ABSTRACT
BACKGROUND: Angiotensin receptor blockers (ARB) and angiotensin-converting enzyme inhibitors (ACEI) increase the expression of ACE2, which is a receptor for entry of SARS-CoV-2 into cells. Though evidence suggests that ARB/ACEI are safe among the general population with COVID-19, their safety in patients with overweight/obesity-related hypertension deserves further evaluation. OBJECTIVE: We assessed the association between ARB/ACEI use and COVID-19 severity in patients with overweight/obesity-related hypertension. METHODS: This study included 439 adult patients with overweight/obesity (body mass index ≥ 25 kg/m2) and hypertension, diagnosed with COVID-19 and admitted to University of Iowa Hospitals and Clinic from March 1 to December 7, 2020. Mortality and severity of COVID-19 were evaluated based on length of stay in hospital, intensive care unit admission, use of supplemental oxygen, mechanical ventilation, and vasopressors. Multivariable logistic regression was used to examine the associations of ARB/ACEI use with mortality and other markers of COVID-19 severity, with a two-sided alpha set at 0.05. RESULTS: Exposure to ARB (n = 91) and ACEI (n = 149) before hospitalization was significantly associated with lower mortality (odds ratio [OR] = 0.362, 95% confidence interval [CI] 0.149 to 0.880, p = 0.025) and a shorter length of stay (95% CI -0.217 to -0.025, p = 0.015). Additionally, patients using ARB/ACEI showed a non-significant trend toward lower intensive care unit admission (OR = 0.727, 95% CI 0.485 to 1.090, p = 0.123), use of supplemental oxygen (OR = 0.929, 95% CI 0.608 to 1.421, p = 0.734), mechanical ventilation (OR = 0.728, 95% CI 0.457 to 1.161, p = 0.182), and vasopressors (OR = 0.677, 95% CI 0.430 to 1.067, p = 0.093). CONCLUSION: Results suggest that hospitalized patients with COVID-19 and overweight/obesity-related hypertension who were prescribed ARB/ACEI before admission to the hospital exhibit lower mortality and less severe COVID-19 than those who were not taking ARB/ACEI. The results also suggest that exposure to ARB/ACEI may protect patients with overweight/obesity-related hypertension from severe COVID-19 and death.
FUNDAMENTO: Os bloqueadores dos receptores da angiotensina (BRA) e os inibidores da enzima conversora da angiotensina (IECA) aumentam a expressão de ACE2, que é um receptor para entrada de SARS-CoV-2 nas células. Embora as evidências sugiram que os IECA/BRA são seguros entre a população geral com COVID-19, sua segurança em pacientes com hipertensão relacionada ao sobrepeso/obesidade merece uma avaliação mais aprofundada. OBJETIVO: Avaliamos a associação entre o uso de IECA/BRA e a gravidade da COVID-19 em pacientes com hipertensão relacionada ao sobrepeso/obesidade. MÉTODOS: O presente estudo incluiu 439 pacientes adultos com sobrepeso/obesidade (índice de massa corporal ≥ 25 kg/m2) e hipertensão, diagnosticados com COVID-19 e internados no University of Iowa Hospitals and Clinic entre 1º de março e 7 de dezembro de 2020. Foram avaliadas a mortalidade e a gravidade da COVID-19 com base no tempo de internação hospitalar, internação em unidade de terapia intensiva, uso de oxigênio suplementar, ventilação mecânica e uso de vasopressores. A regressão logística multivariável foi usada para examinar as associações do uso de IECA/BRA com a mortalidade e outros marcadores de gravidade de COVID-19, com um alfa bilateral definido em 0,05. RESULTADOS: A exposição aos BRA (n = 91) e IECA (n = 149) antes da hospitalização foi significativamente associada a menor mortalidade ( odds ratio [OR] = 0,362, intervalo de confiança [IC] de 95% 0,149 a 0,880, p = 0,025) e menor tempo de internação hospitalar (IC 95% −0,217 a −0,025, p = 0,015). Adicionalmente, os pacientes em uso de IECA/BRA apresentaram uma tendência não significativa de menor internação em unidade de terapia intensiva (OR = 0,727, IC 95% 0,485 a 1,090, p = 0,123), uso de oxigênio suplementar (OR = 0,929, IC 95% 0,608 a 1,421,p = 0,734), ventilação mecânica (OR = 0,728, IC 95% 0,457 a 1,161, p = 0,182) e vasopressores (OR = 0,677, IC 95% 0,430 a 1,067, p = 0,093). CONCLUSÃO: Os resultados sugerem que pacientes internados com COVID-19 e hipertensão relacionada ao sobrepeso/obesidade que receberam IECA/BRA antes da internação apresentam menor mortalidade e COVID-19 menos grave do que aqueles que não estavam tomando IECA/BRA. Os resultados também sugerem que a exposição aos IECA/BRA pode proteger pacientes com hipertensão relacionada ao sobrepeso/obesidade de COVID-19 grave e morte.
Subject(s)
COVID-19 , Hypertension , Adult , Humans , COVID-19/complications , SARS-CoV-2 , Angiotensin-Converting Enzyme Inhibitors/therapeutic use , Retrospective Studies , Renin-Angiotensin System , Angiotensin Receptor Antagonists/therapeutic use , Overweight/complications , Hypertension/drug therapy , Hypertension/complications , Obesity/complications , OxygenABSTRACT
Background: Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has been found to exploit the cell’s ACE2 receptor for viral entry. Renin-angiotensin-aldosterone system (RAAS) antagonism with angiotensin converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) increases the expression of ACE2 receptors which, coupled with the metabolic changes associated with obesity-related hypertension, can make hypertensive patients with obesity more vulnerable to severe COVID-19. Although current evidence suggests that ACEI/ARB use does not increase risk of severe COVID-19 in the general population, potential interactions with obesity-related hypertension are unknown. Methods: We conducted a retrospective study of COVID-19 patients admitted to the University of Iowa Hospitals and Clinics between March 1st and July 8th, 2020. We included adults who are overweight (BMI ≥ 25 kg/m2) or obese (BMI ≥ 30 kg/m2) with hypertension treated as outpatients with or without ACEIs/ARBs. Patients without exposure to RAAS antagonists served as controls. We assessed mortality and the severity of COVID-19 reflected by admission to ICU and usage of supplemental O2, non-invasive ventilation, mechanical ventilation, extracorporeal membrane oxygenation (ECMO) and vasopressors. Results: Of the 369 inpatients with COVID-19, we identified 138 exhibiting obesity-related hypertension who were then allocated into the control (n=59) and ACEI/ARB (n=79) groups. The BMIs between groups at baseline were not statistically significant (Control: 33.6 ± 0.96 vs. ACEI/ARB: 34.99 ± 0.97;p=.32). Women were less represented in the ACEI/ARB group (Control: 47% vs. ACEI/ARB: 24%). The controls had a substantially higher mortality rate (Control: 32.2% vs. ACEI/ARB: 15.1%). In regard to the severity of COVID-19, the ACEI/ARB cohort showed lower usage of supplemental O2 (Control: 52.5% vs. ACEI/ARB: 49.3%), mechanical ventilation (Control: 37.2% vs. ACEI/ARB: 1.2%), vasopressors (Control: 38.9% vs. ACEI/ARB: 31.6%), and had lower ICU admissions (Control: 57.6% vs. ACEI/ARB: 46.8%). However, the ACEI/ARB group had higher rates of: ECMO (Control: 0% vs. ACEI/ARB: 20.2%) and non-invasive ventilation (Control: 18.6% vs. ACEI/ARB: 20.2%). Of note, the rate of diabetes was higher in the ACEI/ARB cohort (Control: 45.7% vs. ACEI/ARB: 63.2%). Conclusion: Our results suggest that a history of RAAS antagonism is associated with lower mortality and less severity of COVID-19 in patients with obesity-related hypertension requiring hospital admission.
ABSTRACT
Palliative and end-of-life care has been pushed to the forefront of medical care during the pandemic caused by the coronavirus-2019 (COVID-19). Palliative care organizations have responded to the growing demand for the rapid dissemination of research, clinical guidance, and instructions for care to clinicians, patients with COVID-19, and their caregivers by creating COVID-19 resource Web pages. Here, end users can access resources that can be updated in real time. These Web pages, however, can be variable in what resources they offer and for whom they are designed for (clinicians, patients, caregivers). Therefore, this project was conducted to consolidate these resources via summary tables of specific contents available through each Web page grouped by palliative care domains (eg, care discussion and planning, communication, symptom management, care access) and to identify the target audience. This environmental scan was conducted by compiling a comprehensive list of COVID-19 resource Web pages of palliative care organizations generated by reviewing previously published research studies and consulting with palliative care research experts. Snowballing techniques were used to identify resource Web pages not captured in the initial scan. Two reviewers independently evaluated eligible Web pages for content via a form developed for the study, and Cohen κ statistic was calculated to ensure interrater reliability. The final κ statistic was 0.76. Of the 24 websites screened, 15 websites met our eligibility criteria. Among the eligible resource Web pages, most (n = 12, 80%) had specific target audiences and care settings, whereas the rest presented information targeted to all audiences. Although 11 Web pages offered resources that addressed all 4 domains, only 1 Web page conveyed all 12 subdomains. We recommend the use of this guide to all frontline clinicians who require guidance in clinically managing patients with COVID-19 receiving palliative care and/or end-of-life care.