Cardiology societies recommend patients taking ACE inhibitors, ARBs who contract COVID-19 should continue treatment
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Several American and European cardiology societies issued statements to dispel misinformation circulating about an association between treatment with renin-angiotensin-aldosterone system antagonists such as ACE inhibitors and angiotensin receptor blockers and increased risk for COVID-19 and increased severity of the disease for those who have contracted COVID-19.
The American Heart Association, the Heart Failure Society of America and the American College of Cardiology issued a joint statement on March 17 and the European Society of Cardiology issued a statement on March 13. The Nephrology Journal Club issued a review with a similar message on March 17.
Renin-angiotensin-aldosterone system (RAAS) antagonists are commonly prescribed treatments for patients with hypertension, HF and/or ischemic heart disease.
Speculative hypotheses
“Based on initial reports from China, and subsequent evidence that arterial hypertension may be associated with increased risk of mortality in hospitalized COVID-19-infected subjects, hypotheses have been put forward to suggest a potential adverse effects of ACE inhibitors or angiotensin receptor blockers,” Giovanni de Simone, MD, FACC, FAHA, FESC, chair of the ESC Council on Hypertension and professor of medicine at Hypertension Research Center Federico II University Hospital, Naples, Italy, wrote on behalf of the ESC. “It has been suggested, especially on social media sites, that these commonly used drugs may increase both the risk of infection and the severity of SARS-CoV-2. The concern arises from the observation that, similar to the coronavirus causing SARS, the COVID-19 virus binds to a specific enzyme called ACE2 to infect cells, and ACE2 levels are increased following treatment with ACE inhibitors and angiotensin receptor blockers.”
The issue was raised in correspondence to The Lancet Respiratory Medicine by Lei Fang, MD, PhD, postdoctoral researcher in the department of biomedicine at University Hospital Basel, Switzerland, and colleagues.
“We suggest that patients with cardiac diseases, hypertension or diabetes who are treated with ACE2-increasing drugs are at higher risk for severe COVID-19 infection and, therefore, should be monitored for ACE2-modulating medications, such as ACE inhibitors or angiotensin receptor blockers,” Fang and colleagues wrote.
These reports, which have spread to social media, have led some patients to stop taking RAAS antagonists. However, patients should not stop treatment unless advised by a physician, according to the society statements.
“This speculation about the safety of ACE inhibitor or angiotensin receptor blockers treatment in relation to COVID-19 does not have a sound scientific basis or evidence to support it,” de Simone wrote in the ESC statement. “Indeed, there is evidence from studies in animals suggesting that these medications might be rather protective against serious lung complications in patients with COVID-19 infection, but to date there are no data in humans. The Council on Hypertension strongly recommends that physicians and patients should continue treatment with their usual antihypertensive therapy because there is no clinical or scientific evidence to suggest that treatment with ACE inhibitors or angiotensin receptor blockers should be discontinued because of the COVID-19 infection.”
Evidence-based decisions
The statement issued by the American societies recommends that:
- patients taking RAAS inhibitors continue to do so until directed by a medical professional;
- a full evaluation of any patient diagnosed with COVID-19 should be done before any medications are discontinued; and
- changes to treatment of heart conditions should be based on the latest scientific evidence and should come after a shared decision-making process.
“We understand the concern — as it has become clear that people with cardiovascular disease are at much higher risk of serious complications including death from COVID-19,” Robert A. Harrington, MD, FAHA, president of the AHA, Arthur L. Bloomfield Professor of Medicine and chair of the department of medicine at Stanford University, said in the joint statement. “However, we have reviewed the latest research — the evidence does not confirm the need to discontinue ACE inhibitor or angiotensin receptor blockers, and we strongly recommend all physicians to consider the individual needs of each patient before making any changes to ACE inhibitor or angiotensin receptor blocker treatment regimens.”
“While the primary symptoms of COVID-19 include respiratory symptoms, the latest evidence demonstrates some patients with COVID-19 may also have severe cardiovascular damage. We must ensure we fully evaluate and treat patients with cardiovascular disease,” Biykem Bozkurt, MD, PhD, FHFSA, president of HFSA, professor of cardiology, the Mary and Gordon Cain Chair of Medicine in the Winters Center for Heart Failure Research and the W.A. “Tex” and Deborah Moncrief Chair in Cardiology at Baylor College of Medicine, said in the statement.
“The continued highest standard of care for cardiovascular disease patients diagnosed with COVID-19 is our top priority, but there are no experimental or clinical data demonstrating beneficial or adverse outcomes among COVID-19 patients using ACE inhibitor or angiotensin receptor blocker medications,” Richard J. Kovacs, MD, president of the ACC and Q.E. and Sally Russell Professor of Cardiology at Indiana University School of Medicine, said in the statement. “We urge urgent, additional research that can guide us to optimal care for the millions of people worldwide with cardiovascular disease and who may contract COVID-19. These recommendations will be adjusted as needed to correspond with the latest research.”
The Nephrology Journal Club issued a review of what is known about the link between COVID-19, hypertension and RAAS antagonists. “We are not convinced the data show a strong, robust link [between high BP and COVID-19],” the authors wrote. “However, the virus uses the renin-angiotensin system — hence all the speculation.”
“There are no clinical data to support that being on an ACE inhibitor or ARB increases a risk, nor does the basic science … support a clear association,” the authors concluded. “Patients who are taking ACE inhibitors or ARBs for hypertension are not advised to change their therapy unless advised to do so by their physician.”
Healio and Cardiology Today are following this news and will report on new developments.
For the latest news on COVID-19 including case counts, information about the global public health response and emerging research, please visit the COVID-19 Resource Center on Healio. – by Erik Swain
Reference:
Fang L, et al. Lancet Respir Med. 2020;doi:10.1016/S2213-2600(20)30116-8.
Disclosures: Bozkurt reports she is a consultant or advisory board member for Abbott Vascular, Bayer Health Care Pharmaceuticals, Bristol-Myers Squibb, Lantheus Medical Imaging, LivaNova Anthem, Respicardia, Sanofi and scPharmaceuticals Inc. Harrington reports he received research grants from AstraZeneca and Bristol-Myers Squibb. De Simone and Kovacs report no relevant financial disclosures.
Editor’s Note: This article was updated on March 18, 2020 to add information from the Nephrology Journal Club.
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