progression.

In Silico Analysis of Bioactive Peptides in Invasive Sea Grass Halophila stipulacea

Halophila stipulacea is a well-known invasive marine sea grass in the Mediterranean Sea. Having been introduced into the Mediterranean Sea via the Suez Channel, it is considered a Lessepsian migrant. Although, unlike other invasive marine seaweeds, it has not demonstrated serious negative impacts on indigenous species, it does have remarkable invasive properties. The present in-silico study reveals the biotechnological features of H. stipulacea by showing bioactive peptides from its rubisc/o protein. These are features such as antioxidant and hypolipideamic activities, dipeptidyl peptidase-IV and angiotensin converting enzyme inhibitions. The reported data open up new applications for such bioactive peptides in the field of pharmacy, medicine and also the food industry.

Cardiac Remodeling and Reversible Pulmonary Hypertension During Pneumonitis in Rats after 13-Gy Partial-Body Irradiation with Minimal Bone Marrow Sparing: Effect of Lisinopril

Total-body irradiation causes acute and delayed toxicity to hematopoietic, pulmonary, cardiac, gastrointestinal, renal, and other organ systems. Angiotensin-converting enzyme inhibitors mitigate many of the delayed injuries to these systems. The purpose of this study was to define echocardiographic features in rats at two times after irradiation, the first before lethal radiation pneumonitis (50 d) and the second after recovery from pneumonitis but before lethal radiation nephropathy (100 d), and to determine the actions of the angiotensin-converting enzyme inhibitor lisinopril. Four groups of female WAG/RijCmcr rats at 11-12 wk of age were studied: nonirradiated, nonirradiated plus lisinopril, 13-Gy partial-body irradiation sparing one hind leg (leg-out partial-body irradiation), and 13-Gy leg-out partial-body irradiation plus lisinopril. Lisinopril was started 7 d after radiation. Echocardiograms were obtained at 50 and 100 d, and cardiac histology was assessed after 100 d. Irradiation without lisinopril demonstrated echocardiographic transient pulmonary hypertension by 50 d which was largely resolved by 100 d in survivors. Irradiated rats given lisinopril showed no increase in pulmonary artery pressures at 50 d but exhibited left ventricular remodeling. By 100 d these rats showed some signs of pulmonary hypertension. Lisinopril alone had no impact on echocardiographic end points at either time point in nonirradiated rats. Mild increases in mast cells and fibrosis in the heart were observed after 100 d following 13-Gy leg-out partial-body irradiation. These data demonstrate irradiation-induced pulmonary hypertension which was reversed in survivors of pneumonitis. Lisinopril modified cardiovascular remodeling to enhance survival in this model from 41% to 86% (p = 0.0013).

Association of depression with mortality in an elderly treated hypertensive population

ABSTRACTBackground:Both elevated blood pressure and/or depression increase the risk of cardiovascular disease and mortality. This study in treated elderly hypertensive patients explored the incidence of depression, its association (pre-existing and incident) with mortality and predictors of incident depression.

METHODS

Data from 6,083 hypertensive patients aged ≥65 years enrolled in the Second Australian National Blood Pressure study were used. Participants were followed for a median of 10.8 years (including 4.1 years in-trial) and classified into: "no depression," "pre-existing" and "incident" depression groups based on either being "diagnosed with depressive disorders" and/or "treated with an anti-depressant drug" at baseline or during in-trial period. Further, we redefined "depression" restricted to presence of both conditions for sensitivity analyses. For the current study, end-points were all-cause and any cardiovascular mortality.

RESULTS

313 (5%) participants had pre-existing depression and a further 916 (15%) participants developed depression during the trial period (incidence 4% per annum). Increased (hazard-ratio, 95% confidence-interval) all-cause mortality was observed among those with either pre-existing (1.23, 1.01-1.50; p = 0.03) or incident (1.26, 1.12-1.41; p &lt; 0.001) depression compared to those without. For cardiovascular mortality, a 24% increased risk (1.24, 1.05-1.47; p = 0.01) was observed among those with incident depression. The sensitivity analyses, using the restricted depression definition showed similar associations. Incident depression was associated with being female, aged ≥75 years, being an active smoker at study entry, and developing new diabetes during the study period.

CONCLUSIONS

This elderly cohort had a high incidence of depression irrespective of their randomised antihypertensive regimen. Both pre-existing and incident depression were associated with increased mortality.

Effect of renin-angiotensin-aldosterone system blocking agents on progression of glomerulopathy in sickle cell disease

Although renin-angiotensin-aldosterone system (RAAS) blocking agents decrease albuminuria in short-term studies, there is no evidence confirming their long-term efficacy in sickle cell disease (SCD). In a single-centre, retrospective study, we evaluated the long-term effect of RAAS blocking agents on proteinuria and declining estimated glomerular filtration rates (eGFR). Eighty-six patients on RAAS blocking agents for proteinuria, followed for a median of 2·28 years, were compared with 68 patients with proteinuria followed for 2·24 years who were not receiving such treatment. The log odds of proteinuria decreased over time in patients on RAAS blocking agents (β: -0·23, P = 0·03) and in the non-treatment group (β: -0·54, P < 0·0001), but was not statistically different between both groups (β: 0·31, P = 0·063). The eGFR declined over time in patients on RAAS blocking agents (β: -2·78, P < 0·0001) and in those not on such treatment (β: -4·7, P < 0·0001), and was statistically different between both groups (β: 1·9, P = 0·0002). Baseline eGFR was associated with mortality (Hazard rato: 0·97, P < 0·0001), but RAAS blocking agents had no significant effect on mortality. These data suggest that RAAS blockade may slow the loss of kidney function in SCD.