Corresponding author
Amer Harky
MRCS, MSc
Department of Cardiothoracic Surgery
Liverpool Heart and Chest
Liverpool, UK
e-mail: aaharky@gmail.com
tel: +44-151-600-1616
Funding: none obtained
Conflict of Interest: None obtained
Key words: COVID-19, Cardiovascular, Heart
Dear Editor,
Khan and colleagues reported on cardiovascular outcomes of
COVID-19[1]. The study has concluded that appropriate risk
stratification and triage is essential in patients with cardiovascular
diseases and COVID-19 as their outcomes could be severely affected.
It is, by now, well established that patients with pre-existing
cardiovascular diseases, such as hypertension or ischaemic heart
disease, are more vulnerable and at risk from severe complications due
to COVID-19. One of the most important pathophysiology of severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2) is lying in its affinity
to renin-angiotensin-aldosterone system (RAAS) through angiotensin
converting enzyme inhibitor (ACEi) or utilization of angiotensin
receptor blockers (ARBs). Several studies have reported equivocal
outcomes in using ACEi and ARBs in patients with COVID-19, whether they
were using ACEi/ARBs prior to contracting COVID-19 or they were
initiated/suspended during the course of the infection; yet there is
lack of robust evidence supporting the use or discontinuation of RAAS
medications[2,3]. Although, there is a theory that ACEi/ARBs
antagonise RAAS which might reduce inflammation in COVID-19 pneumonia,
thus reducing mortality[2,4].
The study by Zhang et al.[4] reports the conclusion of a lower risk
of all-cause mortality in the ACEi/ARBs group compared with the
non-users for hypertension [4]. Yet, this study is associated with
significant confounding variables, foremost being the hypertensive
patients unclassified by staging, signs/symptoms or complications. As
well as there was no differentiation between ACEi/ARBs in the cohort or
whether the patients in the cohort were novice or chronic users.
Future research and observational studies should eliminate the existing
confounding variables in the current studies which are accounted for the
controversial outcomes of ACEi/ARBs in SARS-CoV-2 in the presence of
cardiovascular diseases, which may have significant impact on outcomes
in COVID-19 patients using ACEi/ARBs.
References:
- Khan IH, Zahra SA, Zaim S, Harky A. At the heart of COVID-19. J Card
Surg. 2020;10.1111/jocs.14596. doi:10.1111/jocs.14596
- Mancia G, Rea F, Ludergnani M, Apolone G, Corrao G.
Renin-Angiotensin-Aldosterone System Blockers and the Risk of
Covid-19. N Engl J Med. 2020;NEJMoa2006923. doi:10.1056/NEJMoa2006923
- Lopes RD, Macedo AVS, de Barros E Silva PGM, et al. Continuing versus
suspending angiotensin-converting enzyme inhibitors and angiotensin
receptor blockers: Impact on adverse outcomes in hospitalized patients
with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)
[published online ahead of print, 2020 May 13]. Am Heart J.
2020;10.1016/j.ahj.2020.05.002. doi:10.1016/j.ahj.2020.05.002
- Zhang, P., Zhu, L., Cai, J., et al. 2020. Association of Inpatient Use
of Angiotensin Converting Enzyme Inhibitors and Angiotensin II
Receptor Blockers with Mortality Among Patients With Hypertension
Hospitalized With COVID-19. Circulation Research.