Evidence suggests that ACE inhibitors and angiotensin receptor blockers may improve prognosis in COVID-19 hypertensive patients

Recent concerns that common antihypertensive drugs may have a negative effect in COVID-19 patients are not supported by the evidence, report scientists in a new review published in Mayo Clinic Proceedings


Rochester, MN, March 31, 2020

Patients with underlying health conditions such as hypertension, heart failure, and chronic kidney disease are at increased risk of severe coronavirus disease 2019 (COVID-19). Physicians, healthcare professionals, researchers, and patients are actively debating the potential influence of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) in patients during the COVID-19 outbreak. One of the ways the virus enters the body is through ACE2, the enzyme that converts angiotensin I to angiotensin II in the lungs and other tissues and organs, suggesting to some that the drugs may increase susceptibility to the virus and severity of the disease.

In a new review published in Mayo Clinic Proceedings, a group of scientists working on the frontlines, fighting the deadly virus in Spain, Italy, and the United States, dissect the controversy in considerable detail, to explain the level of evidence on this topic for clinicians. “In agreement with current guidelines, we recommend patients with hypertension should continue taking anti-hypertensive medications without interruption,” says lead author Fabian Sanchis-Gomar, MD, PhD, of the Department of Physiology, Faculty of Medicine, University of Valencia and INCLIVA Biomedical Research Institute, Valencia, Spain; and Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA.

After an in-depth review of more than 60 published studies, Dr. Sanchis-Gomar and his co-authors conclude that, importantly, no studies have reported an increase in circulating ACE2 levels or expression thus far, and increased expression would not necessarily imply an increased risk of infection or disease severity. Their research included studies that suggest that elevated levels of angiotensin II, the target of renin-angiotensin-aldosterone system (RAAS) inhibitors such as ACEIs and ARBs, may foster acute respiratory distress syndrome (ARDS) in COVID-19 patients. Other research suggests that RAAS inhibitors may have a role to play in the treatment of COVID-19. The authors note, however, that much more research and evidence are needed.


Coronavirus. Credit: Mayo Clinic.

In a video accompanying the article, co-author Carl J. Lavie, MD, of the John Ochsner Heart and Vascular Institute, Ochsner Clinical School - University of Queensland School of Medicine, New Orleans, LA, USA, says, “Angiotensin II is known to foster inflammation, oxygenation, vasoconstriction, and fibrosis, so it is quite conceivable that a pharmaceutical agent that can inhibit the production of this hormone could actually be very beneficial for preventing lung injury and also for systemic health. Certainly, it is premature right now to start these agents as a preventive measure for COVID-19 in patients with no other indicator for RAAS inhibitors. However, this is an active area for investigation.”

Current evidence indicates that RAAS inhibitors significantly reduce mortality in cardiovascular disease, reduce the progression of chronic kidney disease, and are the cornerstone of treatment for heart failure and hypertension. “ACEIs or ARBs therapy should be maintained or initiated, as indicated, in patients regardless of COVID-19,” notes Dr. Sanchis-Gomar.

While no differences exist between ARBs and ACEIs in terms of efficacy to decrease blood pressure and improve other outcomes, a cough sometimes associated with the use of ACEIs, and withdrawal rates due to adverse events are lower with ARBs. “Given the equal efficacy but fewer adverse events, ARBs could potentially be a more favorable treatment option in COVID-19 patients at higher risk for developing severe forms of the disease,” says Dr. Sanchis-Gomar.

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Notes for editors
The article is “Angiotensin-Converting Enzyme 2 and Anti-Hypertensives (Angiotensin Receptor Blockers and Angiotensin Converting Enzyme Inhibitors) in Coronavirus Disease 2019 (COVID-19),” by Fabian Sanchis-Gomar, MD; PhD, Carl J. Lavie, MD; Carme Perez-Quilis, MD, PhD; Brandon M. Henry, MD; and Giuseppe Lippi, MD (https://doi.org/10.1016/j.mayocp.2020.03.026). It will appear in Mayo Clinic Proceedings,volume 95, issue 6 (June 2020) published by Elsevier.

The accompanying video by Dr. Lavie is available here.

Full text of the article is also available to credentialed journalists upon request. Contact Brittney Binns at +1 215 297 3278 or mcpmedia@elsevier.com to obtain copies. Journalists wishing to interview the study authors should contact Fabian Sanchis-Gomar at +1 408 439 5760, +34695813115, fabian.sanchis@uv.es, or Carl J. Lavie at +1 504 842 1281, clavie@ochsner.org.

Elsevier’s Novel Coronavirus Information Center provides expert, curated information for the research and health community on Novel Coronavirus (also referred to as COVID-19 and its temporary title 2019-nCoV). All resources are free to access and include guidelines for clinicians and patients. The Research presents the latest early stage and peer-reviewed research from journals including The Lancet and Cell Press, as well as a link to the Coronavirus Hub on ScienceDirect, where you will find every article relevant to Coronavirus, SARS and MERS freely available. Under the Clinical Solutions tab you will find resources for nurses, clinicians and patients, including FAQs on symptoms. www.elsevier.com/connect/coronavirus-information-center

About Mayo Clinic Proceedings
The flagship journal of Mayo Clinic and one of the premier peer-reviewed clinical journals in general medicine, Mayo Clinic Proceedings is among the most widely read and highly cited scientific publications for physicians, with a circulation of approximately 125,000. While the Journal is sponsored by Mayo Clinic, it welcomes submissions from authors worldwide, publishing articles that focus on clinical medicine and support the professional and educational needs of its readers. www.mayoclinicproceedings.org

About Mayo Clinic
Mayo Clinic is a nonprofit worldwide leader in medical care, research, and education for people from all walks of life. For more information visit www.mayoclinic.org/about and www.mayoclinic.org/news.

About Elsevier
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Media contact
Brittney Binns
Elsevier
+1 215 297 3278
mcpmedia@elsevier.com