How Safe Are ACE-I, ARB Medications in COVID-19 Patients With Hypertension?

From almost Day One of the novel coronavirus outbreak, the safety of angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs) has been questioned for patients with COVID-19 infections. With more research, the situation has become clearer. Find out what situations and indicators make those drugs unacceptable in patients with novel coronavirus.

KEENE, NH – Hypertension is the most common co-existing disease among hospitalized COVID-19 patients, and one of the greatest controversies since the beginning of the disease outbreak has been which medications are safe to treat it. .

A presentation at the American Heart Association's Hypertension 2020 Scientific Sessions analyzed 22 studies from eight countries with more than 11,000 total, hospitalized COVID-19 patients. Researchers found 42% of patients had hypertension, followed by diabetes mellitus, which affected 23% of patients.

The Dartmouth-Hitchcock-led researchers note that hypertension, alone, was associated with a higher likelihood of death and was more common than chronic obstructive pulmonary disease (COPD) among hospitalized COVID-19 patients. "More randomized studies are needed to assess the effect of hypertension on mortality in COVID-19 patients," said researchers in the abstract.

Another study featured at the meeting discussed how reducing or eliminating high blood pressure medications if blood pressure becomes hypotensive. Near the beginning of the , falling below 120/70 mm Hg, could prevent acute kidney injury and death in COVID-19 patients, the AHA issued a joint statement with the Heart Failure Society of America and the American College of Cardiology to address the use of ACE-i and ARB medications among patients at risk for developing COVID-19.

Those recommendations called for the continuation of ACE-i or ARB medications among patients already taking them for indications such as heart failure, hypertension or ischemic heart disease.

"While we continue to learn more about the complex impact of COVID-19 every day, we know that people with cardiovascular disease and/or hypertension are at much higher risk for serious complications including death from COVID-19," explained Mariell Jessup, MD, chief science and medical officer of the American Heart Association. "We continue to monitor and review the latest research, and we strongly recommend all physicians to consider the individual needs of each patient before making any changes to ACE-i or ARB treatment regimens. The latest research findings do suggest, however, that these medications should be discontinued in patients who develop hypotension in order to avoid severe kidney damage."

"Acute kidney injury, also known as acute kidney failure, is a serious COVID-19 complication, and many people with the virus are at risk," according to study author Paolo Manunta, MD, Ph.D., chair of nephrology at San Raffaele University in Milan, Italy.

Manunta and colleagues sought to determine which COVID-19 patients are most at risk for kidney damage, focusing on 392 COVID-19 patients hospitalized between March 2 and April 25, 2020, at one center in Italy. Results indicated that:

  • Nearly 60% had a history of hypertension, making it the most common co-occurring health issue in these patients.
  • More than 86% of patients with high blood pressure were taking anti-hypertensive medications daily.
  • Overall, 6.2% of the patients came into the emergency department with acute kidney injury -- kidney function and hypertension were the main determinants of whether a person had acute kidney injury.
  • Having a history of hypertension increased the risk of acute kidney injury by about five-fold.

Severe hypotension, defined as blood pressure lower than 95/50 mm Hg, was linked to a nine times greater likelihood for patients to have acute kidney injury; mild hypotension, blood pressure lower than 120/70 mm Hg but not in the severe range, was linked to a four times greater risk.

While COVID-19 patients were more likely to develop acute kidney injury while hospitalized if they were elderly, hypertensive or had severe respiratory distress, in-hospital death was still twice as likely in patients with mild hypotension when they arrived at the emergency department, regardless of age, other diseases and COVID-19 severity.

"Our study suggests low blood pressure in a person with a history of high blood pressure is an important and independent signal that someone with COVID-19 is developing or has acute kidney injury," Manunta said. "This also suggests that people with high blood pressure should carefully monitor it at home, and their kidney function should be measured when they're first diagnosed with COVID-19. If they or their doctors notice blood pressure levels going down to the hypotensive range, their doctors may consider reducing or stopping their blood pressure medications to prevent kidney damage and possibly even death."

A presentation by University of Miami/JFK Medical Center in Atlantis, FL, described the effects of taking the blood pressure-lowering prescriptions angiotensin-converting enzyme inhibitors (ACE-i) and/or angiotensin receptor blockers (ARBs) in hospitalized COVID-19 patients. They found that patients taking the medications were more likely to die than those who were not taking them.

The single-center, retrospective study involved 172 patients hospitalized for COVID-19 between March and May 2020. Results indicate that 33% of patients taking one or both of the anti-hypertensive medications (ACE-i, ARBs) died in the hospital, vs.13% of those not taking either of the medications. Researchers also report that admission to the intensive care unit was also higher -- at 28% among those on the medications vs. 13% of patients not taking ACE-i and/or ARB medications.

The study suggests that one explanation for the higher risk of death among patients taking the antihypertensive medications could be because people prescribed those medications tend to be older and are more likely to have diabetes mellitus and hypertension.

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