Antihypertensive Drugs During COVID-19: Still Up in the Air

Sandra Adamson Fryhofer, MD


April 10, 2020

This transcript has been edited for clarity.

Hello. I'm Dr Sandra Fryhofer. Welcome to Medicine Matters. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs) are important for managing heart failure, hypertension, ischemic heart disease, and diabetes. A letter published by Michael Roth and colleagues in Lancet Respiratory Medicine raises concerns that ACE inhibitors and ARBs could make getting infected with the SARS-CoV-2 virus easier and the severity of infection worse.

Here's why:

  • The novel coronavirus binds to target cells through ACE 2, which is expressed by epithelial cells of the lung, intestine, kidney, and blood vessels.

  • Use of ACE inhibitors and ARBs may increase expression and upregulation of ACE 2.

In the letter, Roth and colleagues proposed that because of the way the virus attaches and attacks, use of ACE inhibitors and ARBs could theoretically increase risk for severe and fatal disease. Another article, in Journal of Hypertension, published a day later, raised this same red flag.

In a joint statement, cardiologists from the American Heart Association, the Heart Failure Society of America, and the American College of Cardiology urged patients taking ACE inhibitors and ARBs who contract COVID-19 to continue treatment unless otherwise advised by their physician. The European Society of Cardiology agrees. Abruptly stopping these meds could lead to heart failure and uncontrolled hypertension.

In a JAMA Livestream discussion with JAMA editor Howard Bauchner, Dr Anthony Fauci advised that this needed further investigation. He referenced data from Italy summarized by Bloomberg News, finding that 99% of the people who died had previous medical conditions. When they broke down what those underlying conditions were, more than 75% of them had hypertension.

Dr Fauci wondered why someone with well-controlled hypertension would have a much greater chance of dying from COVID-19. He urged delving into this deeper and finding out which medications those individuals were taking.

In a special New England Journal of Medicine report, " Renin–Angiotensin–Aldosterone System (RAAS) Inhibitors in Patients with Covid-19,” posted online March 30, 2020, cardiologists from Brigham and Women’s Hospital, Harvard Medical School, and several other highly esteemed institutions, advised continuing these meds in otherwise stable patients. Preclinical studies show that the renin-angiotensin-aldosterone inhibitors may increase ACE2 expression, but data in humans are lacking. A clinical trial is underway to study the ARB losartan and recombinant human ACE2 in patients with COVID- 19. More data should be forthcoming.

For now, I'm not changing any meds for my patients. But we should all closely follow this thread.

Sandra Adamson Fryhofer, MD, MACP, FRCP, is a board-certified doctor of internal medicine in Atlanta and adjunct associate professor of medicine at Emory University School of Medicine. She is a liaison to the Advisory Committee on Immunization Practices (ACIP) and serves on ACIP Working Groups for several vaccines.

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