CARDIAC

CLINICAL | CARDIAC Controlling hypertension during the COVID-19 pandemic

How should clinicians navigate clinical uncertainty for patients who are taking angiotensinconverting-enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs)?

ANY PATIENTS AND clinicians are aware of the relationship between

COVID-19 and the renin-angiotensin system. Patients concerned about

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susceptibility to coronavirus already have asked whether to continue taking their prescribed ACE inhibitors and ARBs, and patients who test positive for the virus will likely have the same concern.

Experts have postulated both potentially harmful and potentially beneficial effects of these drugs on the natural history of

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COVID-19. Membrane-bound angiotensinconverting enzyme 2 (ACE2) participates in the entry of SARS-CoV-2 into human cells. Conversely, some researchers speculate that ACE inhibitors and ARBs could benefit patients with COVID-19 through various mechanisms. For example, ACE2 converts angiotensin II to angiotensin-(1–7), which has potentially beneficial vasodilatory and anti-inflammatory properties, upregulating ACE2 (with ACE inhibitors or ARBs) could enhance this process. Observational studies have not yielded compelling data on whether COVID-19 patients who take these drugs fare better or worse than otherwise similar patients.

Professional societies have navigated this uncertainty by recommending that patients receiving ACE inhibitors and ARBs should continue taking them. For example, a statement from the American College of Cardiology and American Heart Association (ACC/AHA) notes that, “There are no experimental or clinical data demonstrating beneficial or adverse outcomes with background use of ACE inhibitors [or] ARBs.” The statement recommends continuing these drugs if they are being prescribed for valid cardiovascular indications and advises clinicians not to add or remove them, “Beyond actions based on standard clinical practice.” The ACC/AHA statement provides a good starting point when patients inquire about continuing or stopping ACE inhibitors and ARBs; discussing it with patients often will settle the issue. Nevertheless, some patients might not be reassured by impersonal recommendations from professional societies and will still ask their clinicians “so what do you advise?”

A sensible position for overworked and stressed clinicians facing a global pandemic is to recognise that, for now, the effect of ACE inhibitors and ARBs on the natural history of COVID-19 is unknown. Clinicians should attempt to make decisions that will minimise future regret for themselves and for their patients if the decision eventually is proven ‘wrong’.

REFERENCES

Allan S. Brett, MD and David M. Rind, MD reviewing Patel AB and Verma A. JAMA 2020 Mar 24 Gurwitz D. Drug Dev Res 2020 Mar 4 American College of Cardiology. 2020 Mar 17.

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