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Lee MMY, Kondo T, Campbell RT, Petrie MC, Sattar N, Solomon SD, Vaduganathan M, Jhund PS, McMurray JJV. Effects of renin-angiotensin system blockers on outcomes from COVID-19: a systematic review and meta-analysis of randomized controlled trials. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2024; 10:68-80. [PMID: 37740450 PMCID: PMC10766905 DOI: 10.1093/ehjcvp/pvad067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 09/18/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND AND AIMS Randomized controlled trials (RCTs) have assessed the effects of renin-angiotensin system (RAS) blockers in adults with coronavirus disease 2019 (COVID-19). This meta-analysis provides estimates of the safety and efficacy of treatment with (vs. without) RAS blockers from these trials. METHODS PubMed, Web of Science, and ClinicalTrials.gov were searched (1 March-12 April 2023). Event/patient numbers were extracted, comparing angiotensin-converting enzyme (ACE) inhibitor/angiotensin-receptor blocker (ARB) treatment with no treatment, for the outcomes: intensive care unit (ICU) admission, mechanical ventilation, vasopressor use, acute kidney injury (AKI), renal replacement therapy (RRT), acute myocardial infarction, stroke/transient ischaemic attack, heart failure, thromboembolic events, and all-cause death. Fixed-effects meta-analysis estimates were pooled. RESULTS Sixteen RCTs including 3492 patients were analysed. Compared with discontinuation of RAS blockers, continuation was not associated with increased risk of ICU [risk ratio (RR) 0.96, 0.66-1.41], ventilation (RR 0.77, 0.55-1.09), vasopressors (RR 0.92, 0.58-1.44), AKI (RR 1.01, 0.40-2.56), RRT (RR 1.01, 0.46-2.21), or thromboembolic events (RR 1.07, 0.36-3.19). RAS blocker initiation was not associated with increased risk of ICU (RR 0.71, 0.47-1.08), ventilation (RR 1.12, 0.91-1.38), AKI (RR 1.28, 0.89-1.86), RRT (RR 1.66, 0.89-3.12), or thromboembolic events (RR 1.20, 0.06-23.70), although vasopressor use increased (RR 1.27, 1.02-1.57). The RR for all-cause death in the continuation/discontinuation trials was 1.24 (0.80-1.92), and 1.22 (0.96-1.55) in the initiation trials. In patients with severe/critical COVID-19, RAS blocker initiation increased the risk of all-cause death (RR 1.31, 1.01-1.72). CONCLUSION ACE inhibitors and ARBs may be continued in non-severe COVID-19 infection, where indicated. Conversely, initiation of RAS blockers may be harmful in critically ill patients.PROSPERO registration number: CRD42023408926.
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Affiliation(s)
- Matthew M Y Lee
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, G12 8TA, UK
| | - Toru Kondo
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, G12 8TA, UK
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ross T Campbell
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, G12 8TA, UK
| | - Mark C Petrie
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, G12 8TA, UK
| | - Naveed Sattar
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, G12 8TA, UK
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, G12 8TA, UK
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, G12 8TA, UK
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Raghav PK, Mann Z, Ahluwalia SK, Rajalingam R. Potential treatments of COVID-19: Drug repurposing and therapeutic interventions. J Pharmacol Sci 2023; 152:1-21. [PMID: 37059487 PMCID: PMC9930377 DOI: 10.1016/j.jphs.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 01/31/2023] [Accepted: 02/10/2023] [Indexed: 02/17/2023] Open
Abstract
The coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The infection is caused when Spike-protein (S-protein) present on the surface of SARS-CoV-2 interacts with human cell surface receptor, Angiotensin-converting enzyme 2 (ACE2). This binding facilitates SARS-CoV-2 genome entry into the human cells, which in turn causes infection. Since the beginning of the pandemic, many different therapies have been developed to combat COVID-19, including treatment and prevention. This review is focused on the currently adapted and certain other potential therapies for COVID-19 treatment, which include drug repurposing, vaccines and drug-free therapies. The efficacy of various treatment options is constantly being tested through clinical trials and in vivo studies before they are made medically available to the public.
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Affiliation(s)
- Pawan Kumar Raghav
- Immunogenetics and Transplantation Laboratory, Department of Surgery, University of California San Francisco, San Francisco, CA, USA.
| | | | - Simran Kaur Ahluwalia
- Amity Institute of Biotechnology, Amity University, Sector-125, Noida, Uttar Pradesh, India
| | - Raja Rajalingam
- Immunogenetics and Transplantation Laboratory, Department of Surgery, University of California San Francisco, San Francisco, CA, USA
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Ben-Aicha S, Buchanan J, Punjabi P, Emanueli C, Moscarelli M. Efficacy of treatments tested in COVID-19 patients with cardiovascular disease. A meta-analysis. Perfusion 2023; 38:373-383. [PMID: 35220805 PMCID: PMC8891907 DOI: 10.1177/02676591211056559] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The COVID-19 pandemic has spread globally infecting and killing millions. Those with cardiovascular disease (CVD) are at higher risk of increased disease severity and mortality. We performed a systematic review and meta-analysis to estimate the rate of in-hospital mortality following different treatments on COVID-19 in patients with CVD. METHODS Pertinent articles were identified from the PubMed, Google Scholar, Ovid MEDLINE, and Ovid EMBASE databases. This study protocol was registered under PROSPERO with the identifier CRD42020183057. RESULTS Of the 1673 papers scrutinized, 46 were included in the review. Of the 2553 patients (mean age 63.9 ± 2.7 years/o; 57.2% male), the most frequent CVDs were coronary artery disease (9.09%) and peripheral arterial disease (5.4%) and the most frequent cardiovascular risk factors were hypertension (86.7%) and diabetes (23.7%). Most patients were on multiple treatments. 14 COVID-19 treatments were compared with controls. The pooled event rate for in-hospital mortality was 20% (95% confidence interval (CI): 11-33%); certain heterogeneity was observed across studies. CONCLUSIONS COVID-19 is associated with a high in-hospital mortality rate in patients with CVD. This study shows that previous CVD determines mortality, regardless of the type of COVID-19 administered therapy. Treatments for at-risk patients should be administered carefully and monitored closely until further data are available.
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Affiliation(s)
- Soumaya Ben-Aicha
- National Heart and Lung Institute, Imperial College London, London, UK
| | | | - Prakash Punjabi
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Costanza Emanueli
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Marco Moscarelli
- National Heart and Lung Institute, Imperial College London, London, UK
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Paguio JA, Casipit BA, John TA, Balu A, Lo KB. Angiotensin converting enzyme inhibitors and angiotensin II receptor blockers and outcomes in hospitalized patients with COVID-19: an updated systematic review and meta-analysis of randomized clinical trials. Expert Rev Cardiovasc Ther 2023; 21:219-226. [PMID: 36821251 DOI: 10.1080/14779072.2023.2184351] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
BACKGROUND Our prior analysis demonstrated no significant difference in risk of mortality or disease progression among patients with COVID-19. With the availability of findings from randomized controlled trials (RCTs), we provide an updated review of RCTs which explored the outcomes among hospitalized patients with COVID-19 treated with Angiotensin Converting Enzyme inhibitor (ACEis)/Angiotensin Receptor Blockers (ARBs) versus control. RESEARCH DESIGN AND METHODS This systematic review and meta-analysis covers RCTs exploring mortality, intensive care unit admission, and mechanical ventilation outcomes among hospitalized COVID-19 patients treated with ACEi/ARBs. RESULTS Ten studies were included in this meta-analysis. For mortality with ACEi/ARB utilization among hospitalized COVID-19 patients, the pooled risk ratio (RR) was 0.97 (95% CI 0.64-1.47, p = 0.89) with heterogeneity of 26%. Further, the pooled RR for ACEi/ARB use on ICU admission and mechanical ventilation were 0.55 (0.55-1.08, p = 0.13) with a heterogeneity of 0% and 1.02 (0.78-1.32, p = 0.91) with a heterogeneity of 0%, respectively. CONCLUSION Among hospitalized patients with COVID-19, the use of ACEi/ARB was not associated with increased risk of mortality, ICU admission, or mechanical ventilation compared to control. These findings support continuation of ACEi/ARB for whom baseline clinical indications for these agents exist.
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Affiliation(s)
- Joseph Alexander Paguio
- Department of Medicine, Albert Einstein Medical Center, Philadelphia, Pennsylvania, USA.,Sidney Kimmel College of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Bruce Adrian Casipit
- Department of Medicine, Albert Einstein Medical Center, Philadelphia, Pennsylvania, USA.,Sidney Kimmel College of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Tara A John
- Department of Medicine, Albert Einstein Medical Center, Philadelphia, Pennsylvania, USA.,Sidney Kimmel College of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Aniruddh Balu
- Longfellow Middle School, Fairfax, Pennsylvania, USA
| | - Kevin Bryan Lo
- Department of Medicine, Albert Einstein Medical Center, Philadelphia, Pennsylvania, USA.,Sidney Kimmel College of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Wang Z, Zhan J, Gao H. Computer-aided drug design combined network pharmacology to explore anti-SARS-CoV-2 or anti-inflammatory targets and mechanisms of Qingfei Paidu Decoction for COVID-19. Front Immunol 2022; 13:1015271. [PMID: 36618410 PMCID: PMC9816407 DOI: 10.3389/fimmu.2022.1015271] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022] Open
Abstract
Introduction Coronavirus Disease-2019 (COVID-19) is an infectious disease caused by SARS-CoV-2. Severe cases of COVID-19 are characterized by an intense inflammatory process that may ultimately lead to organ failure and patient death. Qingfei Paidu Decoction (QFPD), a traditional Chines e medicine (TCM) formula, is widely used in China as anti-SARS-CoV-2 and anti-inflammatory. However, the potential targets and mechanisms for QFPD to exert anti-SARS-CoV-2 or anti-inflammatory effects remain unclear. Methods In this study, Computer-Aided Drug Design was performed to identify the antiviral or anti-inflammatory components in QFPD and their targets using Discovery Studio 2020 software. We then investigated the mechanisms associated with QFPD for treating COVID-19 with the help of multiple network pharmacology approaches. Results and discussion By overlapping the targets of QFPD and COVID-19, we discovered 8 common targets (RBP4, IL1RN, TTR, FYN, SFTPD, TP53, SRPK1, and AKT1) of 62 active components in QFPD. These may represent potential targets for QFPD to exert anti-SARS-CoV-2 or anti-inflammatory effects. The result showed that QFPD might have therapeutic effects on COVID-19 by regulating viral infection, immune and inflammation-related pathways. Our work will promote the development of new drugs for COVID-19.
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Agirbasli M. The effects of antihypertensive medications on severity and outcomes of COVID19. J Hum Hypertens 2022; 36:875-879. [PMID: 35810205 PMCID: PMC9281571 DOI: 10.1038/s41371-022-00722-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 06/18/2022] [Accepted: 06/28/2022] [Indexed: 11/12/2022]
Affiliation(s)
- Mehmet Agirbasli
- Department of Cardiology, School of Medicine, Istanbul Medeniyet University, Goztepe Prof. Dr. Suleyman Yalcin City Hospital, Istanbul, Turkey.
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Zheng J, Zhang Y, Zhao H, Liu Y, Baird D, Karim MA, Ghoussaini M, Schwartzentruber J, Dunham I, Elsworth B, Roberts K, Compton H, Miller-Molloy F, Liu X, Wang L, Zhang H, Smith GD, Gaunt TR. Multi-ancestry Mendelian randomization of omics traits revealing drug targets of COVID-19 severity. EBioMedicine 2022; 81:104112. [PMID: 35772218 PMCID: PMC9235320 DOI: 10.1016/j.ebiom.2022.104112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 05/16/2022] [Accepted: 05/28/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Recent omic studies prioritised several drug targets associated with coronavirus disease 2019 (COVID-19) severity. However, little evidence was provided to systematically estimate the effect of drug targets on COVID-19 severity in multiple ancestries. METHODS In this study, we applied Mendelian randomization (MR) and colocalization approaches to understand the putative causal effects of 16,059 transcripts and 1608 proteins on COVID-19 severity in European and effects of 610 proteins on COVID-19 severity in African ancestry. We further integrated genetics, clinical and literature evidence to prioritise drug targets. Additional sensitivity analyses including multi-trait colocalization and phenome-wide MR were conducted to test for MR assumptions. FINDINGS MR and colocalization prioritized four protein targets, FCRL3, ICAM5, ENTPD5 and OAS1 that showed effect on COVID-19 severity in European ancestry. One protein target, SERPINA1 showed a stronger effect in African ancestry but much weaker effect in European ancestry (odds ratio [OR] in Africans=0.369, 95%CI=0.203 to 0.668, P = 9.96 × 10-4; OR in Europeans=1.021, 95%CI=0.901 to 1.157, P = 0.745), which suggested that increased level of SERPINA1 will reduce COVID-19 risk in African ancestry. One protein, ICAM1 showed suggestive effect on COVID-19 severity in both ancestries (OR in Europeans=1.152, 95%CI=1.063 to 1.249, P = 5.94 × 10-4; OR in Africans=1.481, 95%CI=1.008 to 2.176; P = 0.045). The OAS1, SERPINA1 and ICAM1 effects were replicated using updated COVID-19 severity data in the two ancestries respectively, where alternative splicing events in OAS1 and ICAM1 also showed marginal effects on COVID-19 severity in Europeans. The phenome-wide MR of the prioritised targets on 622 complex traits provided information on potential beneficial effects on other diseases and suggested little evidence of adverse effects on major complications. INTERPRETATION Our study identified six proteins as showing putative causal effects on COVID-19 severity. OAS1 and SERPINA1 were targets of existing drugs in trials as potential COVID-19 treatments. ICAM1, ICAM5 and FCRL3 are related to the immune system. Across the six targets, OAS1 has no reliable instrument in African ancestry; SERPINA1, FCRL3, ICAM5 and ENTPD5 showed a different level of putative causal evidence in European and African ancestries, which highlights the importance of more powerful ancestry-specific GWAS and value of multi-ancestry MR in informing the effects of drug targets on COVID-19 across different populations. This study provides a first step towards clinical investigation of beneficial and adverse effects of COVID-19 drug targets. FUNDING No.
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Affiliation(s)
- Jie Zheng
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Shanghai National Clinical Research Center for metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission of the PR China, Shanghai Key Laboratory for Endocrine Tumor, State Key Laboratory of Medical Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; MRC Integrative Epidemiology Unit (IEU), Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN, United Kingdom.
| | - Yuemiao Zhang
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, People's Republic of China
| | - Huiling Zhao
- MRC Integrative Epidemiology Unit (IEU), Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN, United Kingdom
| | - Yi Liu
- MRC Integrative Epidemiology Unit (IEU), Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN, United Kingdom
| | - Denis Baird
- MRC Integrative Epidemiology Unit (IEU), Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN, United Kingdom
| | - Mohd Anisul Karim
- Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, Cambridgeshire CB10 1SA, United Kingdom; Open Targets, Wellcome Genome Campus, Hinxton, Cambridgeshire CB10 1SD, United Kingdom
| | - Maya Ghoussaini
- Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, Cambridgeshire CB10 1SA, United Kingdom; Open Targets, Wellcome Genome Campus, Hinxton, Cambridgeshire CB10 1SD, United Kingdom
| | - Jeremy Schwartzentruber
- Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, Cambridgeshire CB10 1SA, United Kingdom; Open Targets, Wellcome Genome Campus, Hinxton, Cambridgeshire CB10 1SD, United Kingdom
| | - Ian Dunham
- Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, Cambridgeshire CB10 1SA, United Kingdom; Open Targets, Wellcome Genome Campus, Hinxton, Cambridgeshire CB10 1SD, United Kingdom; European Molecular Biology Laboratory, European Bioinformatics Institute (EMBL-EBI), Wellcome Genome Campus, Hinxton, Cambridgeshire CB10 1SD, United Kingdom
| | - Benjamin Elsworth
- MRC Integrative Epidemiology Unit (IEU), Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN, United Kingdom
| | - Katherine Roberts
- Bristol Medical School, University of Bristol, 5 Tyndall Avenue, Bristol, BS8 1UD, United Kingdom
| | - Hannah Compton
- Bristol Medical School, University of Bristol, 5 Tyndall Avenue, Bristol, BS8 1UD, United Kingdom
| | - Felix Miller-Molloy
- Bristol Medical School, University of Bristol, 5 Tyndall Avenue, Bristol, BS8 1UD, United Kingdom
| | - Xingzi Liu
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, People's Republic of China
| | - Lin Wang
- Department of Microbiology and Infectious Disease Centre, School of Basic Medical Sciences, Peking University Health Science Centre, Beijing, China
| | - Hong Zhang
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, People's Republic of China
| | - George Davey Smith
- MRC Integrative Epidemiology Unit (IEU), Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN, United Kingdom; NIHR Biomedical Research Centre at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol, United Kingdom
| | - Tom R Gaunt
- MRC Integrative Epidemiology Unit (IEU), Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN, United Kingdom; NIHR Biomedical Research Centre at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol, United Kingdom.
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Tsampasian V, Corballis N, Vassiliou VS. Renin-Angiotensin-Aldosterone Inhibitors and COVID-19 Infection. Curr Hypertens Rep 2022; 24:425-433. [PMID: 35716247 PMCID: PMC9206216 DOI: 10.1007/s11906-022-01207-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2022] [Indexed: 01/08/2023]
Abstract
Purpose of Review This review summarises the literature data and provides an overview of the role and impact of the use of renin–angiotensin–aldosterone system (RAAS) inhibitors in patients with coronavirus disease 2019 (COVID-19) infection. Recent Findings The angiotensin-converting enzyme 2 (ACE2) has a key role in the regulation of the RAAS pathway, downregulating angiotensin II and attenuating inflammation, vasoconstriction and oxidative stress. Additionally, it plays an instrumental part in COVID-19 infection as it facilitates the cell entry of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and enables its replication. The use and role of RAAS inhibitors therefore during the COVID-19 pandemic have been intensively investigated. Summary Although it was initially assumed that RAAS inhibitors may relate to worse clinical outcomes and severe disease, data from large studies and meta-analyses demonstrated that they do not have an adverse impact on clinical outcomes or prognosis. On the contrary, some experimental and retrospective observational cohort studies showed a potential protective mechanism, although this effect remains to be seen in large clinical trials.
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Affiliation(s)
- Vasiliki Tsampasian
- Norwich Medical School, University of East Anglia, Norwich, UK.,Norfolk and Norwich University Hospital, Norwich, UK
| | - Natasha Corballis
- Norwich Medical School, University of East Anglia, Norwich, UK.,Norfolk and Norwich University Hospital, Norwich, UK
| | - Vassilios S Vassiliou
- Norwich Medical School, University of East Anglia, Norwich, UK. .,Norfolk and Norwich University Hospital, Norwich, UK.
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Loader J, Taylor FC, Lampa E, Sundström J. Renin-Angiotensin Aldosterone System Inhibitors and COVID-19: A Systematic Review and Meta-Analysis Revealing Critical Bias Across a Body of Observational Research. J Am Heart Assoc 2022; 11:e025289. [PMID: 35624081 PMCID: PMC9238740 DOI: 10.1161/jaha.122.025289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background Renin‐angiotensin aldosterone system (RAAS) inhibitor—COVID‐19 studies, observational in design, appear to use biased methods that can distort the interaction between RAAS inhibitor use and COVID‐19 risk. This study assessed the extent of bias in that research and reevaluated RAAS inhibitor—COVID‐19 associations in studies without critical risk of bias. Methods and Results Searches were performed in MEDLINE, EMBASE, and CINAHL databases (December 1, 2019 to October 21, 2021) identifying studies that compared the risk of infection and/or severe COVID‐19 outcomes between those using or not using RAAS inhibitors (ie, angiotensin‐converting enzyme inhibitors or angiotensin II type‐I receptor blockers). Weighted hazard ratios (HR) and 95% CIs were extracted and pooled in fixed‐effects meta‐analyses, only from studies without critical risk of bias that assessed severe COVID‐19 outcomes. Of 169 relevant studies, 164 had critical risks of bias and were excluded. Ultimately, only two studies presented data relevant to the meta‐analysis. In 1 351 633 people with uncomplicated hypertension using a RAAS inhibitor, calcium channel blocker, or thiazide diuretic in monotherapy, the risk of hospitalization (angiotensin‐converting enzyme inhibitor: HR, 0.76; 95% CI, 0.66–0.87; P<0.001; angiotensin II type‐I receptor blockers: HR, 0.86; 95% CI, 0.77–0.97; P=0.015) and intubation or death (angiotensin‐converting enzyme inhibitor: HR, 0.64; 95% CI, 0.48–0.85; P=0.002; angiotensin II type‐I receptor blockers: HR, 0.74; 95% CI, 0.58–0.95; P=0.019) with COVID‐19 was lower in those using a RAAS inhibitor. However, these protective effects are probably not clinically relevant. Conclusions This study reveals the critical risk of bias that exists across almost an entire body of COVID‐19 research, raising an important question: Were research methods and/or peer‐review processes temporarily weakened during the surge of COVID‐19 research or is this lack of rigor a systemic problem that also exists outside pandemic‐based research? Registration URL: www.crd.york.ac.uk/prospero/; Unique identifier: CRD42021237859.
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Affiliation(s)
- Jordan Loader
- Department of Medical Sciences Uppsala University Uppsala Sweden.,Inserm U1300 - HP2 CHU Grenoble Alpes Grenoble France
| | - Frances C Taylor
- Baker Heart and Diabetes Institute Melbourne Victoria Australia.,Mary MacKillop Institute for Health Research, Australian Catholic University Melbourne Victoria Australia
| | - Erik Lampa
- Department of Medical Sciences Uppsala University Uppsala Sweden
| | - Johan Sundström
- Department of Medical Sciences Uppsala University Uppsala Sweden.,The George Institute for Global Health University of New South Wales Sydney Australia
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10
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Yin J, Wang C, Song X, Li X, Miao M. Effects of Renin-Angiotensin System Inhibitors on Mortality and Disease Severity of COVID-19 Patients: A Meta-analysis of Randomized Controlled Trials. Am J Hypertens 2022; 35:462-469. [PMID: 35512430 DOI: 10.1093/ajh/hpac001] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 12/23/2021] [Accepted: 01/04/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND There is controversy over the effects of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) on the prognosis in patients with coronavirus disease 2019 (COVID-19), therefore, we aim to further explore the effect of renin-angiotensin-aldosterone system inhibitors on COVID-19-associated disease severity and mortality. METHODS We systematically searched PubMed, Embase, Cochrane Library databases, medRxiv, and bioRxiv from inception to 6 September 2021. The primary outcome was all-cause mortality. Secondary outcome was severe disease which was defined as admission to the intensive care unit, the use of noninvasive or invasive mechanical ventilation, or death. RESULTS A total of 7 randomized controlled trials involving 1,321 COVID-19 patients were included. Fixed-effects meta-analysis demonstrated that the use of ACEI/ARB was not associated with higher risk of mortality (risk ratio [RR] = 0.84, 95% confidence interval [CI] 0.57-1.22, P = 0.10, I2 = 43%) and disease severity (RR = 0.86, 95% CI 0.71-1.05, P = 0.11, I2 = 47%). However, the subgroup analysis showed that compared with no ACEI/ARB use, the use of ARB was associated with a significant reduction of mortality (RR = 0.23, CI 0.09-0.60, P = 0.55, I2 = 0%) and disease severity (RR = 0.38, CI 0.19-0.77, P = 0.007). CONCLUSIONS In conclusion, based on the available data, ACEI/ARB is not associated with the risk of mortality and disease severity in COVID-19 patients. And ACEI/ARB medications, especially ARB, should not be discontinued for patients with COVID-19.
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Affiliation(s)
- Juntao Yin
- Department of Pharmacy, Huaihe Hospital, Henan University, Henan, China
- Department of Pharmacology, Henan University of Chinese Medicine, Henan, China
| | - Chaoyang Wang
- Translational Medicine Center, Huaihe Hospital, Henan University, Henan, China
| | - Xiaoyong Song
- Translational Medicine Center, Huaihe Hospital, Henan University, Henan, China
- Department of Pharmaceutics, School of Pharmacy, Henan University, Henan, China
| | - Xiumin Li
- National International Cooperation Base of Chinese Medicine, Academy of Chinese Medicine, Henan University of Chinese Medicine, Henan, China
| | - Mingsan Miao
- Department of Pharmacology, Henan University of Chinese Medicine, Henan, China
- National International Cooperation Base of Chinese Medicine, Academy of Chinese Medicine, Henan University of Chinese Medicine, Henan, China
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11
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Asiimwe IG, Pushpakom SP, Turner RM, Kolamunnage-Dona R, Jorgensen AL, Pirmohamed M. Cardiovascular drugs and COVID-19 clinical outcomes: a systematic review and meta-analysis of randomized controlled trials. Br J Clin Pharmacol 2022; 88:3577-3599. [PMID: 35322889 PMCID: PMC9111446 DOI: 10.1111/bcp.15331] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 03/07/2022] [Accepted: 03/19/2022] [Indexed: 11/29/2022] Open
Abstract
Aims: To update our previously reported systematic review and meta‐analysis of observational studies on cardiovascular drug exposure and COVID‐19 clinical outcomes by focusing on newly published randomized controlled trials (RCTs). Methods: More than 500 databases were searched between 1 November 2020 and 2 October 2021 to identify RCTs that were published after our baseline review. One reviewer extracted data with other reviewers verifying the extracted data for accuracy and completeness. Results: After screening 22 414 records, we included 24 and 21 RCTs in the qualitative and quantitative syntheses, respectively. The most investigated drug classes were angiotensin‐converting enzyme inhibitors (ACEIs)/angiotensin receptor blocker (ARBs) and anticoagulants, investigated by 10 and 11 studies respectively. In meta‐analyses, ACEI/ARBs did not affect hospitalization length (mean difference −0.42, 95% confidence interval [CI] −1.83; 0.98 d, n = 1183), COVID‐19 severity (risk ratio/RR 0.90, 95% CI 0.71; 1.15, n = 1661) or mortality (risk ratio [RR] 0.92, 95% CI 0.58; 1.47, n = 1646). Therapeutic anticoagulation also had no effect (hospitalization length mean difference −0.29, 95% CI −1.13 to 0.56 d, n = 1449; severity RR 0.86, 95% CI 0.70; 1.04, n = 2696; and, mortality RR 0.93, 95% CI 0.77; 1.13, n = 5689). Other investigated drug classes were antiplatelets (aspirin, 2 trials), antithrombotics (sulodexide, 1 trial), calcium channel blockers (amlodipine, 1 trial) and lipid‐modifying drugs (atorvastatin, 1 trial). Conclusion: Moderate‐ to high‐certainty RCT evidence suggests that cardiovascular drugs such as ACEIs/ARBs are not associated with poor COVID‐19 outcomes, and should therefore not be discontinued. These cardiovascular drugs should also not be initiated to treat or prevent COVID‐19 unless they are needed for an underlying currently approved therapeutic indication.
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Affiliation(s)
- Innocent G Asiimwe
- The Wolfson Centre for Personalised Medicine, MRC Centre for Drug Safety Science, Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
| | - Sudeep P Pushpakom
- The Wolfson Centre for Personalised Medicine, MRC Centre for Drug Safety Science, Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
| | - Richard M Turner
- The Wolfson Centre for Personalised Medicine, MRC Centre for Drug Safety Science, Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
| | - Ruwanthi Kolamunnage-Dona
- Department of Health Data Science, Institute of Population Health Sciences, University of Liverpool, United Kingdom Institute of Population Health Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Andrea L Jorgensen
- Department of Health Data Science, Institute of Population Health Sciences, University of Liverpool, United Kingdom Institute of Population Health Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Munir Pirmohamed
- The Wolfson Centre for Personalised Medicine, MRC Centre for Drug Safety Science, Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
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12
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Morishita T, Takada D, Shin JH, Higuchi T, Kunisawa S, Fushimi K, Imanaka Y. Effects of the COVID-19 pandemic on heart failure hospitalizations in Japan: interrupted time series analysis. ESC Heart Fail 2021; 9:31-38. [PMID: 34913269 PMCID: PMC8788142 DOI: 10.1002/ehf2.13744] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 11/11/2021] [Accepted: 11/17/2021] [Indexed: 12/22/2022] Open
Abstract
Aims The Coronavirus Disease 2019 (COVID‐19) pandemic has had unprecedented effects on health care utilization for acute cardiovascular diseases. Although hospitalizations for acute coronary syndrome decreased during the COVID‐19 pandemic, there is a paucity of data on the trends and management of heart failure (HF) cases. Furthermore, concerns have been raised that angiotensin‐converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) may increase susceptibility to COVID‐19. This study aimed to elucidate changes in HF hospitalizations from the COVID‐19 state of emergency in Japan and investigated changes in the prescription of ACEIs and ARBs, and in‐hospital mortality. Methods and results We performed an interrupted time series analysis of HF hospitalizations in Japan to verify the impacts of the COVID‐19 state of emergency. Changes in the weekly volume of HF hospitalizations were taken as the primary outcome measure. Between 1 April 2018 and 4 July 2020, 109 429 HF cases required admission. After the state of emergency, an immediate decrease was observed in HF cases per week [−3.6%; 95% confidence interval (CI): −0.3% to −6.7%, P = 0.03]. There was no significant change in the prescription of ACEIs or ARBs after the state of emergency (4.2%; 95% CI: −0.3% to 8.9%, P = 0.07). The COVID‐19 pandemic had no effect on in‐hospital mortality among HF patients (5.3%; 95% CI: −4.9% to 16.6%, P = 0.32). Conclusions We demonstrated a decline in HF hospitalizations during the COVID‐19 pandemic in Japan, with no clear evidence of a negative effect on the prescription of ACEIs and ARBs or in‐hospital mortality.
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Affiliation(s)
- Tetsuji Morishita
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto City, Kyoto, 606-8501, Japan.,Department of Internal Medicine, Matsunami General Hospital, Gifu, Japan
| | - Daisuke Takada
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto City, Kyoto, 606-8501, Japan
| | - Jung-Ho Shin
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto City, Kyoto, 606-8501, Japan
| | - Takuya Higuchi
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto City, Kyoto, 606-8501, Japan
| | - Susumu Kunisawa
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto City, Kyoto, 606-8501, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Yuichi Imanaka
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto City, Kyoto, 606-8501, Japan
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13
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Rezel‐Potts E, Douiri A, Chowienczyk PJ, Gulliford MC. Antihypertensive medications and COVID-19 diagnosis and mortality: Population-based case-control analysis in the United Kingdom. Br J Clin Pharmacol 2021; 87:4598-4607. [PMID: 33908074 PMCID: PMC8239680 DOI: 10.1111/bcp.14873] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 02/15/2021] [Accepted: 04/18/2021] [Indexed: 12/14/2022] Open
Abstract
AIMS Antihypertensive drugs have been implicated in coronavirus disease 2019 (COVID-19) susceptibility and severity, but estimated associations may be susceptible to bias. We aimed to evaluate antihypertensive medications and COVID-19 diagnosis and mortality, accounting for healthcare-seeking behaviour. METHODS A population-based case-control study was conducted including 16 866 COVID-19 cases and 70 137 matched controls from the UK Clinical Practice Research Datalink. We evaluated all-cause mortality among COVID-19 cases. Exposures were angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), beta-blockers (B), calcium-channel blockers (C), thiazide diuretics (D) and other antihypertensive drugs (O). Analyses were adjusted for covariates and consultation frequency. RESULTS ACEIs were associated with lower odds of COVID-19 diagnosis (adjusted odds ratio [AOR] 0.82, 95% confidence interval [CI] 0.77-0.88) as were ARBs (AOR 0.87, 95% CI 0.80-0.95) with little attenuation from adjustment for consultation frequency. C and D were also associated with lower odds of COVID-19 diagnosis. Increased odds of COVID-19 for B (AOR 1.19, 95% CI 1.12-1.26) were attenuated after adjustment for consultation frequency (AOR 1.01, 95% CI 0.95-1.08). Patients treated with ACEIs or ARBs had similar odds of mortality (AOR 1.00, 95% CI 0.83-1.20) to patients treated with classes B, C, D or O or patients receiving no antihypertensive therapy (AOR 0.99, 95% CI 0.83-1.18). CONCLUSIONS There was no evidence that antihypertensive therapy is associated with increased risk of COVID-19 diagnosis or mortality; most classes of antihypertensive therapy showed negative associations with COVID-19 diagnosis.
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Affiliation(s)
- Emma Rezel‐Potts
- King's College LondonSchool of Population Health and Environmental SciencesLondonUK
- National Institute for Health Research Biomedical Research CentreGuy's and St Thomas' NHS Foundation Trust and King's College LondonLondonUK
| | - Abdel Douiri
- King's College LondonSchool of Population Health and Environmental SciencesLondonUK
- National Institute for Health Research Biomedical Research CentreGuy's and St Thomas' NHS Foundation Trust and King's College LondonLondonUK
- National Institute for Health Research Applied Research Collaboration South LondonGuy's and St Thomas' NHS Foundation Trust and King's College LondonLondonUK
| | | | - Martin C. Gulliford
- King's College LondonSchool of Population Health and Environmental SciencesLondonUK
- National Institute for Health Research Biomedical Research CentreGuy's and St Thomas' NHS Foundation Trust and King's College LondonLondonUK
- National Institute for Health Research Applied Research Collaboration South LondonGuy's and St Thomas' NHS Foundation Trust and King's College LondonLondonUK
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14
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Hu S, Jiang S, Qi X, Bai R, Ye XY, Xie T. Races of small molecule clinical trials for the treatment of COVID-19: An up-to-date comprehensive review. Drug Dev Res 2021; 83:16-54. [PMID: 34762760 PMCID: PMC8653368 DOI: 10.1002/ddr.21895] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/18/2021] [Accepted: 10/25/2021] [Indexed: 12/15/2022]
Abstract
The coronavirus disease‐19 (COVID‐19) pandemic has become a global threat since its first outbreak at the end of 2019. Several review articles have been published recently, focusing on the aspects of target biology, drug repurposing, and mechanisms of action (MOAs) for potential treatment. This review gathers all small molecules currently in active clinical trials, categorizes them into six sub‐classes, and summarizes their clinical progress. The aim is to provide the researchers from both pharmaceutical industries and academic institutes with the handful information and dataset to accelerate their research programs in searching effective small molecule therapy for treatment of COVID‐19.
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Affiliation(s)
- Suwen Hu
- School of Pharmacy, Hangzhou Normal University, Hangzhou, China.,Key Laboratory of Elemene Class Anti-Cancer Chinese Medicine of Zhejiang Province, Hangzhou Normal University, Hangzhou, China.,Engineering Laboratory of Development and Application of Traditional Chinese Medicine from Zhejiang Province, Hangzhou Normal University, Hangzhou, China.,Collaborative Innovation Center of Chinese Medicines from Zhejiang Province, Hangzhou Normal Umiversity, Hangzhou, China.,Hangzhou Huadong Medicine Group, Pharmaceutical Research Institute Co. Ltd., Hangzhou, China.,Department of Chemistry and Biochemistry Los Angeles, University of California, Los Angeles, California, USA
| | - Songwei Jiang
- School of Pharmacy, Hangzhou Normal University, Hangzhou, China.,Key Laboratory of Elemene Class Anti-Cancer Chinese Medicine of Zhejiang Province, Hangzhou Normal University, Hangzhou, China.,Engineering Laboratory of Development and Application of Traditional Chinese Medicine from Zhejiang Province, Hangzhou Normal University, Hangzhou, China.,Collaborative Innovation Center of Chinese Medicines from Zhejiang Province, Hangzhou Normal Umiversity, Hangzhou, China
| | - Xiang Qi
- School of Pharmacy, Hangzhou Normal University, Hangzhou, China.,Key Laboratory of Elemene Class Anti-Cancer Chinese Medicine of Zhejiang Province, Hangzhou Normal University, Hangzhou, China.,Engineering Laboratory of Development and Application of Traditional Chinese Medicine from Zhejiang Province, Hangzhou Normal University, Hangzhou, China.,Collaborative Innovation Center of Chinese Medicines from Zhejiang Province, Hangzhou Normal Umiversity, Hangzhou, China
| | - Renren Bai
- School of Pharmacy, Hangzhou Normal University, Hangzhou, China.,Key Laboratory of Elemene Class Anti-Cancer Chinese Medicine of Zhejiang Province, Hangzhou Normal University, Hangzhou, China.,Engineering Laboratory of Development and Application of Traditional Chinese Medicine from Zhejiang Province, Hangzhou Normal University, Hangzhou, China.,Collaborative Innovation Center of Chinese Medicines from Zhejiang Province, Hangzhou Normal Umiversity, Hangzhou, China
| | - Xiang-Yang Ye
- School of Pharmacy, Hangzhou Normal University, Hangzhou, China.,Key Laboratory of Elemene Class Anti-Cancer Chinese Medicine of Zhejiang Province, Hangzhou Normal University, Hangzhou, China.,Engineering Laboratory of Development and Application of Traditional Chinese Medicine from Zhejiang Province, Hangzhou Normal University, Hangzhou, China.,Collaborative Innovation Center of Chinese Medicines from Zhejiang Province, Hangzhou Normal Umiversity, Hangzhou, China
| | - Tian Xie
- School of Pharmacy, Hangzhou Normal University, Hangzhou, China.,Key Laboratory of Elemene Class Anti-Cancer Chinese Medicine of Zhejiang Province, Hangzhou Normal University, Hangzhou, China.,Engineering Laboratory of Development and Application of Traditional Chinese Medicine from Zhejiang Province, Hangzhou Normal University, Hangzhou, China.,Collaborative Innovation Center of Chinese Medicines from Zhejiang Province, Hangzhou Normal Umiversity, Hangzhou, China
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15
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Clinical trials in COVID-19 management & prevention: A meta-epidemiological study examining methodological quality. J Clin Epidemiol 2021; 139:68-79. [PMID: 34274489 PMCID: PMC8280397 DOI: 10.1016/j.jclinepi.2021.07.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 06/16/2021] [Accepted: 07/08/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To describe the characteristics of Covid-19 randomized clinical trials (RCTs) and examine the association between trial characteristics and the likelihood of finding a significant effect. STUDY DESIGN We conducted a systematic review to identify RCTs (up to October 21, 2020) evaluating drugs or blood products to treat or prevent Covid-19. We extracted trial characteristics (number of centers, funding sources, and sample size) and assessed risk of bias (RoB) using the Cochrane RoB 2.0 tool. We performed logistic regressions to evaluate the association between RoB due to randomization, single vs. multicentre, funding source, and sample size, and finding a statistically significant effect. RESULTS We included 91 RCTs (n = 46,802); 40 (44%) were single-center, 23 (25.3%) enrolled <50 patients, 28 (30.8%) received industry funding, and 75 (82.4%) had high or probably high RoB. Thirty-eight trials (41.8%) reported a statistically significant effect. RoB due to randomization and being a single-center trial were associated with increased odds of finding a statistically significant effect. CONCLUSIONS There is high variability in RoB among Covid-19 trials. Researchers, funders, and knowledge-users should be cognizant of the impact of RoB due to randomization and single-center trial status in designing, evaluating, and interpreting the results of RCTs. REGISTRATION CRD42020192095.
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16
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El Hadidi S, Sabra K. What We Learnt After Looking Back At the Community Pharmacists' Experiences Worldwide in COVID-19 Pandemic. J Pharm Pract 2021; 36:198-202. [PMID: 34325564 PMCID: PMC10064179 DOI: 10.1177/08971900211036093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Community pharmacists are key players in COVID-19 response. Community pharmacies are often the first port of call for people who are feeling ill. They are well placed within their communities to offer advice and reinforce essential messages about hand and respiratory hygiene and physical distancing. There are no approved clinical practice guidelines for COVID-19, and pharmacies must therefore play their part in helping to contain the spread of false claims and misinformation circulating in their communities.
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Affiliation(s)
- Seif El Hadidi
- 110118Future University in Egypt, New Cairo, Cairo, Egypt
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17
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Sattar Y, Mukuntharaj P, Zghouzi M, Suleiman ARM, Attique H, Ullah W, Sana MK, Zaher N, Mehmood M, Doshi RP, Panchal A, Mir T, Nadeem M, Ali OE, Mohamed M, Bagur R, Elgendy IY, Mamas MA, Alraies MC. Safety and Efficacy of Renin-Angiotensin-Aldosterone System Inhibitors in COVID-19 Population. High Blood Press Cardiovasc Prev 2021; 28:405-416. [PMID: 34181203 PMCID: PMC8237039 DOI: 10.1007/s40292-021-00462-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 05/19/2021] [Indexed: 11/09/2022] Open
Abstract
Introduction The safety of renin–angiotensin–aldosterone system inhibitors (RAASi) among COVID-19 patients has been controversial since the onset of the pandemic. Methods Digital databases were queried to study the safety of RAASi in COVID-19. The primary outcome of interest was mortality. The secondary outcome was seropositivity improvement/viral clearance, clinical manifestation progression, and progression to intensive care units. A random-effect model was used to compute an unadjusted odds ratio (OR). Results A total of 49 observational studies were included in the analysis consisting of 83,269 COVID-19 patients (RAASi n = 34,691; non-RAASi n = 48,578). The mean age of the sample was 64, and 56% were males. We found that RAASi was associated with similar mortality outcomes as compared to non-RAASi groups (OR 1.07; 95% CI 0.99–1.15; p > 0.05). RAASi was associated with seropositivity improvement including negative RT-PCR or antibodies, (OR 0.96; 95% CI 0.93–0.99; p < 0.05). There was no association between RAASi versus control with progression to ICU admission (OR 0.99; 95% CI 0.79–1.23; p > 0.05) or higher odds of worsening of clinical manifestations (OR 1.04; 95% CI 0.97–1.11; p > 0.05). Metaregression analysis did not change our outcomes for effect modifiers including age, sex, comorbidities, RAASi type, or study type on outcomes. Conclusions COVID-19 is not a contraindication to hold or discontinue RAASi as they are not associated with higher mortality or worsening symptoms. Continuation of RAASi might be associated with favorable outcomes in COVID-19, including seropositivity/viral clearance. Supplementary Information The online version contains supplementary material available at 10.1007/s40292-021-00462-w.
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Affiliation(s)
- Yasar Sattar
- Icahn School of Medicine at Mount, Sinai Elmhurst Hospital, Queens, NY, USA
| | | | - Mohamed Zghouzi
- Detroit Medical Center, DMC Heart Hospital, 311 Mack Ave, Detroit, MI, 48201, USA
| | | | | | - Waqas Ullah
- Abington Jefferson Health, Abington, PA, USA
| | | | - Nathan Zaher
- Detroit Medical Center, DMC Heart Hospital, 311 Mack Ave, Detroit, MI, 48201, USA
| | - Maham Mehmood
- Icahn School of Medicine at Mount Sinai BronxCare Health System, Bronx, NY, USA
| | | | - Ankur Panchal
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Tanveer Mir
- Detroit Medical Center, DMC Heart Hospital, 311 Mack Ave, Detroit, MI, 48201, USA
| | | | - Omar E Ali
- Detroit Medical Center, DMC Heart Hospital, 311 Mack Ave, Detroit, MI, 48201, USA
| | - Mohamad Mohamed
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, UK
| | | | | | - Mamas A Mamas
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, UK
| | - M Chadi Alraies
- Detroit Medical Center, DMC Heart Hospital, 311 Mack Ave, Detroit, MI, 48201, USA.
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18
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Asiimwe IG, Pushpakom S, Turner RM, Kolamunnage-Dona R, Jorgensen AL, Pirmohamed M. Cardiovascular drugs and COVID-19 clinical outcomes: A living systematic review and meta-analysis. Br J Clin Pharmacol 2021; 87:4534-4545. [PMID: 34101232 PMCID: PMC8239929 DOI: 10.1111/bcp.14927] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 05/03/2021] [Accepted: 05/18/2021] [Indexed: 12/19/2022] Open
Abstract
Aims The aim of this study was to continually evaluate the association between cardiovascular drug exposure and COVID‐19 clinical outcomes (susceptibility to infection, disease severity, hospitalization, hospitalization length, and all‐cause mortality) in patients at risk of/with confirmed COVID‐19. Methods Eligible publications were identified from more than 500 databases on 1 November 2020. One reviewer extracted data with 20% of the records independently extracted/evaluated by a second reviewer. Results Of 52 735 screened records, 429 and 390 studies were included in the qualitative and quantitative syntheses, respectively. The most‐reported drugs were angiotensin‐converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs) with ACEI/ARB exposure having borderline association with confirmed COVID‐19 infection (OR 1.14, 95% CI 1.00–1.31). Among COVID‐19 patients, unadjusted estimates showed that ACEI/ARB exposure was associated with hospitalization (OR 1.76, 95% CI 1.34–2.32), disease severity (OR 1.40, 95% CI 1.26–1.55) and all‐cause mortality (OR 1.22, 95% CI 1.12–1.33) but not hospitalization length (mean difference −0.27, 95% CI −1.36–0.82 days). After adjustment, ACEI/ARB exposure was not associated with confirmed COVID‐19 infection (OR 0.92, 95% CI 0.71–1.19), hospitalization (OR 0.93, 95% CI 0.70–1.24), disease severity (OR 1.05, 95% CI 0.81–1.38) or all‐cause mortality (OR 0.84, 95% CI 0.70–1.00). Similarly, subgroup analyses involving only hypertensive patients revealed that ACEI/ARB exposure was not associated with confirmed COVID‐19 infection (OR 0.93, 95% CI 0.79–1.09), hospitalization (OR 0.84, 95% CI 0.58–1.22), hospitalization length (mean difference −0.14, 95% CI −1.65–1.36 days), disease severity (OR 0.92, 95% CI 0.76–1.11) while it decreased the odds of dying (OR 0.76, 95% CI 0.65–0.88). A similar trend was observed for other cardiovascular drugs. However, the validity of these findings is limited by a high level of heterogeneity and serious risk of bias. Conclusion Cardiovascular drugs are not associated with poor COVID‐19 outcomes in adjusted analyses. Patients should continue taking these drugs as prescribed.
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Affiliation(s)
- Innocent G Asiimwe
- The Wolfson Centre for Personalized Medicine, MRC Centre for Drug Safety Science, Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, L69 3GL, UK
| | - Sudeep Pushpakom
- The Wolfson Centre for Personalized Medicine, MRC Centre for Drug Safety Science, Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, L69 3GL, UK
| | - Richard M Turner
- The Wolfson Centre for Personalized Medicine, MRC Centre for Drug Safety Science, Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, L69 3GL, UK
| | - Ruwanthi Kolamunnage-Dona
- Department of Biostatistics, Institute of Population Health Sciences, University of Liverpool, Liverpool, L69 3GL, UK
| | - Andrea L Jorgensen
- Department of Biostatistics, Institute of Population Health Sciences, University of Liverpool, Liverpool, L69 3GL, UK
| | - Munir Pirmohamed
- The Wolfson Centre for Personalized Medicine, MRC Centre for Drug Safety Science, Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, L69 3GL, UK
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19
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Bezabih YM, Bezabih A, Alamneh E, Peterson GM, Bezabhe W. Comparison of renin-angiotensin-aldosterone system inhibitors with other antihypertensives in association with coronavirus disease-19 clinical outcomes. BMC Infect Dis 2021; 21:527. [PMID: 34090358 PMCID: PMC8178664 DOI: 10.1186/s12879-021-06088-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 04/20/2021] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Reports on the effects of renin-angiotensin-aldosterone system (RAAS) inhibitors on the clinical outcomes of coronavirus disease-19 (COVID-19) have been conflicting. We performed this meta-analysis to find conclusive evidence. METHODS We searched published articles through PubMed, EMBASE and medRxiv from 5 January 2020 to 3 August 2020. Studies that reported clinical outcomes of patients with COVID-19, stratified by the class of antihypertensives, were included. Random and fixed-effects models were used to estimate pooled odds ratio (OR). RESULTS A total 36 studies involving 30,795 patients with COVID-19 were included. The overall risk of poor patient outcomes (severe COVID-19 or death) was lower in patients taking RAAS inhibitors (OR = 0.79, 95% CI: [0.67, 0.95]) compared with those receiving non-RAAS inhibitor antihypertensives. However, further sub-meta-analysis showed that specific RAAS inhibitors did not show a reduction of poor COVID-19 outcomes when compared with any class of antihypertensive except beta-blockers (BBs). For example, compared to calcium channel blockers (CCBs), neither angiotensin-I-converting enzyme inhibitors (ACEIs) (OR = 0.91, 95% CI: [0.67, 1.23]) nor angiotensin-II receptor blockers (ARBs) (OR = 0.90, 95% CI: [0.62, 1.33]) showed a reduction of poor COVID-19 outcomes. When compared with BBs, however, both ACEIs (OR = 0.85, 95% CI: [0.73, 0.99) and ARBs (OR = 0.72, 95% CI: [0.55, 0.94]) showed an apparent decrease in poor COVID-19 outcomes. CONCLUSIONS RAAS inhibitors did not increase the risk of mortality or severity of COVID-19. Differences in COVID-19 clinical outcomes between different class of antihypertensive drugs were likely due to the underlying comorbidities for which the antihypertensive drugs were prescribed, although adverse effects of drugs such as BBs could not be excluded.
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Affiliation(s)
- Yihienew M. Bezabih
- Arsi University College of Health Sciences, Arsi University, P. O. Box, 04, Assela, Ethiopia
| | - Alemayehu Bezabih
- École Nationale Vétérinaire, Agroalimentaire et de L’alimentation, Nantes-Atlantique, BIOEPAR (UMR1300 INRA/ONIRIS), Atlanpole-Chantrerie CS-40706 44307, Nantes Cedex 3, France
| | - Endalkachew Alamneh
- School of Pharmacy and Pharmacology, University of Tasmania, Private Bag 26, Hobart, TAS 7001 Australia
| | - Gregory M. Peterson
- School of Pharmacy and Pharmacology, University of Tasmania, Private Bag 26, Hobart, TAS 7001 Australia
| | - Woldesellassie Bezabhe
- School of Pharmacy and Pharmacology, University of Tasmania, Private Bag 26, Hobart, TAS 7001 Australia
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20
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Xu J, Teng Y, Shang L, Gu X, Fan G, Chen Y, Tian R, Zhang S, Cao B. The Effect of Prior Angiotensin-Converting Enzyme Inhibitor and Angiotensin Receptor Blocker Treatment on Coronavirus Disease 2019 (COVID-19) Susceptibility and Outcome: A Systematic Review and Meta-analysis. Clin Infect Dis 2021; 72:e901-e913. [PMID: 33079200 PMCID: PMC7665377 DOI: 10.1093/cid/ciaa1592] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Indexed: 12/22/2022] Open
Abstract
There have been arguments on whether angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) treatment alters the risk of COVID-19 susceptibility and disease severity. We identified a total of 102 eligible studies for systematic review, in which 49 studies adjusting for confounders were included in the meta-analysis. We found no association between prior ACEI/ARB use and risk of SARS-CoV-2 infection in general population (adjusted OR [aOR] 1.00, 95% confidence interval [CI] 0.94-1.05). The risk of mortality (aOR 0.87, 95%CI 0.66-1.04) and severe outcomes (aOR 0.95, 95%CI 0.73-1.24) are also unchanged among COVID-19 patients taking ACEI/ARB. These findings remain consistent in subgroup analyses stratified by populations, drug exposures and in other secondary outcomes. This systematic review provides evidence-based support to current medical guidelines and position statements that ACEI/ARB should not be discontinued. Additionally, there has been no evidence for initiating ACEI/ARB regimen as prevention or treatment of COVID-19.
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Affiliation(s)
- Jiuyang Xu
- Tsinghua University School of Medicine, Beijing, China
| | - Yaqun Teng
- Tsinghua University School of Medicine, Beijing, China.,Department of Cardiology, Peking Union Medical College Hospital, Beijing, China
| | - Lianhan Shang
- Beijing University of Chinese Medicine, Beijing, China.,Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, National Center for Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Xiaoying Gu
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, National Center for Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China
| | - Guohui Fan
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, National Center for Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China
| | - Yijun Chen
- Tsinghua University School of Medicine, Beijing, China
| | - Ran Tian
- Department of Cardiology, Peking Union Medical College Hospital, Beijing, China
| | - Shuyang Zhang
- Tsinghua University School of Medicine, Beijing, China.,Department of Cardiology, Peking Union Medical College Hospital, Beijing, China.,Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Tsinghua University-Peking University Joint Center for Life Sciences, Beijing, China
| | - Bin Cao
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, National Center for Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,Tsinghua University-Peking University Joint Center for Life Sciences, Beijing, China
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21
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COVID-19 in Patients with Hypertension. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1318:243-261. [PMID: 33973183 DOI: 10.1007/978-3-030-63761-3_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Hypertension has been listed in several case series and retrospective cohorts as a potential risk factor for the incidence and severity of the new coronavirus (SARS-CoV-2)-associated disease (COVID-19). The debate is noteworthy because almost one billion people around the globe are estimated to have hypertensive diseases, according to the Global Burden of Disease study. Considering the SARS-CoV-2's high infectivity rates, a possible interaction between COVID-19 and hypertension is worrisome. Additionally, antihypertensive drugs, especially the renin-angiotensin-aldosterone system (RAAS) inhibitors, could also influence the natural course of COVID-19 infection. Not only can these associations hold from an epidemiologic standpoint, a mechanistic scenario possibly exists. Hypertension and antihypertensive drugs can increase the expression of transmembrane angiotensin-converting enzyme (ACE)-2 receptors, the entry target of the viruses, thus facilitating infectivity. On the other hand, an increase in ACE-2 could be protective considering the anti-inflammatory, antithrombotic effects of the ACE-2-angiotensin 1-7/Mas pathway. So far, little is known about the whole picture. Observational studies appear to indicate at least a twofold increased risk of mortality for hypertensive patients with COVID-19; however, the previous and continued use of RAAS inhibitors may be protective in this subgroup of patients. The scarcity of randomized clinical trials precludes evidence-based decision-making. At least one randomized study in a non-specified sub-analysis demonstrated no relationship between an angiotensin-converting enzyme inhibitor and incidence or severity of the disease. It is reflected mainly by observational studies and, therefore, by international cardiology societies' guidelines, which state that antihypertensive drugs, particularly RAAS inhibitors, should not be discontinued unless necessary on a case-by-case basis.
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22
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Oz M, Lorke DE, Kabbani N. A comprehensive guide to the pharmacologic regulation of angiotensin converting enzyme 2 (ACE2), the SARS-CoV-2 entry receptor. Pharmacol Ther 2021; 221:107750. [PMID: 33275999 PMCID: PMC7854082 DOI: 10.1016/j.pharmthera.2020.107750] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/18/2020] [Accepted: 11/19/2020] [Indexed: 02/06/2023]
Abstract
The recent emergence of coronavirus disease-2019 (COVID-19) as a global pandemic has prompted scientists to address an urgent need for defining mechanisms of disease pathology and treatment. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent for COVID-19, employs angiotensin converting enzyme 2 (ACE2) as its primary target for cell surface attachment and likely entry into the host cell. Thus, understanding factors that may regulate the expression and function of ACE2 in the healthy and diseased body is critical for clinical intervention. Over 66% of all adults in the United States are currently using a prescription drug and while earlier findings have focused on possible upregulation of ACE2 expression through the use of renin angiotensin system (RAS) inhibitors, mounting evidence suggests that various other widely administered drugs used in the treatment of hypertension, heart failure, diabetes mellitus, hyperlipidemias, coagulation disorders, and pulmonary disease may also present a varied risk for COVID-19. Specifically, we summarize mechanisms on how heparin, statins, steroids and phytochemicals, besides their established therapeutic effects, may also interfere with SARS-CoV-2 viral entry into cells. We also describe evidence on the effect of several vitamins, phytochemicals, and naturally occurring compounds on ACE2 expression and activity in various tissues and disease models. This comprehensive review aims to provide a timely compendium on the potential impact of commonly prescribed drugs and pharmacologically active compounds on COVID-19 pathology and risk through regulation of ACE2 and RAS signaling.
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Key Words
- adam17, a disintegrin and metalloprotease 17
- ace, angiotensin i converting enzyme
- ace-inh., angiotensin i converting enzyme inhibitor
- ampk, amp-activated protein kinase
- ang-ii, angiotensin ii
- arb, angiotensin ii type 1-receptor blocker
- ards, acute respiratory distress syndrome
- at1-r, angiotensin ii type 1-receptor
- βarb, β-adrenergic receptor blockers
- bk, bradykinin
- ccb, calcium channel blockers
- ch25h, cholesterol-25-hydroxylase
- copd, chronic obstructive lung disease
- cox, cyclooxygenase
- covid-19, coronavirus disease-2019
- dabk, [des-arg9]-bradykinin
- erk, extracellular signal-regulated kinase
- 25hc, 25-hydroxycholesterol
- hs, heparan sulfate
- hspg, heparan sulfate proteoglycan
- ibd, inflammatory bowel disease
- map, mitogen-activated protein
- mers, middle east respiratory syndrome
- mrb, mineralocorticoid receptor blocker
- nos, nitric oxide synthase
- nsaid, non-steroid anti-inflammatory drug
- ras, renin-angiotensin system
- sars-cov, severe acute respiratory syndrome coronavirus
- sh, spontaneously hypertensive
- s protein, spike protein
- sirt1, sirtuin 1
- t2dm, type 2 diabetes mellitus
- tcm, traditional chinese medicine
- tmprss2, transmembrane protease, serine 2
- tnf, tumor necrosis factor
- ufh, unfractionated heparin
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Affiliation(s)
- Murat Oz
- Department of Pharmacology and Therapeutics, Faculty of Pharmacy, Kuwait University, Safat 13110, Kuwait.
| | - Dietrich Ernst Lorke
- Department of Anatomy and Cellular Biology, College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, United Arab Emirates; Center for Biotechnology, Khalifa University of Science and Technology, Abu Dhabi, United Arab Emirates
| | - Nadine Kabbani
- School of Systems Biology, George Mason University, Fairfax, VA 22030, USA
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23
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Bartoszko JJ, Siemieniuk RAC, Kum E, Qasim A, Zeraatkar D, Martinez JPD, Azab M, Ibrahim S, Izcovich A, Soto GB, Roldan Y, Agarwal A, Agoritsas T, Chu DK, Couban R, Devji T, Foroutan F, Ghadimi M, Honarmand K, Khamis A, Lamontagne F, Loeb M, McLeod SL, Motaghi S, Murthy S, Mustafa RA, Rochwerg B, Switzer C, Thabane L, Vandvik PO, Vernooij RWM, Wang Y, Yao L, Guyatt GH, Brignardello-Petersen R. Prophylaxis against covid-19: living systematic review and network meta-analysis. BMJ 2021; 373:n949. [PMID: 33903131 PMCID: PMC8073806 DOI: 10.1136/bmj.n949] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
UPDATES This is the second version (first update) of the living systematic review, replacing the previous version (available as a data supplement). When citing this paper please consider adding the version number and date of access for clarity. OBJECTIVE To determine and compare the effects of drug prophylaxis on severe acute respiratory syndrome coronavirus virus 2 (SARS-CoV-2) infection and coronavirus disease 2019 (covid-19). DESIGN Living systematic review and network meta-analysis (NMA). DATA SOURCES World Health Organization covid-19 database, a comprehensive multilingual source of global covid-19 literature to 4 March 2022. STUDY SELECTION Randomised trials in which people at risk of covid-19 were allocated to prophylaxis or no prophylaxis (standard care or placebo). Pairs of reviewers independently screened potentially eligible articles. METHODS After duplicate data abstraction, we conducted random-effects bayesian network meta-analysis. We assessed risk of bias of the included studies using a modification of the Cochrane risk of bias 2.0 tool and assessed the certainty of the evidence using the grading of recommendations assessment, development and evaluation (GRADE) approach. RESULTS The second iteration of this living NMA includes 32 randomised trials which enrolled 25 147 participants and addressed 21 different prophylactic drugs; adding 21 trials (66%), 18 162 participants (75%) and 16 (76%) prophylactic drugs. Of the 16 prophylactic drugs analysed, none provided convincing evidence of a reduction in the risk of laboratory confirmed SARS-CoV-2 infection. For admission to hospital and mortality outcomes, no prophylactic drug proved different than standard care or placebo. Hydroxychloroquine and vitamin C combined with zinc probably increase the risk of adverse effects leading to drug discontinuation—risk difference for hydroxychloroquine (RD) 6 more per 1000 (95% credible interval (CrI) 2 more to 10 more); for vitamin C combined with zinc, RD 69 more per 1000 (47 more to 90 more), moderate certainty evidence. CONCLUSIONS Much of the evidence remains very low certainty and we therefore anticipate future studies evaluating drugs for prophylaxis may change the results for SARS-CoV-2 infection, admission to hospital and mortality outcomes. Both hydroxychloroquine and vitamin C combined with zinc probably increase adverse effects. SYSTEMATIC REVIEW REGISTRATION This review was not registered. The protocol established a priori is included as a supplement. FUNDING This study was supported by the Canadian Institutes of Health Research (grant CIHR-IRSC:0579001321).
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Affiliation(s)
- Jessica J Bartoszko
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Joint first authors
| | - Reed AC Siemieniuk
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Joint first authors
| | - Elena Kum
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Joint first authors
| | - Anila Qasim
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Joint first authors
| | - Dena Zeraatkar
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Joint first authors
| | - Juan Pablo Diaz Martinez
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Maria Azab
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Sara Ibrahim
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Ariel Izcovich
- Servicio de Clinica Médica del Hospital Alemán, Buenos Aires, Argentina
| | - Gonzalo Bravo Soto
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Yetiani Roldan
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Arnav Agarwal
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Thomas Agoritsas
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Division of General Internal Medicine & Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
| | - Derek K Chu
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Rachel Couban
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Tahira Devji
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Farid Foroutan
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Maryam Ghadimi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Kimia Honarmand
- Department of Medicine, Western University, London, ON, Canada
| | - Assem Khamis
- Wolfson Palliative Care Research Centre, Hull York Medical School, Hull, UK
| | - Francois Lamontagne
- Department of Medicine and Centre de recherche du CHU de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Mark Loeb
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Shelley L McLeod
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Sharhzad Motaghi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Srinivas Murthy
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Reem A Mustafa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Department of Medicine, University of Kansas Medical Center, Kansas City, MO, USA
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Charlotte Switzer
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Per O Vandvik
- Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Robin WM Vernooij
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Ying Wang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Liang Yao
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Romina Brignardello-Petersen
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
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24
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Ma Z, Wang MP, Liu L, Yu S, Wu TR, Zhao L, Zhang YP, Liang HF, Yang XC. Does taking an angiotensin inhibitor increase the risk for COVID-19? - a systematic review and meta-analysis. Aging (Albany NY) 2021; 13:10853-10865. [PMID: 33886504 PMCID: PMC8109111 DOI: 10.18632/aging.202902] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 01/04/2021] [Indexed: 04/08/2023]
Abstract
Because SARS-COV2 entry into cells is dependent on angiotensin converting enzyme 2 (ACE2) and angiotensin converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) increase ACE2 activity, the safety of ACEI/ARB usage during the coronavirus disease 2019 (COVID-19) pandemic is a controversial topic. To address that issue, we performed a meta-analysis following The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Searches of the Embase, MEDLINE, PubMed, and Cochrane Library databases identified 16 case-control studies examining the effect of ACEI/ARB on the incidence of COVID-19 and its severity. ACEI/ARB usage was associated with an increased risk of COVID-19 morbidity (odds ratio (OR) 1.20, 95% confidence interval (CI) 1.07-1.33, P=0.001) among the general population but not in a hypertensive population (OR 1.05, 95% CI 0.90-1.21, P=0.553). ACEI/ARB usage was not associated with an increased risk of COVID-19 morbidity (coefficient 1.00, 95% CI 1.00-1.00, P=0.660) when we adjusted for hypertension in the general population. ACEI/ARB usage was also not associated with an increased risk of severe illness (OR 0.90, 95%CI 0.55-1.47, P=0.664) or mortality (OR 1.43, 95%CI 0.97-2.10, P=0.070) in COVID-19 patients. Our meta-analysis revealed that ACEI/ARB usage was not associated with either the increased risk of SARS-COV2 infection or the adverse outcomes in COVID-19 patients.
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Affiliation(s)
- Zheng Ma
- Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Chaoyang 100020, Beijing, China
| | - Mei-Ping Wang
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Fengtai 100054, Beijing, China
| | - Lian Liu
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Fengtai 100070, Beijing, China
| | - Shuang Yu
- Yuetan Community Health Service Center, Fuxing Hospital, Capital Medical University, Xicheng 100045, Beijing, China
| | - Tian-Ran Wu
- Monash Medical Centre, Clayton, VIC 3168, Australia
| | - Lei Zhao
- Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Chaoyang 100020, Beijing, China
| | - Ye-Ping Zhang
- Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Chaoyang 100020, Beijing, China
| | - Hai-Feng Liang
- Heart Center, Fuxing Hospital, Capital Medical University, Xicheng 100038, Beijing, China
| | - Xin-Chun Yang
- Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Chaoyang 100020, Beijing, China
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25
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Lorca LA, Torres-Castro R, Ribeiro IL, Benavente P, Pizarro M, San Cristobal B, Ugarte J, Laura C, Huanchicay C, Mamani A. Linguistic Validation and Cross-Cultural Adaptation of the Post-COVID-19 Functional Status Scale for the Chilean Population. Am J Phys Med Rehabil 2021; 100:313-320. [PMID: 33496442 DOI: 10.1097/phm.0000000000001706] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Patients with COVID-19 can present functional status and disability alterations in the medium- and long-term. On the international level, a multicentered study is being carried out to validate the Post-COVID-19 Functional Status scale for different nations, thus allowing visualizing the needs for a multidisciplinary approach and planning intervention plans. The objective of this study was to perform a linguistic validation and cross-cultural adaptation of the Post-COVID-19 Functional Status scale for people infected with COVID-19 for the Chilean population. METHODS A cross-sectional study of scale validation was carried out. The study was performed in two phases: (1) forward-translation, reverse-translation and (2) apparent cross-validity adaptation. For the apparent validity analysis, 29 individuals who had been hospitalized in Hospital del Salvador with a COVID-19 infection diagnosis and at the time of the interview were in their homes participated. RESULTS In phase 1 forward-translation, an item required semantical changes. The reverse-translation versions were similar, and the most relevant doubts were resolved in a consensus meeting. In phase 2, the pilot study confirmed adequate understanding and scale applicability. CONCLUSIONS Using a systematic and rigorous methodology allowed obtaining a Spanish version of the Post-COVID-19 Functional Status scale for Chile, which is conceptually and linguistically equivalent to the original instrument and adequate to assess the functional status of people infected with COVID-19.
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Affiliation(s)
- Luz Alejandra Lorca
- From the Hospital del Salvador, Servicio de Salud Metropolitano Oriente, Santiago de Chile (LAL, PB, MP, BSC, JU, CL, CH, AM); Departamento de Kinesiología, Facultad de Medicina, Universidad de Chile, Santiago de Chile (RT-C); and Departamento de Kinesiología, Facultad de Ciencias de la Salud, Universidad Católica del Maule, Talca, Chile (ILR)
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26
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Baral R, Tsampasian V, Debski M, Moran B, Garg P, Clark A, Vassiliou VS. Association Between Renin-Angiotensin-Aldosterone System Inhibitors and Clinical Outcomes in Patients With COVID-19: A Systematic Review and Meta-analysis. JAMA Netw Open 2021; 4:e213594. [PMID: 33787911 PMCID: PMC8013817 DOI: 10.1001/jamanetworkopen.2021.3594] [Citation(s) in RCA: 81] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
IMPORTANCE The chronic receipt of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) has been assumed to exacerbate complications associated with COVID-19 and produce worse clinical outcomes. OBJECTIVE To conduct an updated and comprehensive systematic review and meta-analysis comparing mortality and severe adverse events (AEs) associated with receipt vs nonreceipt of ACEIs or ARBs among patients with COVID-19. DATA SOURCES PubMed and Embase databases were systematically searched from December 31, 2019, until September 1, 2020. STUDY SELECTION The meta-analysis included any study design, with the exception of narrative reviews or opinion-based articles, in which COVID-19 was diagnosed through laboratory or radiological test results and in which clinical outcomes (unadjusted or adjusted) associated with COVID-19 were assessed among adult patients (≥18 years) receiving ACEIs or ARBs. DATA EXTRACTION AND SYNTHESIS Three authors independently extracted data on mortality and severe AEs associated with COVID-19. Severe AEs were defined as intensive care unit admission or the need for assisted ventilation. For each outcome, a random-effects model was used to compare the odds ratio (OR) between patients receiving ACEIs or ARBs vs those not receiving ACEIs or ARBs. MAIN OUTCOMES AND MEASURES Unadjusted and adjusted ORs for mortality and severe AEs associated with COVID-19. RESULTS A total of 1788 records from the PubMed and Embase databases were identified; after removal of duplicates, 1664 records were screened, and 71 articles underwent full-text evaluation. Clinical data were pooled from 52 eligible studies (40 cohort studies, 6 case series, 4 case-control studies, 1 randomized clinical trial, and 1 cross-sectional study) enrolling 101 949 total patients, of whom 26 545 (26.0%) were receiving ACEIs or ARBs. When adjusted for covariates, significant reductions in the risk of death (adjusted OR [aOR], 0.57; 95% CI, 0.43-0.76; P < .001) and severe AEs (aOR, 0.68; 95% CI, 0.53-0.88; P < .001) were found. Unadjusted and adjusted analyses of a subgroup of patients with hypertension indicated decreases in the risk of death (unadjusted OR, 0.66 [95% CI, 0.49-0.91]; P = .01; aOR, 0.51 [95% CI, 0.32-0.84]; P = .008) and severe AEs (unadjusted OR, 0.70 [95% CI, 0.54-0.91]; P = .007; aOR, 0.55 [95% CI, 0.36-0.85]; P = .007). CONCLUSIONS AND RELEVANCE In this systematic review and meta-analysis, receipt of ACEIs or ARBs was not associated with a higher risk of multivariable-adjusted mortality and severe AEs among patients with COVID-19 who had either hypertension or multiple comorbidities, supporting the recommendations of medical societies. On the contrary, ACEIs and ARBs may be associated with protective benefits, particularly among patients with hypertension. Future randomized clinical trials are warranted to establish causality.
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Affiliation(s)
- Ranu Baral
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, United Kingdom
- Department of Cardiology, Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Vasiliki Tsampasian
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - Maciej Debski
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - Brendan Moran
- National Health Service 111 COVID-19 Clinical Assessment Service, Bicester, United Kingdom
- Neasden Medical Centre, London, United Kingdom
- Healix International, Esher, United Kingdom
| | - Pankaj Garg
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, United Kingdom
- Department of Cardiology, Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Allan Clark
- Department of Medical Statistics, Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Vassilios S. Vassiliou
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, United Kingdom
- Department of Cardiology, Norwich Medical School, University of East Anglia, Norwich, United Kingdom
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27
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Cohen JB, South AM, Shaltout HA, Sinclair MR, Sparks MA. Renin-angiotensin system blockade in the COVID-19 pandemic. Clin Kidney J 2021; 14:i48-i59. [PMID: 33796285 PMCID: PMC7929063 DOI: 10.1093/ckj/sfab026] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 01/19/2021] [Indexed: 01/08/2023] Open
Abstract
In the early months of the coronavirus disease 2019 (COVID-19) pandemic, a hypothesis emerged suggesting that pharmacologic inhibitors of the renin–angiotensin system (RAS) may increase COVID-19 severity. This hypothesis was based on the role of angiotensin-converting enzyme 2 (ACE2), a counterregulatory component of the RAS, as the binding site for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), allowing viral entry into host cells. Extrapolations from prior evidence led to speculation that upregulation of ACE2 by RAS blockade may increase the risk of adverse outcomes from COVID-19. However, counterarguments pointed to evidence of potential protective effects of ACE2 and RAS blockade with regard to acute lung injury, as well as substantial risks from discontinuing these commonly used and important medications. Here we provide an overview of classic RAS physiology and the crucial role of ACE2 in systemic pathways affected by COVID-19. Additionally, we critically review the physiologic and epidemiologic evidence surrounding the interactions between RAS blockade and COVID-19. We review recently published trial evidence and propose important future directions to improve upon our understanding of these relationships.
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Affiliation(s)
- Jordana B Cohen
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew M South
- Section of Nephrology, Department of Pediatrics, Brenner Children's Hospital, Wake Forest School of Medicine, Winston Salem, NC, USA.,Department of Epidemiology and Prevention, Division of Public Health Sciences, Wake Forest School of Medicine, Winston Salem, NC, USA.,Department of Surgery, Hypertension and Vascular Research, Wake Forest School of Medicine, Winston Salem, NC, USA.,Cardiovascular Sciences Center, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Hossam A Shaltout
- Department of Surgery, Hypertension and Vascular Research, Wake Forest School of Medicine, Winston Salem, NC, USA.,Cardiovascular Sciences Center, Wake Forest School of Medicine, Winston Salem, NC, USA.,Department of Obstetrics and Gynecology, Wake Forest School of Medicine, Winston Salem, NC, USA.,Department of Pharmacology and Toxicology, School of Pharmacy, University of Alexandria, Alexandria, Egypt
| | - Matthew R Sinclair
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | - Matthew A Sparks
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA.,Renal Section, Durham VA Health Care System, Durham, NC, USA
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Mackey K, Kansagara D, Vela K. Update Alert 7: Risks and Impact of Angiotensin-Converting Enzyme Inhibitors or Angiotensin-Receptor Blockers on SARS-CoV-2 Infection in Adults. Ann Intern Med 2021; 174:W25-W29. [PMID: 33395346 PMCID: PMC7791405 DOI: 10.7326/l20-1446] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
| | | | - Kathryn Vela
- VA Portland Health Care System, Portland, Oregon
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Peng Y, Tao H, Satyanarayanan SK, Jin K, Su H. A Comprehensive Summary of the Knowledge on COVID-19 Treatment. Aging Dis 2021; 12:155-191. [PMID: 33532135 PMCID: PMC7801274 DOI: 10.14336/ad.2020.1124] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 11/24/2020] [Indexed: 01/08/2023] Open
Abstract
Currently, the world is challenged by the coronavirus disease 2019 (COVID-19) pandemic. Epidemiologists and researchers worldwide are invariably trying to understand and combat this precarious new disease. Scrutinizing available drug options and developing potential new drugs are urgent needs to subdue this pandemic. Several intervention strategies are being considered and handled worldwide with limited success, and many drug candidates are yet in the trial phase. Despite these limitations, the development of COVID-19 treatment strategies has been accelerated to improve the clinical outcome of patients with COVID-19, and some countries have efficiently kept it under control. Recently, the use of natural and traditional medicine has also set the trend in coronavirus treatment. This review aimed to discuss the prevailing COVID-19 treatment strategies available globally by examining their efficacy, potential mechanisms, limitations, and challenges in predicting a future potential treatment candidate and bridging them with the effective traditional Chinese medicine (TCM). The findings might enrich the knowledge on traditional alternative medication and its complementary role with Western medicine in managing the COVID-19 epidemic.
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Affiliation(s)
- Yu Peng
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macao, China.
| | - Hongxun Tao
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macao, China.
| | - Senthil Kumaran Satyanarayanan
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macao, China.
| | - Kunlin Jin
- Department of Pharmacology and Neuroscience, University of North Texas Health Science Center, Fort Worth, TX 76107, USA.
| | - Huanxing Su
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macao, China.
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30
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Determinants of healing among patients with coronavirus disease 2019: the results of the SARS-RAS study of the Italian Society of Hypertension. J Hypertens 2021; 39:376-380. [PMID: 33186327 DOI: 10.1097/hjh.0000000000002666] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The burst of COVID-19 epidemics in Italy prompted the Italian Society of Hypertension to start an observational study to explore the characteristics of the hospitalized victims of the disease. The current analysis aimed to investigate the predictors of healing among Italian COVID-19 patients. We also assessed the effect of angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers on the outcome. METHODS We designed a cross-sectional, observational, multicenter, nationwide survey in Italy to explore the demographic and clinical characteristics of patients with confirmed COVID-19 infection. We analyzed information from 2446 charts of Italian patients admitted for certified COVID-19 in 27 hospitals. Healing from COVID-19 infection, defined as two consecutive negative swabs, was reported in 544 patients (22.2%), 95% of them were hospitalized. RESULTS Age and Charlson Comorbidity Index were significantly lower in healing compared with nonhealing patients (63 ± 15 vs. 69 ± 15 and 2 ± 2 vs. 3 ± 2, both P < 0.05). In multivariable regression model, predictors of healing were younger age (OR: 0.99; 95% CI 0.98-0.99, P = 0.0001), absence of chronic kidney disease (OR: 0.35; 95% CI 0.17-0.70, P = 0.003) or heart failure (OR: 0.44; 95% CI, 0.28-0.70, P = 0.001). In the subgroup of patients suffering from hypertension and/or heart failure (n = 1498), no differences were observed in the use of ACE inhibitors and angiotensin receptor blockers. CONCLUSION Our study demonstrated that younger age and absence of comorbidities play a major role in determining healing in patients with COVID-19. No effects of ACE inhibitors and angiotensin receptor blockers on the outcome was reported.
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31
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Cabezón Villalba G, Amat-Santos IJ, Dueñas C, Lopez Otero D, Catala P, Aparisi A, López-Pais J, Cacho Antonio CE, Candela J, Antúnez Muiños P, Gil JF, Gonzalez Ferrero T, Marcos M, Pérez-Poza M, Rojas G, Otero Garcia O, Veras C, Jiménez Ramos V, Uribarri A, Revilla A, Garcia-Granja PE, Gómez I, González-Juanatey JR, San Román JA. Impact of the presence of heart disease, cardiovascular medications and cardiac events on outcome in COVID-19. Cardiol J 2021; 28:360-368. [PMID: 33843043 PMCID: PMC8169179 DOI: 10.5603/cj.a2021.0034] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 02/23/2021] [Accepted: 02/25/2021] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Cardiovascular risk factors and usage of cardiovascular medication are prevalent among coronavirus disease 2019 (COVID-19) patients. Little is known about the cardiovascular implications of COVID-19. The goal herein, was to evaluate the prognostic impact of having heart disease (HD) and taking cardiovascular medications in a population diagnosed of COVID-19 who required hospitalization. Also, we studied the development of cardiovascular events during hospitalization. METHODS Consecutive patients with definitive diagnosis of COVID-19 made by a positive real time- -polymerase chain reaction of nasopharyngeal swabs who were admitted to the hospital from March 15 to April 14 were included in a retrospective registry. The association of HD with mortality and with mortality or respiratory failure were the primary and secondary objectives, respectively. RESULTS A total of 859 patients were included in the present analysis. Cardiovascular risk factors were related to death, particularly diabetes mellitus (hazard ratio in the multivariate analysis: 1.810 [1.159- -2.827], p = 0.009). A total of 113 (13.1%) patients had HD. The presence of HD identified a group of patients with higher mortality (35.4% vs. 18.2%, p < 0.001) but HD was not independently related to prognosis; renin-angiotensin-aldosterone system inhibitors, calcium channel blockers, diuretics and beta-blockers did not worsen prognosis. Statins were independently associated with decreased mortality (0.551 [0.329-0.921], p = 0.023). Cardiovascular events during hospitalization identified a group of patients with poor outcome (mortality 31.8% vs. 19.3% without cardiovascular events, p = 0.007). CONCLUSIONS The presence of HD is related to higher mortality. Cardiovascular medications taken before admission are not harmful, statins being protective. The development of cardiovascular events during the course of the disease is related to poor outcome.
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Affiliation(s)
- Gonzalo Cabezón Villalba
- Department of Cardiology, Institute of Heart Sciences (ICICOR), Hospital Clínico Universitario, Valladolid, Spain
| | - Ignacio J Amat-Santos
- Department of Cardiology, Institute of Heart Sciences (ICICOR), Hospital Clínico Universitario, Valladolid, Spain
| | - Carlos Dueñas
- Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Diego Lopez Otero
- Complejo Hospitalario Universitario de Santiago de Compostela, Rua da Choupana s/n, 15702 Santiago de Compostela, Spain
| | - Pablo Catala
- Department of Cardiology, Institute of Heart Sciences (ICICOR), Hospital Clínico Universitario, Valladolid, Spain
| | - Alvaro Aparisi
- Department of Cardiology, Institute of Heart Sciences (ICICOR), Hospital Clínico Universitario, Valladolid, Spain
| | - Javier López-Pais
- Complejo Hospitalario Universitario de Santiago de Compostela, Rua da Choupana s/n, 15702 Santiago de Compostela, Spain
| | - Carla Eugenia Cacho Antonio
- Complejo Hospitalario Universitario de Santiago de Compostela, Rua da Choupana s/n, 15702 Santiago de Compostela, Spain
| | - Jordi Candela
- Department of Cardiology, Institute of Heart Sciences (ICICOR), Hospital Clínico Universitario, Valladolid, Spain
| | - Pablo Antúnez Muiños
- Complejo Hospitalario Universitario de Santiago de Compostela, Rua da Choupana s/n, 15702 Santiago de Compostela, Spain
| | - Jose Francisco Gil
- Department of Cardiology, Institute of Heart Sciences (ICICOR), Hospital Clínico Universitario, Valladolid, Spain
| | - Teba Gonzalez Ferrero
- Complejo Hospitalario Universitario de Santiago de Compostela, Rua da Choupana s/n, 15702 Santiago de Compostela, Spain
| | - Marta Marcos
- Department of Cardiology, Institute of Heart Sciences (ICICOR), Hospital Clínico Universitario, Valladolid, Spain
| | - Marta Pérez-Poza
- Complejo Hospitalario Universitario de Santiago de Compostela, Rua da Choupana s/n, 15702 Santiago de Compostela, Spain
| | - Gino Rojas
- Department of Cardiology, Institute of Heart Sciences (ICICOR), Hospital Clínico Universitario, Valladolid, Spain
| | - Oscar Otero Garcia
- Complejo Hospitalario Universitario de Santiago de Compostela, Rua da Choupana s/n, 15702 Santiago de Compostela, Spain
| | - Carlos Veras
- Department of Cardiology, Institute of Heart Sciences (ICICOR), Hospital Clínico Universitario, Valladolid, Spain
| | - Victor Jiménez Ramos
- Complejo Hospitalario Universitario de Santiago de Compostela, Rua da Choupana s/n, 15702 Santiago de Compostela, Spain
| | - Aitor Uribarri
- Department of Cardiology, Institute of Heart Sciences (ICICOR), Hospital Clínico Universitario, Valladolid, Spain
| | - Ana Revilla
- Department of Cardiology, Institute of Heart Sciences (ICICOR), Hospital Clínico Universitario, Valladolid, Spain
| | - Pablo Elpidio Garcia-Granja
- Department of Cardiology, Institute of Heart Sciences (ICICOR), Hospital Clínico Universitario, Valladolid, Spain
| | - Itziar Gómez
- Department of Cardiology, Institute of Heart Sciences (ICICOR), Hospital Clínico Universitario, Valladolid, Spain
| | - José Ramón González-Juanatey
- Complejo Hospitalario Universitario de Santiago de Compostela, Rua da Choupana s/n, 15702 Santiago de Compostela, Spain
| | - J Alberto San Román
- Department of Cardiology, Institute of Heart Sciences (ICICOR), Hospital Clínico Universitario, Valladolid, Spain.
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Rezkalla SH, Kloner RA. Viral myocarditis: 1917-2020: From the Influenza A to the COVID-19 pandemics. Trends Cardiovasc Med 2020; 31:163-169. [PMID: 33383171 PMCID: PMC7965406 DOI: 10.1016/j.tcm.2020.12.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 12/03/2020] [Accepted: 12/21/2020] [Indexed: 12/12/2022]
Abstract
Myocarditis is common during viral infection with cases described as early as the influenza pandemic of 1917, and the current COVID-19 pandemic is no exception. The hallmark is elevated troponin, which occurs in 36% of COVID patients, with electrocardiogram, echocardiogram, and cardiac magnetic resonance being valuable tools to assist in diagnosis. Cardiac inflammation may occur secondary to direct cardiac invasion with the virus, or to intense cytokine storm, often encountered during the course of the disease. Angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and judicious use of beta-blockers are beneficial in management of myocarditis. Corticosteroids may be avoided during the very early phase of viral replication, but can be of clear benefit in hospitalized, critically ill patients. Statins are beneficial to shorten the course of the disease and may decrease mortality.
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Affiliation(s)
- Shereif H Rezkalla
- Department of Cardiology & Cardiovascular Research, Marshfield Clinic Health System, 1000 North Oak Avenue, Marshfield, WI 54449 USA; Adjunct Professor, University of Wisconsin, School of Medicine USA.
| | - Robert A Kloner
- Chief Science Officer, Scientific Director of Cardiovascular Research Institute, Huntington Medical Research Institutes, Pasadena, CA USA; Professor of Medicine (Clinical Scholar), Cardiovascular Division, Dept. of Medicine, Keck School of Medicine of University of Southern California, Los Angeles, CA USA.
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Chu C, Zeng S, Hasan AA, Hocher CF, Krämer BK, Hocher B. Comparison of infection risks and clinical outcomes in patients with and without SARS-CoV-2 lung infection under renin-angiotensin-aldosterone system blockade: Systematic review and meta-analysis. Br J Clin Pharmacol 2020; 87:2475-2492. [PMID: 33217033 PMCID: PMC7753617 DOI: 10.1111/bcp.14660] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 10/28/2020] [Accepted: 11/10/2020] [Indexed: 02/06/2023] Open
Abstract
Aims Angiotensin‐converting enzyme‐2 (ACE2) is the receptor for SARS‐CoV‐2. Animal studies suggest that renin–angiotensin–aldosterone system (RAAS) blockers might increase the expression of ACE2 and potentially increase the risk of SARS‐CoV‐2 infection. Methods and Results The effect of ACE inhibitor (ACEI) treatment on the pneumonia incidence in non‐COVID‐19 patients (25 studies, 330 780 patients) was associated with a 26% reduction of pneumonia risk (odds ratio [OR]: 0.74, P < .001). Pneumonia‐related death cases in ACEI‐treated non‐COVID‐19 patients were reduced by 27% (OR: 0.73, P = .004). However, angiotensin II receptor blockers (ARB) treatment (10 studies, 275 621 non‐COVID‐19 patients) did not alter pneumonia risk in patients. Pneumonia‐related death cases in ARB‐treated non‐COVID‐19 patients was analysed only in 1 study and was significantly reduced (OR, 0.47; 95% confidence interval, 0.30 to 0.72). Results from 11 studies (8.4 million patients) showed that the risk of getting infected with the SARS‐CoV‐2 virus was reduced by 13% (OR: 0.87, P = .014) in patients treated with ACEI, whereas analysis from 10 studies (8.4 million patients) treated with ARBs showed no effect (OR, 0.92, P = .354). Results from 34 studies in 67 644 COVID‐19 patients showed that RAAS blockade reduces all‐cause mortality by 24% (OR = 0.76, P = .04). Conclusion ACEIs reduce the risk of getting infected with the SARS‐CoV‐2 virus. Blocking the RAAS may decrease all‐cause mortality in COVID‐19 patients. ACEIs also reduce the risk of non‐COVID pneumonia. All‐cause mortality due to non‐COVID pneumonia is reduced by ACEI and potentially by ARBs.
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Affiliation(s)
- Chang Chu
- Fifth Department of Medicine (Nephrology/Endocrinology/Rheumatology), University Medical Centre Mannheim, University of Heidelberg, Germany.,Department of Nephrology, Charité-Universitätsmedizin Berlin, Campus Mitte, Berlin, Germany
| | - Shufei Zeng
- Fifth Department of Medicine (Nephrology/Endocrinology/Rheumatology), University Medical Centre Mannheim, University of Heidelberg, Germany.,Department of Nephrology, Charité-Universitätsmedizin Berlin, Campus Mitte, Berlin, Germany
| | - Ahmed A Hasan
- Fifth Department of Medicine (Nephrology/Endocrinology/Rheumatology), University Medical Centre Mannheim, University of Heidelberg, Germany.,Department of Nutritional Toxicology, Institute of Nutritional Science, University of Potsdam, Nuthetal, Germany.,Department of Biochemistry, Faculty of Pharmacy, Zagazig University, Egypt
| | - Carl-Friedrich Hocher
- Fifth Department of Medicine (Nephrology/Endocrinology/Rheumatology), University Medical Centre Mannheim, University of Heidelberg, Germany
| | - Bernhard K Krämer
- Fifth Department of Medicine (Nephrology/Endocrinology/Rheumatology), University Medical Centre Mannheim, University of Heidelberg, Germany.,European Center of Angioscience, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - Berthold Hocher
- Fifth Department of Medicine (Nephrology/Endocrinology/Rheumatology), University Medical Centre Mannheim, University of Heidelberg, Germany.,Key Laboratory of Study and Discovery of Small Targeted Molecules of Hunan Province, School of Medicine, Hunan Normal University, Changsha, China.,Reproductive and Genetic Hospital of CITIC-Xiangya, Changsha, China.,IMD Institut für Medizinische Diagnostik Berlin-Potsdam GbR, Berlin, Germany
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Dillman A, Park JJH, Zoratti MJ, Zannat NE, Lee Z, Dron L, Hsu G, Smith G, Khakabimamaghani S, Harari O, Thorlund K, Mills EJ. Reporting and design of randomized controlled trials for COVID-19: A systematic review. Contemp Clin Trials 2020; 101:106239. [PMID: 33279656 PMCID: PMC7834682 DOI: 10.1016/j.cct.2020.106239] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 11/09/2020] [Accepted: 11/30/2020] [Indexed: 12/23/2022]
Abstract
Background The novel coronavirus 2019 (COVID-19) pandemic has mobilized global research at an unprecedented scale. While challenges associated with the COVID-19 trial landscape have been discussed previously, no comprehensive reviews have been conducted to assess the reporting, design, and data sharing practices of randomized controlled trials (RCTs). Purpose The purpose of this review was to gain insight into the current landscape of reporting, methodological design, and data sharing practices for COVID-19 RCTs. Data sources We conducted three searches to identify registered clinical trials, peer-reviewed publications, and pre-print publications. Study selection After screening eight major trial registries and 7844 records, we identified 178 registered trials and 38 publications describing 35 trials, including 25 peer-reviewed publications and 13 pre-prints. Data extraction Trial ID, registry, location, population, intervention, control, study design, recruitment target, actual recruitment, outcomes, data sharing statement, and time of data sharing were extracted. Data synthesis Of 178 registered trials, 112 (62.92%) were in hospital settings, median planned recruitment was 100 participants (IQR: 60, 168), and the majority (n = 166, 93.26%) did not report results in their respective registries. Of 35 published trials, 31 (88.57%) were in hospital settings, median actual recruitment was 86 participants (IQR: 55.5, 218), 10 (28.57%) did not reach recruitment targets, and 27 trials (77.14%) reported plans to share data. Conclusions The findings of our study highlight limitations in the design and reporting practices of COVID-19 RCTs and provide guidance towards more efficient reporting of trial results, greater diversity in patient settings, and more robust data sharing.
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Affiliation(s)
- Alison Dillman
- School of Public Health, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Jay J H Park
- Department of Experimental Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Michael J Zoratti
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Noor-E Zannat
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Zelyn Lee
- Department of Physiology & Department of Neuroscience, University of Toronto, Toronto, Canada
| | - Louis Dron
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Grace Hsu
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Gerald Smith
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | | | - Ofir Harari
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Kristian Thorlund
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Edward J Mills
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
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Caldeira D, Alves M, Gouveia e Melo R, Silvério António P, Cunha N, Nunes-Ferreira A, Prada L, Costa J, Pinto FJ. Angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers and the risk of COVID-19 infection or severe disease: Systematic review and meta-analysis. IJC HEART & VASCULATURE 2020; 31:100627. [PMID: 32875060 PMCID: PMC7451091 DOI: 10.1016/j.ijcha.2020.100627] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/11/2020] [Accepted: 08/20/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Animal studies suggested that angiotensin-converting enzyme inhibitors (ACEi) and angiotensin-receptor blockers (ARB) facilitate the inoculation of potentially leading to a higher risk of infection and/or disease severity. We aimed to systematically evaluate the risk of COVID-19 infection and the risk of severe COVID-19 disease associated with previous exposure to (ACEi) and/or ARB). METHODS MEDLINE, CENTRAL, PsycINFO, Web of Science Core Collection were searched in June 2020 for controlled studies. Eligible studies were included and random-effects meta-analyses were performed. The estimates were expressed as odds ratios (OR) and 95% confidence intervals (95%CI). Heterogeneity was assessed with I2 test. The confidence in the pooled evidence was appraised using the GRADE framework. RESULTS Twenty-seven studies were included in the review. ACEi/ARB exposure did not increase the risk of having a positive test for COVID-19 infection (OR 0.99, 95%CI 0.89-1.11; I2 = 36%; 5 studies, GRADE confidence moderate). The exposure to ACEi/ARB did not increase the risk of all-cause mortality among patients with COVID-19 (OR 0.91, 95%CI 0.74-1.11; I2 = 20%; 17 studies; GRADE confidence low) nor severe/critical COVID-19 disease (OR 0.90, 95%CI 0.74-1.11; I2 = 55%; 17 studies; GRADE confidence very low). Exploratory analyses in studies enrolling hypertensive patients showed a association of ACEi/ARB with a significant decrease of mortality risk. CONCLUSIONS ACEi/ARB exposure does not seem to increase the risk of having the SARS-CoV-2 infection or developing severe stages of the disease including mortality. The potential benefits observed in mortality of hypertensive patients reassure safety, but robust studies are required to increase the confidence in the results.
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Affiliation(s)
- Daniel Caldeira
- Centro Cardiovascular da Universidade de Lisboa (CCUL), Faculdade de Medicina, Univerisdade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisboa, Portugal
- Cardiology Department, Hospital Universitário de Santa Maria (CHULN), Avenida Professor Egas Moniz, 1649-028 Lisboa, Portugal
- Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Avenida Professor Egas Moniz, 1649-028 Lisboa, Portugal
| | - Mariana Alves
- Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Avenida Professor Egas Moniz, 1649-028 Lisboa, Portugal
- Serviço de Medicina III, Hospital Pulido Valente (CHULN), Lisboa, Portugal
- Instituto de Medicina Molecular, Faculty of Medicine, University of Lisbon, Lisboa, Portugal
| | - Ryan Gouveia e Melo
- Centro Cardiovascular da Universidade de Lisboa (CCUL), Faculdade de Medicina, Univerisdade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisboa, Portugal
- Vascular Surgery Department, Hospital Santa Maria, Centro Hospitalar Universitário Lisboa Norte (CHULN), Avenida Professor Egas Moniz, 1649-028 Lisboa, Portugal
| | - Pedro Silvério António
- Centro Cardiovascular da Universidade de Lisboa (CCUL), Faculdade de Medicina, Univerisdade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisboa, Portugal
- Cardiology Department, Hospital Universitário de Santa Maria (CHULN), Avenida Professor Egas Moniz, 1649-028 Lisboa, Portugal
| | - Nélson Cunha
- Centro Cardiovascular da Universidade de Lisboa (CCUL), Faculdade de Medicina, Univerisdade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisboa, Portugal
- Cardiology Department, Hospital Universitário de Santa Maria (CHULN), Avenida Professor Egas Moniz, 1649-028 Lisboa, Portugal
| | - Afonso Nunes-Ferreira
- Centro Cardiovascular da Universidade de Lisboa (CCUL), Faculdade de Medicina, Univerisdade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisboa, Portugal
- Cardiology Department, Hospital Universitário de Santa Maria (CHULN), Avenida Professor Egas Moniz, 1649-028 Lisboa, Portugal
| | - Luisa Prada
- Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Avenida Professor Egas Moniz, 1649-028 Lisboa, Portugal
| | - João Costa
- Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Avenida Professor Egas Moniz, 1649-028 Lisboa, Portugal
- Instituto de Medicina Molecular, Faculty of Medicine, University of Lisbon, Lisboa, Portugal
| | - Fausto J Pinto
- Centro Cardiovascular da Universidade de Lisboa (CCUL), Faculdade de Medicina, Univerisdade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisboa, Portugal
- Cardiology Department, Hospital Universitário de Santa Maria (CHULN), Avenida Professor Egas Moniz, 1649-028 Lisboa, Portugal
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Hasan SS, Kow CS, Hadi MA, Zaidi STR, Merchant HA. Mortality and Disease Severity Among COVID-19 Patients Receiving Renin-Angiotensin System Inhibitors: A Systematic Review and Meta-analysis. Am J Cardiovasc Drugs 2020; 20:571-590. [PMID: 32918209 PMCID: PMC7486167 DOI: 10.1007/s40256-020-00439-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The use of renin-angiotensin system (RAS) inhibitors, including angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), was alleged to cause a more severe course of novel coronavirus disease 2019 (COVID-19). METHODS We systematically reviewed the published studies to assess the association of RAS inhibitors with mortality as well as disease severity in COVID-19 patients. A systematic literature search was performed to retrieve relevant original studies investigating mortality and severity (severe/critical disease) in COVID-19 patients with and without exposure to RAS inhibitors. RESULTS A total of 59 original studies were included for qualitative synthesis. Twenty-four studies that reported adjusted effect sizes (24 studies reported mortality outcomes and 16 studies reported disease severity outcomes), conducted in RAS inhibitor-exposed and unexposed groups, were pooled in random-effects models to estimate overall risk. Quality assessment of studies revealed that most of the studies included were of fair quality. The use of an ACEI/ARB in COVID-19 patients was significantly associated with lower odds (odds ratio [OR] = 0.73, 95% confidence interval [CI] 0.56-0.95; n = 18,749) or hazard (hazard ratio [HR] = 0.75, 95% CI 0.60-0.95; n = 26,598) of mortality compared with non-use of ACEI/ARB. However, the use of an ACEI/ARB was non-significantly associated with lower odds (OR = 0.91, 95% CI 0.75-1.10; n = 7446) or hazard (HR = 0.73, 95% CI 0.33-1.66; n = 6325) of developing severe/critical disease compared with non-use of an ACEI/ARB. DISCUSSION Since there was no increased risk of harm, the use of RAS inhibitors for hypertension and other established clinical indications can be maintained in COVID-19 patients.
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Affiliation(s)
- Syed Shahzad Hasan
- Department of Pharmacy, University of Huddersfield, Huddersfield, HD1 3DH, UK.
| | - Chia Siang Kow
- School of Postgraduate Studies, International Medical University, Kuala Lumpur, 57000, Malaysia
| | - Muhammad Abdul Hadi
- Institute of Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Syed Tabish Razi Zaidi
- School of Healthcare, University of Leeds, Leeds, LS2 9JT, UK
- Leeds Teaching Hospitals NHS Trust, Leeds, LS2 9JT, UK
| | - Hamid A Merchant
- Department of Pharmacy, University of Huddersfield, Huddersfield, HD1 3DH, UK
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Coronavirus and Cardiovascular Disease, Myocardial Injury, and Arrhythmia: JACC Focus Seminar. J Am Coll Cardiol 2020; 76:2011-2023. [PMID: 33092737 PMCID: PMC7572122 DOI: 10.1016/j.jacc.2020.08.059] [Citation(s) in RCA: 139] [Impact Index Per Article: 34.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/10/2020] [Accepted: 08/18/2020] [Indexed: 02/06/2023]
Abstract
The cardiovascular system is affected broadly by severe acute respiratory syndrome coronavirus 2 infection. Both direct viral infection and indirect injury resulting from inflammation, endothelial activation, and microvascular thrombosis occur in the context of coronavirus disease 2019. What determines the extent of cardiovascular injury is the amount of viral inoculum, the magnitude of the host immune response, and the presence of co-morbidities. Myocardial injury occurs in approximately one-quarter of hospitalized patients and is associated with a greater need for mechanical ventilator support and higher hospital mortality. The central pathophysiology underlying cardiovascular injury is the interplay between virus binding to the angiotensin-converting enzyme 2 receptor and the impact this action has on the renin-angiotensin system, the body’s innate immune response, and the vascular response to cytokine production. The purpose of this review was to describe the mechanisms underlying cardiovascular injury, including that of thromboembolic disease and arrhythmia, and to discuss their clinical sequelae. The cardiovascular system is affected in diverse ways by severe acute respiratory syndrome coronavirus 2 infection (COVID-19). Myocardial injury can be detected in ∼25% of hospitalized patients with COVID-19 and is associated with an increased risk of mortality. Described mechanisms of myocardial injury in patients with COVID-19 include oxygen supply–demand imbalance, direct viral myocardial invasion, inflammation, coronary plaque rupture with acute myocardial infarction, microvascular thrombosis, and adrenergic stress.
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Gillette M, Bozkurt B. Ins and Outs: Perspectives of Inpatient Prescribing for Sacubitril/Valsartan. Ann Pharmacother 2020; 55:805-813. [PMID: 33111533 DOI: 10.1177/1060028020964923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Heart failure is a major public health concern with a rising prevalence and significant financial detriment. Although sacubitril/valsartan was shown to reduce the risk of death and hospitalization from heart failure in a contemporary cohort, it continues to remain substantially underutilized. A recent article in the Annals highlights the evidence behind inpatient initiation of sacubitril/valsartan. We provide further considerations and summarize the evidence for inpatient initiation of other guideline directed medical therapies. Overall, there is a need to improve methods to identify ideal populations and increase utilization in those who may benefit from sacubitril/valsartan. Further research is also needed to identify the risks versus benefits among underrepresented populations (i.e., advanced heart failure, heart failure with preserved ejection fraction, in conjunction with other contemporary evidence-based therapies that can lower blood pressure, etc.).
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Affiliation(s)
- Michael Gillette
- Michael DeBakey VA Medical Center & Baylor College of Medicine, Houston, TX, USA
| | - Biykem Bozkurt
- Michael DeBakey VA Medical Center & Baylor College of Medicine, Houston, TX, USA
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Wang Y, Tse G, Li G, Lip GYH, Liu T. ACE Inhibitors and Angiotensin II Receptor Blockers May Have Different Impact on Prognosis of COVID-19. J Am Coll Cardiol 2020; 76:2041. [PMID: 33092742 PMCID: PMC7572104 DOI: 10.1016/j.jacc.2020.07.068] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/04/2020] [Accepted: 07/07/2020] [Indexed: 11/28/2022]
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Reply: ACE Inhibitors and Angiotensin II Receptor Blockers May Have Different Impact on Prognosis of COVID-19. J Am Coll Cardiol 2020; 76:2042. [PMID: 33092743 PMCID: PMC7572061 DOI: 10.1016/j.jacc.2020.08.064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 08/20/2020] [Indexed: 11/20/2022]
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41
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Kerneis M, Ferrante A, Guedeney P, Vicaut E, Montalescot G. Severe acute respiratory syndrome coronavirus 2 and renin-angiotensin system blockers: A review and pooled analysis. Arch Cardiovasc Dis 2020; 113:797-810. [PMID: 33199208 PMCID: PMC7580526 DOI: 10.1016/j.acvd.2020.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 08/26/2020] [Accepted: 09/07/2020] [Indexed: 01/08/2023]
Abstract
A novel coronavirus called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is causing an international outbreak of respiratory illness described as coronavirus disease 2019 (COVID-19). SARS-CoV-2 infects human cells by binding to angiotensin-converting enzyme 2. Small studies suggest that renin-angiotensin system (RAS) blockers may upregulate the expression of angiotensin-converting enzyme 2, affecting susceptibility to SARS-CoV-2. This may be of great importance considering the large number of patients worldwide who are treated with RAS blockers, and the well-proven clinical benefit of these treatments in several cardiovascular conditions. In contrast, RAS blockers have also been associated with better outcomes in pneumonia models, and may be beneficial in COVID-19. This review sought to analyse the evidence regarding RAS blockers in the context of COVID-19 and to perform a pooled analysis of the published observational studies to guide clinical decision making. A total of 21 studies were included, comprising 11,539 patients, of whom 3417 (29.6%) were treated with RAS blockers. All-cause mortality occurred in 587/3417 (17.1%) patients with RAS blocker treatment and in 982/8122 (12.1%) patients without RAS blocker treatment (odds ratio 1.00, 95% confidence interval 0.69-1.45; P=0.49; I2=84%). As several hypotheses can be drawn from experimental analysis, we also present the ongoing randomized studies assessing the efficacy and safety of RAS blockers in patients with COVID-19. In conclusion, according to the current data and the results of the pooled analysis, there is no evidence supporting any harmful effect of RAS blockers on the course of patients with COVID-19, and it seems reasonable to recommend their continuation.
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Affiliation(s)
- Mathieu Kerneis
- Sorbonne université, ACTION Study Group, INSERM UMRS 1166, institute of cardiology, hôpital Pitié-Salpêtrière, AP-HP, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - Arnaud Ferrante
- Sorbonne université, ACTION Study Group, INSERM UMRS 1166, institute of cardiology, hôpital Pitié-Salpêtrière, AP-HP, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - Paul Guedeney
- Sorbonne université, ACTION Study Group, INSERM UMRS 1166, institute of cardiology, hôpital Pitié-Salpêtrière, AP-HP, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - Eric Vicaut
- ACTION Study Group, unité de recherche clinique, hôpital Saint-Louis, AP-HP, université de Paris, 75010 Paris, France
| | - Gilles Montalescot
- Sorbonne université, ACTION Study Group, INSERM UMRS 1166, institute of cardiology, hôpital Pitié-Salpêtrière, AP-HP, 47-83, boulevard de l'Hôpital, 75013 Paris, France.
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Casucci G, Acanfora D, Incalzi RA. The Cross-Talk between Age, Hypertension and Inflammation in COVID-19 Patients: Therapeutic Targets. Drugs Aging 2020; 37:779-785. [PMID: 33084001 PMCID: PMC7575413 DOI: 10.1007/s40266-020-00808-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2020] [Indexed: 01/10/2023]
Abstract
This paper presents a brief overview of the complex interaction between age, hypertension, the renin–angiotensin–aldosterone system (RAAS), inflammation, and severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection. Coronavirus disease 2019 (COVID-19) is more frequent and more severe in comorbid elderly patients, especially those with hypertension, diabetes, obesity, or cardiovascular diseases. There are concerns regarding the use of RAAS inhibitors in patients with COVID-19. Some physicians have considered the need for interrupting RAAS inhibition in order to reduce the possibility of SARS-CoV2 entering lung cells after binding to angiotensin-converting enzyme 2 (ACE2) receptors. We offer a different point of view in relation to the need for continuing to use RAAS inhibitors in patients with COVID-19. We focused our article on elderly patients because of the distinctive imbalance between the immune response, which is depressed, and the exacerbated inflammatory response, ‘inflammaging’, which makes the geriatric patient an appropriate candidate for therapeutic strategies aimed at modulating the inflammatory response. Indeed, COVID-19 is an inflammatory storm that starts and worsens during the course of the disease. During the COVID-19 pandemic, various therapeutic approaches have been tested, including antiviral drugs, interferon, anti-interleukins, hydroxychloroquine, anti-inflammatories, immunoglobulins from recovered patients, and heparins. Some of these therapeutic approaches did not prove to be beneficial, or even induced serious complications. Based on current evidence, in the early stages of the disease modulation of the inflammatory response through the inhibition of neprilysin and modulation of the RAAS could affect the course and outcome of COVID-19.
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Affiliation(s)
- Gerardo Casucci
- Unit of Internal Medicine, San Francesco Hospital, Viale Europa 21, 82037, Telese Terme, BN, Italy
| | - Domenico Acanfora
- Unit of Internal Medicine, San Francesco Hospital, Viale Europa 21, 82037, Telese Terme, BN, Italy.
| | - Raffaele Antonelli Incalzi
- Unit of Geriatrics, Policlinico Universitario Campus Bio-Medico di Roma, Via Álvaro del Portillo 21, 00128, Rome, Italy
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The Controversy of Renin-Angiotensin-System Blocker Facilitation Versus Countering COVID-19 Infection. J Cardiovasc Pharmacol 2020; 76:397-406. [PMID: 32769760 DOI: 10.1097/fjc.0000000000000894] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The ongoing COVID-19 pandemic has produced serious turmoil world-wide. Lung injury causing acute respiratory distress syndrome seems to be a most dreaded complication occurring in ∼30%. Older patients with cardiovascular comorbidities and acute respiratory distress syndrome have an increased mortality. Although the precise mechanisms involved in the development of lung injury have not been fully elucidated, the role of the extended renin-angiotensin system seems to be pivotal. In this context, angiotensin-converting enzyme 2 (ACE2), an angiotensin-converting enzyme homologue, has been recognized as a facilitator of viral entry into the host, albeit its involvement in other counter-regulatory effects, such as converting angiotensin (Ang) II into Ang 1-7 with its known protective actions. Thus, concern was raised that the use of renin-angiotensin system inhibitors by increasing ACE2 expression may enhance patient susceptibility to the COVID-19 virus. However, current data have appeased such concerns because there has been no clinical evidence of a harmful effect of these agents as based on observational studies. However, properly designed future studies will be needed to further confirm or refute current evidence. Furthermore, other pathways may also play important roles in COVID-19 transmission and pathogenesis; spike (S) protein proteases facilitate viral transmission by cleaving S protein that promotes viral entry into the host; neprilysin (NEP), a neutral endopeptidase known to cleave natriuretic peptides, degrades Ang I into Ang 1-7; NEP can also catabolize bradykinin and thus mitigate bradykinin's role in inflammation, whereas, in the same context, specific bradykinin inhibitors may also negate bradykinin's harmful effects. Based on these intricate mechanisms, various preventive and therapeutic strategies may be devised, such as upregulating ACE2 and/or using recombinant ACE2, and exploiting the NEP, bradykinin and serine protease pathways, in addition to anti-inflammatory and antiviral therapies. These issues are herein reviewed, available studies are tabulated and pathogenetic mechanisms are pictorially illustrated.
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Mackey K, Kansagara D, Vela K. Update Alert 3: Risks and Impact of Angiotensin-Converting Enzyme Inhibitors or Angiotensin-Receptor Blockers on SARS-CoV-2 Infection in Adults. Ann Intern Med 2020; 173:130-131. [PMID: 32845705 PMCID: PMC7472718 DOI: 10.7326/l20-1068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Affiliation(s)
- Katherine Mackey
- VA Portland Health Care System, Portland, Oregon (K.M., D.K., K.V.)
| | - Devan Kansagara
- VA Portland Health Care System, Portland, Oregon (K.M., D.K., K.V.)
| | - Kathryn Vela
- VA Portland Health Care System, Portland, Oregon (K.M., D.K., K.V.)
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45
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Ye Q, Lu D, Shang S, Fu J, Gong F, Shu Q, Mao J. Crosstalk between coronavirus disease 2019 and cardiovascular disease and its treatment. ESC Heart Fail 2020; 7:3464-3472. [PMID: 32935928 PMCID: PMC7754975 DOI: 10.1002/ehf2.12960] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 07/20/2020] [Accepted: 07/30/2020] [Indexed: 02/06/2023] Open
Abstract
People with cardiovascular disease (CVD) often contract coronavirus disease 2019 (COVID-19). However, the interaction between COVID-19 and CVD is unclear. In this systematic review, the available evidence for the crosstalk between COVID-19 and CVD and its treatment was analysed. A search was performed in the electronic databases MEDLINE and EMBASE. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infects human cells via angiotensin-converting enzyme 2. SARS-CoV-2 can cause CVD by inducing cytokine storms, creating an imbalance in the oxygen supply and demand and disrupting the renin-angiotensin-aldosterone system; SARS-CoV-2 infection can also lead to the development of CVD through the side effects of therapeutic drugs, psychological factors, and aggravation of underlying CVD. The most common CVDs caused by SARS-CoV-2 infection are acute myocardial injury, arrhythmia, and heart failure. Studies have found that there is an interaction between COVID-19 and CVD. Underlying CVD is associated with a high risk of mortality in patients with COVID-19. SARS-CoV-2 infection can also cause new-onset CVD. Clinicians need to pay close attention to cardiovascular complications during the diagnosis and treatment of patients with COVID-19 to reduce patient mortality.
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Affiliation(s)
- Qing Ye
- National Clinical Research Center for Child Health, National Children's Regional Medical Center, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, 310052, China
| | - Dezhao Lu
- College of Life Science, Zhejiang Chinese Medical University, Hangzhou, China
| | - Shiqiang Shang
- National Clinical Research Center for Child Health, National Children's Regional Medical Center, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, 310052, China
| | - Junfen Fu
- National Clinical Research Center for Child Health, National Children's Regional Medical Center, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, 310052, China
| | - Fangqi Gong
- National Clinical Research Center for Child Health, National Children's Regional Medical Center, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, 310052, China
| | - Qiang Shu
- National Clinical Research Center for Child Health, National Children's Regional Medical Center, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, 310052, China
| | - Jianhua Mao
- National Clinical Research Center for Child Health, National Children's Regional Medical Center, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, 310052, China
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Zhang J, Wang M, Ding W, Wan J. The interaction of RAAS inhibitors with COVID-19: Current progress, perspective and future. Life Sci 2020; 257:118142. [PMID: 32712300 PMCID: PMC7377983 DOI: 10.1016/j.lfs.2020.118142] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 07/13/2020] [Accepted: 07/21/2020] [Indexed: 12/15/2022]
Abstract
Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is currently defined as the worst pandemic disease. SARS-CoV-2 infects human cells via the binding of its S protein to the receptor angiotensin-converting enzyme (ACE2). The use of ACEIs/ARBs (RAAS inhibitors) regulates the renin-angiotensin-aldosterone system (RAAS) and may increase ACE2 expression. Considering the large use of ACEIs/ARBs in hypertensive patients, some professional groups are concerned about whether the use of RAAS inhibitors affects the risk of SARS-CoV-2 infection or the risk of severe illness and mortality in COVID-19 patients. In this review, we summarize preclinical and clinical studies to investigate whether the use of ACEIs/ARBs increases ACE2 expression in animals or patients. We also analyzed whether the use of these drugs affects the risk of SARS-CoV-2 infection, severe illness or mortality based on recent studies. Finally, the review suggests that current evidence does not support the concerns.
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Affiliation(s)
| | | | | | - Jun Wan
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, China; Cardiovascular Research Institute, Wuhan University, Wuhan, China; Hubei Key Laboratory of Cardiology, Wuhan, China.
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Effect of Coronavirus Disease 2019 in Pulmonary Circulation. The Particular Scenario of Precapillary Pulmonary Hypertension. Diagnostics (Basel) 2020; 10:diagnostics10080548. [PMID: 32752129 PMCID: PMC7459745 DOI: 10.3390/diagnostics10080548] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 07/30/2020] [Accepted: 07/30/2020] [Indexed: 02/06/2023] Open
Abstract
The Coronavirus Disease of 2019 (COVID-19) has supposed a global health emergency affecting millions of people, with particular severity in the elderly and patients with previous comorbidities, especially those with cardiovascular disease. Patients with pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) could represent an especially vulnerable population because of the high mortality rates reported for respiratory infections. However, the number of COVID-19 cases reported among PAH and CTEPH patients is surprisingly low. Furthermore, the clinical picture that has been described in these patients is far from the severity that experts would expect. Endothelial dysfunction is a common feature between patients with PAH/CTEPH and COVID-19, leading to ventilation/perfusion mismatch, vasoconstriction, thrombosis and inflammation. In this picture, the angiotensin-converting enzyme 2 plays an essential role, being directly involved in the pathophysiology of both clinical entities. Some of these common characteristics could explain the good adaptation of PAH and CTEPH patients to COVID-19, who could also have obtained a benefit from the disease's specific treatments (anticoagulant and pulmonary vasodilators), probably due to its protective effect on the endothelium. Additionally, these common features could also lead to PAH/CTEPH as a potential sequelae of COVID-19. Throughout this comprehensive review, we describe the similarities and differences between both conditions and the possible pathophysiological and therapeutic-based mechanisms leading to the low incidence and severity of COVID-19 reported in PAH/CTEPH patients to date. Nevertheless, international registries should look carefully into this population for better understanding and management.
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Siemieniuk RA, Bartoszko JJ, Zeraatkar D, Kum E, Qasim A, Martinez JPD, Izcovich A, Lamontagne F, Han MA, Agarwal A, Agoritsas T, Azab M, Bravo G, Chu DK, Couban R, Devji T, Escamilla Z, Foroutan F, Gao Y, Ge L, Ghadimi M, Heels-Ansdell D, Honarmand K, Hou L, Ibrahim Q, Khamis A, Lam B, Mansilla C, Loeb M, Miroshnychenko A, Marcucci M, McLeod SL, Motaghi S, Murthy S, Mustafa RA, Pardo-Hernandez H, Rada G, Rizwan Y, Saadat P, Switzer C, Thabane L, Tomlinson G, Vandvik PO, Vernooij RW, Viteri-García A, Wang Y, Yao L, Zhao Y, Guyatt GH, Brignardello-Petersen R. Drug treatments for covid-19: living systematic review and network meta-analysis. BMJ 2020; 370:m2980. [PMID: 32732190 PMCID: PMC7390912 DOI: 10.1136/bmj.m2980] [Citation(s) in RCA: 484] [Impact Index Per Article: 121.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To compare the effects of treatments for coronavirus disease 2019 (covid-19). DESIGN Living systematic review and network meta-analysis. DATA SOURCES WHO covid-19 database, a comprehensive multilingual source of global covid-19 literature, up to 3 December 2021 and six additional Chinese databases up to 20 February 2021. Studies identified as of 1 December 2021 were included in the analysis. STUDY SELECTION Randomised clinical trials in which people with suspected, probable, or confirmed covid-19 were randomised to drug treatment or to standard care or placebo. Pairs of reviewers independently screened potentially eligible articles. METHODS After duplicate data abstraction, a bayesian network meta-analysis was conducted. Risk of bias of the included studies was assessed using a modification of the Cochrane risk of bias 2.0 tool, and the certainty of the evidence using the grading of recommendations assessment, development, and evaluation (GRADE) approach. For each outcome, interventions were classified in groups from the most to the least beneficial or harmful following GRADE guidance. RESULTS 463 trials enrolling 166 581 patients were included; 267 (57.7%) trials and 89 814 (53.9%) patients are new from the previous iteration; 265 (57.2%) trials evaluating treatments with at least 100 patients or 20 events met the threshold for inclusion in the analyses. Compared with standard care, three drugs reduced mortality in patients with mostly severe disease with at least moderate certainty: systemic corticosteroids (risk difference 23 fewer per 1000 patients, 95% credible interval 40 fewer to 7 fewer, moderate certainty), interleukin-6 receptor antagonists when given with corticosteroids (23 fewer per 1000, 36 fewer to 7 fewer, moderate certainty), and Janus kinase inhibitors (44 fewer per 1000, 64 fewer to 20 fewer, high certainty). Compared with standard care, two drugs probably reduce hospital admission in patients with non-severe disease: nirmatrelvir/ritonavir (36 fewer per 1000, 41 fewer to 26 fewer, moderate certainty) and molnupiravir (19 fewer per 1000, 29 fewer to 5 fewer, moderate certainty). Remdesivir may reduce hospital admission (29 fewer per 1000, 40 fewer to 6 fewer, low certainty). Only molnupiravir had at least moderate quality evidence of a reduction in time to symptom resolution (3.3 days fewer, 4.8 fewer to 1.6 fewer, moderate certainty); several others showed a possible benefit. Several drugs may increase the risk of adverse effects leading to drug discontinuation; hydroxychloroquine probably increases the risk of mechanical ventilation (moderate certainty). CONCLUSION Corticosteroids, interleukin-6 receptor antagonists, and Janus kinase inhibitors probably reduce mortality and confer other important benefits in patients with severe covid-19. Molnupiravir and nirmatrelvir/ritonavir probably reduce admission to hospital in patients with non-severe covid-19. SYSTEMATIC REVIEW REGISTRATION This review was not registered. The protocol is publicly available in the supplementary material. READERS' NOTE This article is a living systematic review that will be updated to reflect emerging evidence. Updates may occur for up to two years from the date of original publication. This is the fifth version of the original article published on 30 July 2020 (BMJ 2020;370:m2980), and previous versions can be found as data supplements. When citing this paper please consider adding the version number and date of access for clarity.
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Affiliation(s)
- Reed Ac Siemieniuk
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Joint first authors
| | - Jessica J Bartoszko
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Joint first authors
| | - Dena Zeraatkar
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Joint first authors
| | - Elena Kum
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Anila Qasim
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Juan Pablo Díaz Martinez
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Ariel Izcovich
- Servicio de Clinica Médica del Hospital Alemán, Buenos Aires, Argentina
| | - Francois Lamontagne
- Department of Medicine and Centre de recherche du CHU de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Mi Ah Han
- Department of Preventive Medicine, College of Medicine, Chosun University, Gwangju, Republic of Korea
| | - Arnav Agarwal
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Thomas Agoritsas
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Division of General Internal Medicine & Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
| | - Maria Azab
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Gonzalo Bravo
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Derek K Chu
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Rachel Couban
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Tahira Devji
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Zaira Escamilla
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Farid Foroutan
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Ted Rogers Center for Heart Research, Toronto General Hospital, ON, Canada
| | - Ya Gao
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Long Ge
- Evidence Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, Gansu, China
- Joint first authors
| | - Maryam Ghadimi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Diane Heels-Ansdell
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Kimia Honarmand
- Department of Medicine, Western University, London, ON, Canada
| | - Liangying Hou
- Evidence Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, Gansu, China
| | - Quazi Ibrahim
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Assem Khamis
- Wolfson Palliative Care Research Centre, Hull York Medical School, Hull, UK
| | - Bonnie Lam
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Christian Mansilla
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Mark Loeb
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Anna Miroshnychenko
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Maura Marcucci
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Shelley L McLeod
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Sharhzad Motaghi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Srinivas Murthy
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Reem A Mustafa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Department of Medicine, University of Kansas Medical Center, Kansas City, MO, USA
| | - Hector Pardo-Hernandez
- Iberoamerican Cochrane Centre, Sant Pau Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Gabriel Rada
- Epistemonikos Foundation, Santiago, Chile
- UC Evidence Center, Cochrane Chile Associated Center, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Yamna Rizwan
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Pakeezah Saadat
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Charlotte Switzer
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - George Tomlinson
- Department of Medicine, University Health Network, Toronto, ON, Canada
| | | | - Robin Wm Vernooij
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Andrés Viteri-García
- Epistemonikos Foundation, Santiago, Chile
- Centro de Investigación de Salud Pública y Epidemiología Clínica (CISPEC), Facultad de Ciencias de la Salud Eugenio Espejo, Universidad UTE, Quito, Ecuador
| | - Ying Wang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Liang Yao
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Yunli Zhao
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Romina Brignardello-Petersen
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
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Pun M, Turner R, Strapazzon G, Brugger H, Swenson ER. Lower Incidence of COVID-19 at High Altitude: Facts and Confounders. High Alt Med Biol 2020; 21:217-222. [PMID: 32716669 DOI: 10.1089/ham.2020.0114] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Pun, Matiram, Rachel Turner, Giacomo Strapazzon, Hermann Brugger, and Erik R. Swenson. Lower incidence of COVID-19 at high altitude: Facts and confounders. High Alt Med Biol. 21:217-222, 2020.-The rapid transmission, increased morbidity, and mortality of coronavirus disease 2019 (COVID-19) has exhausted many health care systems and the global economy. Large variations in COVID-19 prevalence and incidence have been reported across and within many countries worldwide; however, this remains poorly understood. The variability and susceptibility across the world have been mainly attributed to differing socioeconomic status, burden of chronic diseases, access to health care, strength of health care systems, and early or late adoption of control measures. Environmental factors such as pollution, ambient temperature, humidity, and seasonal weather patterns at different latitudes may influence how severe the pandemic is and the incidence of infection in any part of the world. In addition, recent epidemiological data have been used to propose that altitude of residence may not only influence those environmental features considered key to lesser viral transmission, but also susceptibility to more severe forms of COVID-19 through hypoxic-hypobaria driven genomic or nongenomic adaptations specific to high-altitude populations. In this review, we critically examine these factors and attempt to determine based upon available scientific and epidemiological data whether living in high-altitude regions might be protective against COVID-19 as recent publications have claimed.
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Affiliation(s)
- Matiram Pun
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Rachel Turner
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - Giacomo Strapazzon
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy.,Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Hermann Brugger
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy.,Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Erik R Swenson
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA.,Medical Service, VA Puget Sound Health Care System, Seattle, Washington, USA
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50
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Bloch MJ. Renin-Angiotensin System Blockade in COVID-19: Good, Bad, or Indifferent? J Am Coll Cardiol 2020; 76:277-279. [PMID: 32674791 PMCID: PMC7357969 DOI: 10.1016/j.jacc.2020.06.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 05/27/2020] [Accepted: 06/01/2020] [Indexed: 01/22/2023]
Affiliation(s)
- Michael J Bloch
- Department of Medicine, University of Nevada, Reno School of Medicine, Reno, Nevada; Vascular Care, Renown Institute for Heart and Vascular Health, Reno, Nevada.
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