Angiotensin II receptor blocker or angiotensin-converting enzyme inhibitor use and COVID-19-related outcomes among US Veterans.

BACKGROUND: Angiotensin II receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACEIs) may positively or negatively impact outcomes in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We investigated the association of ARB or ACEI use with coronavirus disease 2019 (COVID-19)-related outcomes in US Veterans with treated hypertension using an active comparator design, appropriate covariate adjustment, and negative control analyses. METHODS AND FINDINGS: In this retrospective cohort study of Veterans with treated hypertension in the Veterans Health Administration (01/19/2020-08/28/2020), we compared users of (A) ARB/ACEI vs. non-ARB/ACEI (excluding Veterans with compelling indications to reduce confounding by indication) and (B) ARB vs. ACEI among (1) SARS-CoV-2+ outpatients and (2) COVID-19 hospitalized inpatients. The primary outcome was all-cause hospitalization or mortality (outpatients) and all-cause mortality (inpatients). We estimated hazard ratios (HR) using propensity score-weighted Cox regression. Baseline characteristics were well-balanced between exposure groups after weighting. Among outpatients, there were 5.0 and 6.0 primary outcomes per 100 person-months for ARB/ACEI (n = 2,482) vs. non-ARB/ACEI (n = 2,487) users (HR 0.85, 95% confidence interval [CI] 0.73-0.99, median follow-up 87 days). Among outpatients who were ARB (n = 4,877) vs. ACEI (n = 8,704) users, there were 13.2 and 14.8 primary outcomes per 100 person-months (HR 0.91, 95%CI 0.86-0.97, median follow-up 85 days). Among inpatients who were ARB/ACEI (n = 210) vs. non-ARB/ACEI (n = 275) users, there were 3.4 and 2.0 all-cause deaths per 100 person months (HR 1.25, 95%CI 0.30-5.13, median follow-up 30 days). Among inpatients, ARB (n = 1,164) and ACEI (n = 2,014) users had 21.0 vs. 17.7 all-cause deaths, per 100 person-months (HR 1.13, 95%CI 0.93-1.38, median follow-up 30 days). CONCLUSIONS: This observational analysis supports continued ARB or ACEI use for patients already using these medications before SARS-CoV-2 infection. The novel beneficial association observed among outpatients between users of ARBs vs. ACEIs on hospitalization or mortality should be confirmed with randomized trials.

Measuring and Managing Blood Pressure in a Primary Care Setting: A Pragmatic Implementation Study.

BACKGROUND: Accurate blood pressure (BP) measurement is essential to hypertension diagnosis and management. Automated office blood pressure (AOBP) and home blood pressure measurement (HBPM) may improve assessment, but barriers exist in primary care settings. METHODS: We implemented an AOBP/HBPM program in a primary care clinic in 2015 to 2016. Patients with elevated BP determined by guideline-quality observed BP measurement and/or AOBP entered the HBPM program. Patients with average home BP ≥ 135/85 mm Hg provided HBPM results for medication adjustment. Clinic staff and patients completed satisfaction questionnaires. RESULTS: Initial HBPM results in 183 patients with elevated office BP revealed white-coat BP elevation in 35% of untreated patients and in 37% of treated patients. The prevalence of white-coat BP elevation was similar whether enrollment BP was by observed BP or AOBP. Subsequent HBPM facilitated BP control in 49% of patients with elevated home BP. Most providers, staff, and patients endorsed the utility of the program. Barriers to implementation included a temporary period of incorrect AOBP technique, patients failing to provide HBPM results, and incorrect HBPM technique. DISCUSSION: Our clinic-based AOBP/HBPM program detected white-coat BP elevation in one third of enrolled patients, facilitated control of home BP, and was acceptable to staff and patients. We identified barriers to be addressed to ensure sustainability.