Should Patients Continue Using Cardiovascular Disease Drugs During COVID-19 Pandemic?

Pharmacists continue to be the most accessible health care professionals, especially in the current novel coronavirus (COVID-19) pandemic. It is not surprising that there is much disinformation being spread among news outlets and on social media. As pharmacists, we have the opportunity to preserve and spread evidence-based information to our patients.

Recently, many providers have become worried about the potential of certain medications to worsen transmission and outcomes in the setting of this global pandemic. Just like other coronaviruses, the current SARS-CoV-2 uses the membrane-bound angiotensin converting enzyme 2 (ACE2) receptor to facilitate entry into the host cell.¹

ACE2, previously identified as a mechanism of cardio-protection, is upregulated by the administration of angiotensin converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB).² Thus, even though ACEi and ARBs do not directly affect the activity of ACE2, they do upregulate the enzyme itself. Of note, calcium channel blockers have not been identified to upregulate ACE2.⁶

Patients with cardiovascular disease are known to be at higher rates of complications due to COVID-19. Specifically, it has been found that patients with hypertension, diabetes, and other comorbidities are at higher risk of death compared with survivors of the virus.^4,5 The question has been posed whether the presence of ACEi’s and ARBs increases the likelihood of SARS-CoV-2 infection and, therefore, increases the chance of complications from COVID-19.

The CDC had already published specific recommendation on how to minimize transmission to high-risk patients. ⁶ In terms of withholding ACEi and ARBs, this is not an evidence-backed measure and should be discouraged.

A case series from China on 112 patients showed that there was no correlation.⁷ The case series is based on a small number of patients, but the lack of correlation is reassuring. To date, there are no data to suggest that ACEi/ARBs can worsen outcomes. In fact, one should presume that these life-saving medications reduce cardiovascular disease burden, and thus improve patient outcomes.

The European Society of Cardiology and its council on hypertension released a statement informing its providers on the very same issue.⁸ Despite the buzz surrounding the topic of ACEi/ARBs and COVID-19, we should not be jumping to conclusions and should not be withholding life-saving therapies from patients, especially those at already high risk for cardiovascular disease complications and those with heart failure.

Instead, these patients should follow precautions in order to not get infected, and if they do feel sick, they should seek immediate help.

References

1. Zhang H, Penninger JM, Li Y, Zhong N, Slutsky AS. Angiotensin-converting enzyme 2 (ACE2) as a SARS-CoV-2 receptor: molecular mechanisms and potential therapeutic target [published online ahead of print, 2020 Mar 3]. Intensive Care Med. 2020;10.1007/s00134-020-05985-9. doi:10.1007/s00134-020-05985-9

2. Ferrario CM, Jessup J, Chappell MC, et al. Effect of angiotensin-converting enzyme inhibition and angiotensin II receptor blockers on cardiac angiotensin-converting enzyme 2. Circulation. 2005;111(20):2605—2610. doi:10.1161/CIRCULATIONAHA.104.510461

3. Fang L, Karakiulakis G. Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection? Lancet. 2020;doi:10.1016/S2213-2600(20)30116-8

4. Zheng YY, Ma YT, Zhang JY, Xie X. COVID-19 and the cardiovascular system [published online ahead of print, 2020 Mar 5]. Nat Rev Cardiol. 2020;10.1038/s41569-020-0360-5. doi:10.1038/s41569-020-0360-5

5. Zhou F, Yu T, Ronghui D, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;doi:10.1016/S0140-6736(20)30566-3

6. Centers for Disease Control and Prevention. People at Risk for Serious Illness from COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/high-risk-complications.html. Accessed March 12, 2020.

7. Peng Yudong, Meng Kai, Guan Hongquan, et al. Clinical characteristics and outcome of 112 patients with cardiovascular disease infected with new coronavirus pneumonia [J/OL]. Chinese Journal of Cardiovascular Disease, 2020, 48 (2020-03- 02). http://rs.yiigle.com/yufabiao/1183314.htm. DOI: 10.3760 / cma.j.cn112148-20200220-00105. [Internet pre-publishing]

8. de Simone G. Position Statement of the ESC Council on Hypertension on ACE-Inhibitors and Angiotensin Receptor Blockers. European Society of Cardiology. https://www.escardio.org/Councils/Council-on-Hypertension-(CHT)/News/position-statement-of-the-esc-council-on-hypertension-on-ace-inhibitors-and-ang. Published: March 13, 2020. Accessed: March 17, 2020.