Continued angiotensin-converting enzyme inhibitor (ACEi) or angiotensin II receptor blocker (ARB) use in the hospital among hypertensive patients with coronavirus disease 2019 (COVID-19) results in better clinical outcomes, according to a study recently published in the Journal of Infectious Diseases.
Hypertension is a common comorbidity in patients with COVID-19 and is associated with worse clinical outcomes. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) enters cells through ACE2 receptors. ACEi and ARBs may upregulate ACE2 receptors, raising concerns about increased morbidity and mortality associated with use in patients with COVID-19. However, ACE2 receptors also exhibit anti-inflammatory, vasodilatory, and antifibrotic effects that may alleviate the severity of the disease. Previous studies reported that ACEi/ARB use in hypertensive COVID-19 patients did not worsen disease severity or increase mortality, though these studies focused on ACEi/ARB use prior to hospitalization or did not account for discontinuation due to the development of hypotension or acute kidney disease (AKI). This retrospective, single-center study investigated the effects of in-hospital continuation and discontinuation of ACEi/ARBs on the clinical outcomes of hypertensive COVID-19 patients.
In total, 614 patients between February 7 and May 23 were hypertensive and tested positive for COVID-19 at Stony Brook University Hospital COVID-19 Persons Under Investigation Registry. Infection with COVID-19 was confirmed with a positive real-time polymerase chain reaction test for SARS-CoV-2 using a nasopharyngeal swab. These hypertensive patients were divided into 2 groups: patients not taking ACEi/ARB at home and patients who were. The latter group was further divided according to patients who discontinued or continued therapy during hospital stay:
- Group A: patients not taking ACEi/ARB at home
- Group B: patients who discontinued ACEi/ARB during hospital stay
- Group C: patients who continued ACEi/ARB during hospital stay
Patients were stratified by development of hypertension and AKI during the index hospitalization to account for confounders. Electronic health records were used to collect and analyze demographics, comorbidities, vital signs, laboratory data, and ACEi/ARB use for each patient. The primary outcome of this study was in-hospital mortality; the secondary outcome was intensive care unit (ICU) admission.
The median age of patients in the non-ACEi/ARB group (73 years; interquartile range [IQR], 62-83) was higher compared to the ACEi/ARB group (68 years; IQR, 58-79; P =.004); sex and ethnicity were not significantly different between groups. Prevalence of diabetes mellitus was higher in the ACEi/ARB group (P =.01) but lower in patients with chronic kidney disease at baseline (P =.001). Hematocrit (P =.003), sodium (P =.001), D-dimer (P =.003), and troponin (P =.005) levels were significantly different between the non-ACEi/ARB and ACEi/ARB groups.
Continued ACEi/ARB use in hypertensive COVID-19 patients yields better clinical outcomes. Between the ACEi/ARB group and the non-ACEi/ARB group, mortality (17% versus 22%; P >.05) and intensive care unit admission (19% versus 19%; P >.05) rates were not significantly different. However, patients who continued ACEi/ARB therapy during their hospital stay saw lower ICU admission rates (12% vs 26%; P =.001) and lower mortality rates (6% vs 28%; P =.001) compared to patients who discontinued therapy. When accounting for development of hypotension or AKI as a reason for discontinuing therapy, the mortality rate remained significantly lower.
Findings conclude that continuation of “ACEi/ARB use does not worsen clinical outcomes in COVID-19 patients with a history of hypertension,” but also suggest, “COVID-19 patients who are on ACEi/ARBs should continue these medications in the hospital as they may have beneficial effects, as long as these patients do not develop hypotension of AKI.”
Lam KW, Chow KW, Vo J, et al. Continued in-hospital angiotensin-converting enzyme inhibitor and angiotensin II receptor blocker use in hypertensive COVID-19 patients is associated with positive clinical outcome. J Infect Dis. 2020;222:1256-1264. doi:10.1093.infdis/jiaa447.