Renin-Angiotensin-Aldosterone System Blockers and the Risk of Covid-19

High-Intensity Statins Promote PCSK9 Secretion and aortic valve calcification in patients with severe aortic stenosis: In vitro and clinical evidence

Aortic stenosis (AS) is the most common valvular disease, characterized by progressive fibro-calcific remodeling of the aortic leaflets, leading to increased morbidity and mortality. It is now well known that statins influence the production of proprotein convertase subtilisin/kexin type 9 (PCSK9), which in turn is linked to calcification. Here, we found that statins significantly increased, in a dose dependent manner, both PCSK9 secretion and valve interstitial cell (VIC) calcification, in vitro. These effects were blunted by PCSK9 genetic knock-down or by PCSK9 antibody neutralization. In AS patients, contrast-enhanced computed tomography evaluation showed a higher aortic valve calcium (AVC) content in patients on high-intensity statins compared to low-intensity ones, with no significant difference between low-intensity statin and non-users. At follow-up, high-intensity statin users exhibited a higher annual AVC accumulation compared to low-intensity statins and non-users. In a real-world scenario, high-intensity statin therapy was associated with a 30 % increased rate of hospitalization for non-rheumatic aortic valve disease. Our findings highlight the need for further investigation into the intricate relationship between statin therapy and aortic valve health to identify the optimal lipid-lowering strategy in the management of patients at risk of developing or afflicted by AS.

The impact of bias due to exponentiation in the estimation of hazard, risk, and odds ratios: an empirical investigation from 1,495,059 effect sizes from MEDLINE/PubMed abstracts

BACKGROUND

Parameter estimation using regression methods plays a vital role in medical research. Often a non-linear transformation of a regression parameter is preferred for its more intuitive interpretation. Important examples in medical research are odds ratios, risk ratios, and hazard ratios, which are obtained by exponentiating the estimated regression coefficients of the logit link binomial generalized linear model, log link Poisson generalized linear model or Cox proportional hazards model, respectively. A lot of attention has been devoted to studying and removing the bias of the estimators on the scale of the regression, but the bias of the transformed parameters is rarely addressed.

METHODS

Two approaches for reducing the bias due to the exponentiation are reviewed and applied to odds ratios, risk ratios, and hazard ratios reported in the abstracts published in the MEDLINE subset of English-language PubMed records.

RESULTS

We show that correcting for the bias due to the exponentiation may yield substantially different estimates, potentially resulting in a large shrinkage of the reported effect size estimates.

CONCLUSION

Given the wide availability of methods to reduce the bias on the scale of regression, we encourage their routine use to improve estimation. In situations where the consequences of biased estimation are larger at the exponentiated scale than at the scale of regression, as for example in some policy and planning settings, we additionally encourage the removal of the bias due to the exponentiation.

Incidence and mortality trends of people living with dementia among 7 million individuals over 10 years in Italy: A retrospective cohort study using administrative linked data

PURPOSE

We aimed to estimate trends of dementia incidence and to compute and compare all-cause mortality among people living with and without dementia, in a whole regional population, from 2013 to 2023.

METHODS

Our retrospective population-wide cohort study included 7,030,374 people aged 50 years and older from regional administrative data, living in Lombardy, the most populous Italian region. We computed annual age-standardised dementia incidence estimated rates and age-standardised all-cause mortality estimated rates among people living with and without dementia, both overall and stratified by age and sex.

RESULTS

Over the last decade, age-standardised dementia incidence estimated rates have decreased by 52.8 % for women and 53.1 % for males. In contrast, age-standardised all-cause mortality estimated rates among people living with dementia grew by 14.0 % for women and 21.8 % for males. Conversely, during the pandemic, there was a higher excess in mortality estimated rates in the female population living with dementia compared to the male, up to 60 % in older groups aged 80 or older. In the male population without dementia compared to the female, the higher excess was up to 50 % in age groups of 70-74 and 75-79.

CONCLUSIONS

Our study reported a reduction in dementia incidence and increase in all-cause mortality of people living with dementia over the last decade, indicating that dementia prevalence is declining. Moreover, previously under-investigated gender disparities in mortality estimated rates emerged across different age groups during the pandemic.

Prevalence and Risk Factors for Acute Kidney Injury in COVID-19-Hospitalized Patients in Poland Across Three Pandemic Periods

Background/Objectives: Acute kidney injury (AKI) is a serious and prevalent complication of COVID-19. This study examines the prevalence, risk factors, and outcomes of AKI in hospitalized COVID-19 patients. Methods: We analyzed the data of 1223 adult COVID-19 hospitalized patients from a single district hospital during three pandemic periods: 3 November 2020-31 December 2020, 17 March 2021-8 May 2021, and 4 November 2021-21 February 2022. The analysis included demographic data, comorbidities, laboratory results, chest radiographs (CT lung scans), and outcomes. Results: We found an overall AKI incidence of 29.02%. AKI patients versus non-AKI ones were significantly older (median age 76.0 vs. 71.0, p < 0.001) and had more comorbidities, especially previous renal diseases, heart failure, coronary artery disease, and hypertension; they also significantly more often used diuretics, angiotensin receptor blockers (ARBs), and angiotensin-converting enzyme inhibitors (ACE-Is). AKI patients more frequently presented with abnormal CT lung scans and had higher white blood cell counts, lower lymphocytes percentages, higher C-reactive protein (CRP) levels, and lower platelet counts. They more often required oxygen therapy, more days of hospitalization, and had higher mortality rates. Conclusions: Older age, comorbidities, the use of diuretics, and renin-angiotensin system inhibitors (RASI) are key risk factors for AKI, which is consequently linked to a more severe disease course and poorer prognosis.

Investigation of renal function in patients with long COVID in the Amazon region: a cross-sectional study

BACKGROUND

COVID-19 became a pandemic disease in 2020, with multisystem involvement and high renal morbidity during the acute phase. Some affected patients began to present new or persistent symptoms in a condition known as Long COVID. The study aimed to evaluate renal function using clinical and laboratory findings, and to establish the frequency and staging of renal function decline in Long COVID patients, as well as the associated factors.

METHODS

This is a cross-sectional observational study that selected participants from a Long COVID clinical care program between 2020 and 2022.

RESULTS

A total of 246 patients were selected for this study, and renal function decline was found in 83 (33.7%). Patients over 60 years (29.6%) and those who developed glycaemic alterations (41.8%) exhibited a higher prevalence of renal outcomes in long COVID. Some laboratory test as LDH levels and glycated hemoglobin seems to have a statistic relation with a decrease in renal function (p < 0.05).

CONCLUSION

A decline in renal function was common in patients with Long COVID in this study, and older age and glycaemic alterations were relevant to this condition. Some laboratory markers can be used to predict this outcome.

Endocan as a marker of endotheliitis in COVID-19 patients: modulation by veno-venous extracorporeal membrane oxygenation, arterial hypertension and previous treatment with renin-angiotensin-aldosterone system inhibitors

BACKGROUND AND AIMS

Endocan has been scarcely explored in COVID-19, especially regarding its modulation by veno-venous extracorporeal membrane oxygenation (VV-ECMO), hypertension or previous renin-angiotensin-aldosterone system (RAAS) inhibitors treatment. We compared endocan and other endotheliitis markers in hospitalized COVID-19 patients and assessed their modulation by VV-ECMO, hypertension and previous RAAS inhibitors treatment.

MATERIAL AND METHODS

Serum endocan, intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1) and E-selectin were measured in "severe" (n = 27), "critically ill" (n = 17) and "critically ill on VV-ECMO" (n = 17) COVID-19 patients at admission, days 3-4, 5-8 and weekly thereafter, and in controls (n = 23) at a single time point.

RESULTS

Admission endocan and VCAM-1 were increased in all patients, but "critically ill on VV-ECMO" patients had higher endocan and E-Selectin. Endocan remained elevated throughout hospitalization in all groups. "Severe" and "critically ill" hypertensive patients or previously treated with RAAS inhibitors had higher endocan and/or VCAM-1, but in VV-ECMO patients the raised endocan values seemed unrelated with these factors. Among all COVID-19 hypertensive patients, those with previous RAAS inhibitors treatment had higher endocan.

CONCLUSIONS

In our study, endocan stands out as the best marker of endotheliitis in hospitalized COVID-19 patients, being upregulated by VV-ECMO support, hypertension and previous RAAS inhibitor treatment.

Long-term exposure to antihypertensive drugs and the risk of cancer occurrence: evidence from a large population-based study

OBJECTIVE

Available data on the association between antihypertensive drugs and cancer are characterized by a few years follow-up. Our aim has been to evaluate the association between long-term exposure to antihypertensive drugs and the risk of cancer occurrence.

METHODS

Using the healthcare utilization databases of the Lombardy region (Italy), individuals aged 40-85 years who had no previous history of cancer and were newly dispensed with at least one antihypertensive drug from the major drug classes between 2009 and 2011 were followed from the first drug dispensation to December 31, 2020. Data were analyzed according to the first drug used and the intention to treat principle, but also via an "as treated" approach, that is, by considering changes of and exposure to drugs during follow-up. The association between the duration of exposure to each drug class and the risk of cancer occurrence was evaluated using the adjusted Cox regression models.

RESULTS

The study cohort included 338 910 new drug users (median age, 59 years; 49.5% males). During a median follow-up of 10.2 years, 36 556 cancers occurred. There was no consistent significant association between the risk of cancer occurrence and angiotensin-converting-enzyme inhibitors, angiotensin-receptor blockers, or thiazides. A progressive, weak increase in cancer occurrence was associated with progressive exposure to calcium channel blockers and, limited to long-term exposure, to beta-blockers. A modest progressive increase in risk was observed also for thiazide-like and loop diuretics in the as treated, although not in the intention to treat approach.

CONCLUSIONS

Long-term evaluation of exposure to antihypertensive drugs did not show consistent associations between thiazides, angiotensin-receptor blockers, or angiotensin-converting-enzyme inhibitors and the risk of cancer occurrence. A weak association was observed between cancer and the duration of exposure to calcium channel blockers and beta-blockers.

Prostaglandins and non-steroidal anti-inflammatory drugs in Covid-19

In response to different viral infections, including SARS-CoV-2 infection, pro-inflammatory, anti-inflammatory cytokines, and bioactive lipids are released from infected and immune cells. One of the most critical bioactive lipids is prostaglandins (PGs) which favor perseverance of inflammation leading to chronic inflammation as PGs act as cytokine amplifiers. PGs trigger the release of pro-inflammatory cytokines, activate Th cells, recruit immune cells, and increase the expression of pro-inflammatory genes. Therefore, PGs may induce acute and chronic inflammations in various inflammatory disorders and viral infections like SARS-CoV-2. PGs are mainly inhibited by non-steroidal anti-inflammatory drugs (NSAIDs) by blocking cyclooxygenase enzymes (COXs), which involve PG synthesis. NSAIDs reduce inflammation by selective or non-selective blocking activity of COX2 or COX1/2, respectively. In the Covid-19 era, there is a tremendous controversy regarding the use of NSAIDs in the management of SARS-CoV-2 infection. As well, the possible role of PGs in the pathogenesis of SARS-CoV-2 infection is not well-defined. Thus, the objective of the present study is to review the potential role of PGs and NSAIDs in Covid-19 in a narrative review regarding the preponderance of assorted views.

Cushing's syndrome and COVID-19

PURPOSE

This review aims to present current data on the course of COVID-19 in patients with Cushing syndrome (CS) and discuss treatment for CS during to the pandemic.

METHODS

Literature review using PubMed (pubmed.ncbi.nlm.nih.gov). The search included the following terms: "COVID19" in combination with "Cushing syndrome", "Hypercortisolism" and "Glucocorticoid".

RESULTS

Chronic hypercortisolism has been reported to increase infectious risk and worsens prognostic of patients with COVID-19 potentially due to its direct impact on the immune system: lymphopenia, impairment of monocytes and neutrophils activity, diminution of complement activation. Main metabolic complications of CS - i.e. diabetes, hypertension and obesity - have been recognized as COVID-19 complications risk factors. Patients with CS treated with steroidogenesis inhibitors might experience adrenal insufficiency during COVID-19. Special attention should be paid to patients with CS and COVID-19. The pandemic has impacted - and delayed - care of chronic illnesses including CS. Specific recommendations had been provided during the pandemic: favor telemedicine consultations, limit in-hospital explorations and postpone surgery when feasible.

CONCLUSION

There are enough evidence for an increased prevalence and severity of COVID-19 to recommend a specific attention and caution in patients with CS.

The Bidirectional Association Between Metabolic Syndrome and Long-COVID-19

Background

The rapid global spread of a new coronavirus disease known as COVID-19 has led to a significant increase in mortality rates, resulting in an unprecedented worldwide pandemic.

Methods

The impact of COVID-19, particularly its long-term effects, has also had a profound effect on the health and well-being of individuals.Metabolic syndrome increases the risk of heart and brain diseases, presenting a significant danger to human well-being.

Purpose

The prognosis of long COVID and the progression of metabolic syndrome interact with each other, but there is currently a lack of systematic reports.In this paper, the pathogenesis, related treatment and prognosis of long COVID and metabolic syndrome are systematically reviewed.

Acute and Post-Acute COVID-19 Cardiovascular Complications: A Comprehensive Review

PURPOSE OF REVIEW

The risk of cardiovascular complications due to SARS-CoV-2 are significantly increased within the first 6 months of the infection. Patients with COVID-19 have an increased risk of death, and there is evidence that many may experience a wide range of post-acute cardiovascular complications. Our work aims to provide an update on current clinical aspects of diagnosis and treatment of cardiovascular manifestations during acute and long-term COVID-19.

RECENT FINDINGS

SARS-CoV-2 has been shown to be associated with increased incidence of cardiovascular complications such as myocardial injury, heart failure, and dysrhythmias, as well as coagulation abnormalities not only during the acute phase but also beyond the first 30 days of the infection, associated with high mortality and poor outcomes. Cardiovascular complications during long-COVID-19 were found regardless of comorbidities such as age, hypertension, and diabetes; nevertheless, these populations remain at high risk for the worst outcomes during post-acute COVID-19. Emphasis should be given to the management of these patients. Treatment with low-dose oral propranolol, a beta blocker, for heart rate management may be considered, since it was found to significantly attenuate tachycardia and improve symptoms in postural tachycardia syndrome, while for patients on ACE inhibitors or angiotensin-receptor blockers (ARBs), under no circumstances should these medications be withdrawn. In addition, in patients at high risk after hospitalization due to COVID-19, thromboprophylaxis with rivaroxaban 10 mg/day for 35 days improved clinical outcomes compared with no extended thromboprophylaxis. In this work we provide a comprehensive review on acute and post-acute COVID-19 cardiovascular complications, symptomatology, and pathophysiology mechanisms. We also discuss therapeutic strategies for these patients during acute and long-term care and highlight populations at risk. Our findings suggest that older patients with risk factors such as hypertension, diabetes, and medical history of vascular disease have worse outcomes during acute SARS-CoV-2 infection and are more likely to develop cardiovascular complications during long-COVID-19.

Use of drugs for hypertension or heart failure and the risk of death in COVID-19: association with loop-diuretics

PURPOSE

To study the association between the use of drugs for hypertension or heart failure, particularly diuretics, and risk of death in COVID-19.

METHODS

We conducted a cohort study, based on record linked individual-based data from national registers, of all Swedish inhabitants 50 years and older (n = 3,909,321) at the start of the first SARS-CoV-2 wave in Sweden. The association between use of angiotensin-converting enzyme inhibitors (ACEI), angiotensin II receptor blockers (ARB), thiazides, loop diuretics, aldosterone antagonists, beta blocking agents and calcium channel blockers at the index date 6 March 2020, and death in COVID-19 during 7 March to 31 July 2020, was analysed using Cox-proportional hazards regression, adjusted for a wide range of possible confounders.

RESULTS

Use of loop diuretics was associated with higher risk [adjusted hazard ratio (HR) 1.26; 95% confidence interval (95% CI) 1.17-1.35] and thiazides with reduced risk (0.78; 0.69-0.88) of death in COVID-19. In addition, lower risk was observed for ACEI and higher risk for beta-blocking agents, although both associations were weak. For ARB, aldosterone antagonists and calcium channel blockers no significant associations were found.

CONCLUSION

In this nationwide cohort of nearly 4 million persons 50 years and older, the use of loop diuretics was associated with increased risk of death in COVID-19 during the first SARS-CoV-2 wave in Sweden. This contrasted to the decreased risk observed for thiazides. As treatment with loop diuretics is common, particularly in the elderly, the group most affected by severe COVID-19, this finding merit further investigation.

Implications of Dysnatremia and Endocrine Disturbances in COVID-19 Patients

Sodium imbalance is a common electrolyte disturbance in COVID-19, often linked to disruptions in hormonal regulation. This review explores the relationship between sodium dysregulation and endocrine disturbances, particularly focusing on primary and secondary hypothyroidism, hypocortisolism, and the renin-angiotensin-aldosterone system (RAAS). Hypocortisolism in COVID-19, due to adrenal insufficiency or secondary to pituitary dysfunction, can lead to hyponatremia through inadequate cortisol levels, which impair renal free water excretion and enhance antidiuretic hormone (ADH) secretion. Similarly, hypothyroidism is associated with decreased renal blood flow and the glomerular filtration rate (GFR), which also increases ADH activity, leading to water retention and dilutional hyponatremia. Furthermore, COVID-19 can disrupt RAAS (primarily through its interaction with the angiotensin-converting enzyme 2 (ACE2) receptor), diminishing aldosterone secretion and further contributing to sodium loss and hyponatremia. These hormonal disruptions suggest that sodium imbalance in COVID-19 is multifactorial and warrants further investigation into the complex interplay between COVID-19, endocrine function, and sodium homeostasis. Future research should focus on understanding these mechanisms to develop management algorithms that address both sodium imbalance and underlying hormonal disturbances in order to improve prognosis and outcomes in COVID-19 patients.

The trends of antihypertensive drug prescription based on the Japanese national data throughout the COVID-19 pandemic period

In 2020, concerns arose about the potential adverse effects of angiotensin II type 1 receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACEIs) on patients with the Coronavirus Disease 2019 (COVID-19). However, there is no national data on antihypertensive prescriptions during the COVID-19 pandemic in Japan. This study aimed to explore the trends in antihypertensive drug prescriptions in Japan throughout COVID-19 pandemic period. This study used data from the National Database (NDB) Open Data in Japan, an annual publication by the Ministry of Health, Labour and Welfare. To capture changes before and after social activity restrictions, the present study focused on extracting the number of prescribed oral medicine tablets for outpatients from the NDB Open Data from 2018 to 2021. The fiscal year 2020 exhibited the lowest for both outpatient claims and prescribed drugs. In contrast, all categories of antihypertensive drug prescription showed annual increases, and no specific changes in the prescription patterns of ARBs and ACEIs around fiscal year 2020 were observed. This study implies that antihypertensive drug prescriptions were adequately maintained throughout the COVID-19 pandemic in Japan.

COVID-19 in the Initiation and Progression of Atherosclerosis: Pathophysiology During and Beyond the Acute Phase

The incidence of atherosclerotic cardiovascular disease is increasing globally, especially in low- and middle-income countries, despite significant efforts to reduce traditional risk factors. Premature subclinical atherosclerosis has been documented in association with several viral infections. The magnitude of the recent COVID-19 pandemic has highlighted the need to understand the association between SARS-CoV-2 and atherosclerosis. This review examines various pathophysiological mechanisms, including endothelial dysfunction, platelet activation, and inflammatory and immune hyperactivation triggered by SARS-CoV-2 infection, with specific attention on their roles in initiating and promoting the progression of atherosclerotic lesions. Additionally, it addresses the various pathogenic mechanisms by which COVID-19 in the post-acute phase may contribute to the development of vascular disease. Understanding the overlap of these syndromes may enable novel therapeutic strategies. We further explore the need for guidelines for closer follow-up for the often-overlooked evidence of atherosclerotic cardiovascular disease among patients with recent COVID-19, particularly those with cardiometabolic risk factors.

Individual risk factors associated with SARS-CoV-2 infection during Alpha variant in high-income countries: a systematic review and meta-analysis

Objectives

This study aimed to systematically appraise risk factors associated with SARS-CoV-2 infection in high-income countries during the period of predominance of the Alpha variant (January 2020 to April 2021).

Methods

Four electronic databases were used to search observational studies. Literature search, study screening, data extraction and quality assessment were conducted by two authors independently. Meta-analyses were conducted for each risk factor, when appropriate.

Results

From 12,094 studies, 27 were included. The larger sample size was 17,288,532 participants, more women were included, and the age range was 18-117 years old. Meta-analyses identified men [Odds Ratio (OR): 1.23, 95% Confidence Interval (CI): 1.97-1.42], non-white ethnicity (OR: 1.63, 95% CI: 1.39-1.91), household number (OR: 1.08, 95% CI: 1.06-1.10), diabetes (OR: 1.22, 95% CI: 1.08-1.37), cancer (OR: 0.82, 95% CI: 0.68-0.98), cardiovascular diseases (OR: 0.92, 95% CI: 0.84-1.00), asthma (OR: 0.83, 95% CI: 0.75-0.92) and ischemic heart disease (OR: 0.82, 95% CI: 0.74-0.91) as associated with SARS-CoV-2 infection.

Conclusion

This study indicated several risk factors for SARS-CoV-2 infection. Due to the heterogeneity of the studies included, more studies are needed to understand the factors that increase the risk for SARS-CoV-2 infection.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021244148, PROSPERO registration number, CRD42021244148.

Effect of Renin-Angiotensin-Aldosterone System Blockers on Adverse Outcomes in COVID-19 Patients

INTRODUCTION

Angiotensin-converting enzyme 2 (ACE2) of the renin-angiotensin-aldosterone system (RAAS) serves as a functional receptor to gain entry into the cells for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19). The interaction between SARS-CoV-2 and ACE2 is a potential virulent factor in infectivity. Our study aimed to ascertain the association of RAAS inhibitors with adverse cardiovascular and other outcomes in hospitalized COVID-19 patients.

METHODS

This is a retrospective study of medical records of ≥18-year-old patients hospitalized for COVID-19 from March 2020 to October 2020. Primary outcomes were acute cardiovascular events (ST-elevation myocardial infarction, non-ST-elevation myocardial infarction type 1, acute congestive heart failure, acute stroke) and mortality. Secondary outcomes were respiratory failure, need for and duration of mechanical ventilation, acute deep vein thrombosis or pulmonary embolism (DVT/PE), and readmission rate.

RESULTS

Among 376 hospitalized COVID-19 patients, 149 were on RAAS inhibitors. No statistically significant differences were found between RAAS inhibitor and non-RAAS inhibitor groups with respect to acute cardiovascular events (6% vs. 6.2%, p = 0.94), acute DVT/PE (4.7% vs. 4.8%, p = 0.97), hypoxia (62.4% vs. 58.6%, p = 0.46), need for mechanical ventilation (18.1% vs. 16.7%, p = 0.72), mortality (19.5% vs. 22%, p = 0.56), and readmission rate (11.4% vs. 14.1%, p = 0.45). Some nuances discovered were a higher rate of hospitalizations among Native Americans receiving RAAS inhibitors (30.2% vs. 19.8%) and significantly lower levels of procalcitonin in patients on RAAS inhibitors.

CONCLUSIONS

Among hospitalized patients with COVID-19, those on RAAS inhibitors showed no significant differences in acute cardiovascular events, acute DVT/PE, hypoxia, need for mechanical ventilation, readmission, or mortality rate compared to those not on them. However, further large-scale studies are needed to validate these findings.

Cell type-specific expression of angiotensin receptors in the human lung with implications for health, aging, and chronic disease

The renin-angiotensin system is a highly characterized integrative pathway in mammalian homeostasis whose clinical spectrum has been expanded to lung disorders such as chronic obstructive pulmonary disease (COPD)-emphysema, idiopathic pulmonary fibrosis (IPF), and COVID pathogenesis. Despite this widespread interest, specific localization of this receptor family in the mammalian lung is limited, partially due to the imprecision of available antibody reagents. In this study, we establish the expression pattern of the two predominant angiotensin receptors in the human lung, AGTR1 and AGTR2, using complementary and comprehensive bulk and single-cell RNA-sequence datasets that are publicly available. We show these two receptors have distinct localization patterns and developmental trajectories in the human lung, pericytes for AGTR1 and a subtype of alveolar epithelial type 2 cells for AGTR2. In the context of disease, we further pinpoint AGTR2 localization to the COPD-associated subpopulation of alveolar epithelial type 2 (AT2B) and AGTR1 localization to fibroblasts, where their expression is upregulated in individuals with COPD, but not in individuals with IPF. Finally, we examine the genetic variation of the angiotensin receptors, finding AGTR2 associated with lung phenotype (i.e., cystic fibrosis) via rs1403543. Together, our findings provide a critical foundation for delineating this pathway's role in lung homeostasis and constructing rational approaches for targeting specific lung disorders.

Cardiovascular disease development in COVID-19 patients admitted to a tertiary medical centre in Iran

Cardiovascular diseases (CVDs) have been reported to occur in a significant number of patients diagnosed with coronavirus disease 2019 (COVID-19). We report our experience regarding the occurrence of symptomatic and asymptomatic CVDs in COVID-19 patients. In this cross-sectional study, 690 COVID-19 patients were included. Cardiovascular consultation had been requested for all of the patients based on their primary clinical examination, vital signs, and electrocardiogram (ECG). Additionally, 2D transthoracic echocardiography (TTE), and myocardial injury serum biomarkers assays (creatine phosphokinase-MB [CPK-MB] and cardiac troponins [cTn]) were measured once. Manifestations of CVDs, such as chest pain, abnormal serum markers, unstable angina, myocardial infarction (MI), myocarditis, and new-onset hypertension, were documented. The most common symptom was left hemithorax and interscapular pain (317 patients, 46%). New-onset high systolic and diastolic blood pressures were seen in 67 patients (10%). Unstable angina, MI, and myocarditis were, respectively, diagnosed in 20 (2.8%), five (0.7%), and 12 (1.7%) patients. On TTE, pericardial effusion was diagnosed in 139 patients (31.1%). The most common abnormal ECG changes seen were regarding the T-wave, including flat T-wave (148 cases, 21.4%) and inverted T-wave (141 cases, 20.4%). Serum cTn levels were positive or weekly positive in 17 cases (7.4%). The incidence rate of cardiovascular involvements was high in COVID-19 patients.

Role of the RAAS in mediating the pathophysiology of COVID-19

The renin-angiotensin-aldosterone system (RAAS) holds a position of paramount importance as enzymatic and endocrine homeostatic regulator concerning the water-electrolyte and acid-base balance. Nevertheless, its intricacy is influenced by the presence of various complementary angiotensins and their specific receptors, thereby modifying the primary RAAS actions. Angiotensin-converting enzyme 2 (ACE2) acts as a surface receptor for SARS-CoV-2, establishing an essential connection between RAAS and COVID-19 infection. Despite the recurring exploration of the RAAS impact on the trajectory of COVID-19 along with the successful resolution of many inquiries, its complete role in the genesis of delayed consequences encompassing long COVID and cardiovascular thrombotic outcomes during the post-COVID phase as well as post-vaccination, remains not fully comprehended. Particularly noteworthy is the involvement of the RAAS in the molecular mechanisms underpinning procoagulant processes throughout COVID-19. These processes significantly contribute to the pathogenesis of organ complications as well as determine clinical outcomes and are discussed in this manuscript.

[Features of the Course of Arterial Hypertension in the Era of the COVID-19 Pandemic: Common Pathogenetic Links Between Hypertension and SARS-CoV-2]

The aim of this review was to present the mechanism of infection with severe acute respiratory syndrome-related coronavirus-2 (SARS-CoV-2) and its possible effect on the course of arterial hypertension. Another aim was to evaluate the relationship of the renin-angiotensin-aldosterone system with the pathogenetic stages of infection caused by SARS-CoV-2 virus.

Use of chronic medications and risk of death due to COVID-19 in hospitalised patients

OBJECTIVES

To evaluate the potential association between chronic exposure to medication and death related to COVID-19.

METHODS

This is a retrospective cross-sectional study that included all patients hospitalised due to COVID-19 from 11 March to 4 June 2020 in our centre. Chronic patient medication was classified by the Anatomical Therapeutic Chemical (ATC) classification; demographic and clinical data were analysed. Multivariate logistic regression models were used to estimate the adjusted odds ratios (aOR) of death for each drug exposure; each aOR represents an independent model adjusted by clinical factors related to COVID-19 mortality.

RESULTS

The study included 978 patients with a mean (SD) age of 64.5 (17.7) years who were predominantly male (531, 54.3%). Of all 978 patients, 182 (18.61%) died during the follow-up of the study. The most common Charlson Comorbidity Index (CCI) was 0, 4.2% were smokers, 16.7% were obese, 47.4% had hypertension, and 19.4% were diabetic. Most patients (70.8%) were prescribed at least one treatment, 32.5% used >5 treatments, and 8.6% >10. Our data suggest that COVID-19 hospitalised patients taking trimethoprim and analogues, leukotriene receptor antagonists, calcineurin inhibitors, aldosterone antagonists, selective immunosuppressants, propulsives, insulins and analogues, and benzodiazepine derivatives have a higher risk of death.

CONCLUSIONS

This study investigated the association between chronic exposure to drugs and the risk of death in COVID-19 patients. Our results have shed some light on the impact of chronic drug exposure on the risk of severe COVID-19; however, further research is needed to increase the understanding about its relevance.

FGF7 enhances the expression of ACE2 in human islet organoids aggravating SARS-CoV-2 infection

The angiotensin-converting enzyme 2 (ACE2) is a primary cell surface viral binding receptor for SARS-CoV-2, so finding new regulatory molecules to modulate ACE2 expression levels is a promising strategy against COVID-19. In the current study, we utilized islet organoids derived from human embryonic stem cells (hESCs), animal models and COVID-19 patients to discover that fibroblast growth factor 7 (FGF7) enhances ACE2 expression within the islets, facilitating SARS-CoV-2 infection and resulting in impaired insulin secretion. Using hESC-derived islet organoids, we demonstrated that FGF7 interacts with FGF receptor 2 (FGFR2) and FGFR1 to upregulate ACE2 expression predominantly in β cells. This upregulation increases both insulin secretion and susceptibility of β cells to SARS-CoV-2 infection. Inhibiting FGFR counteracts the FGF7-induced ACE2 upregulation, subsequently reducing viral infection and replication in the islets. Furthermore, retrospective clinical data revealed that diabetic patients with severe COVID-19 symptoms exhibited elevated serum FGF7 levels compared to those with mild symptoms. Finally, animal experiments indicated that SARS-CoV-2 infection increased pancreatic FGF7 levels, resulting in a reduction of insulin concentrations in situ. Taken together, our research offers a potential regulatory strategy for ACE2 by controlling FGF7, thereby protecting islets from SARS-CoV-2 infection and preventing the progression of diabetes in the context of COVID-19.

Aldosterone levels do not predict 28-day mortality in patients treated for COVID-19 in the intensive care unit

The immunotropic effects of aldosterone might play a role in COVID-19, as SARS-CoV-2 reportedly uses angiotensin-converting enzyme 2 receptors as an entry point into cells. Aldosterone function is closely linked to its action on mineralocorticoid receptors in kidneys; it increases the renal retention of sodium and the excretion of potassium, which increases blood pressure. Despite the large number of studies examining the effect of Ang-II and its blockers on the course of COVID-19 infection, there is still uncertainty about the role of aldosterone. The aim of the study was to assess the correlation of aldosterone, urea, creatinine, C-reactive protein (CRP), and procalcitonin (PCT) levels with 28 days of mortality in patients treated for COVID19 in an intensive care unit (ICU). This cross-selection study involved 115 adult patients who were divided into two groups: those who died within a 28-day period (n = 82) and those who survived (n = 33). The correlation of aldosterone, urea, creatinine, C-reactive protein (CRP), and procalcitonin (PCT) levels with 28 days of mortality in patients treated for COVID-19 were performed. The patients' age, sex, scores from the APACHE II, SAPS II, and SOFA scales and comorbidities like HA, IHD and DM were also analyzed. Remarkably, the individuals who survived for 28 days were of significantly lower mean age and achieved notably lower scores on the APACHE II, SAPS II, and SOFA assessment scales. Statistically significantly higher CRP levels were observed on days 3, 5, and 7 in individuals who survived for 28 days. Creatinine levels in the same group were also statistically significantly lower on days 1, 3, and 5 than those of individuals who died within 28 days. The investigation employed both univariate and multivariate Cox proportional hazard regression models to explore factors related to mortality. In the univariate analysis, variables with a p value of less than 0.50 were included in the multivariate model. Age, APACHE II, SAPS II, and SOFA demonstrated significance in univariate analysis and were considered to be associated with mortality. The outcomes of the multivariate analysis indicated that age (HR = 1.03, p = 0.033) served as a robust predictor of mortality in the entire study population. In conclusion the plasma aldosterone level is not associated with ICU mortality in patients with COVID-19. Other factors, including the patient's age, creatinine or CRP contribute to the severity and prognosis of the disease. This study was retrospectively registered in the Australian New Zealand Clinical Trials Registry (ANZCTR) with registration no. ACTRN12621001300864 (27/09/2021: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=382563&isReview=true ).

Current status of hypertension care and management in the Philippines

AIMS

In this paper, we discuss the existing data on the burden of hypertension in the Philippines and present the status of management, prevention, and control of hypertension in the country.

METHODS

A literature review was conducted to synthesize the status of hypertension care in the Philippines.

RESULTS

Hypertension continues to contribute to the country's leading causes of death. Similar to the global trend, almost half of hypertensive Filipinos are still not aware of their condition, and only 27 % have it under control. The prevalence of hypertension has steadily increased from 22 % in 1993 to 25.15 % in 2013. The 2020 Philippine Society for Hypertension clinical practice guideline defines hypertension as an office BP of 140/90 mm Hg or above following the proper standard BP measurement. During the past decade, monotherapy has been the mode of treatment in more than 80 % of Filipino patients. This could also explain why the BP control rates have been low. The most prevalent complications of hypertension in the Philippines were stroke (11.6 %), ischemic heart disease (7.7 %), chronic kidney disease (6.30 %), and hypertensive retinopathy (2.30 %). Hypertension causes economic tolls on patients, from the cost of drugs to hospitalization and complications. Hospitalization from hypertensive complications can easily wipe out the savings of middle-class families and is catastrophic for lower-income Filipinos.

CONCLUSION

In this review, we summarize the existing data on the burden of hypertension among Filipinos and the risk factors associated with the disease. We present the current screening tools, diagnostics, treatment, and prevention strategies for hypertension in the Philippines. Lastly, we propose solutions to meet the global targets of hypertension management and help relieve the growing burden of this disease.

The Renin-Angiotensin System (RAS) in COVID-19 Disease: Where We Are 3 Years after the Beginning of the Pandemic

The RAS is a hormonal system playing a pivotal role in the control of blood pressure and electrolyte homeostasis, the alteration of which is associated with different pathologies, including acute respiratory distress syndrome (ARDS). As such, it is not surprising that a number of studies have attempted to elucidate the role and balance of the renin-angiotensin system (RAS) in COVID-19. In this review article, we will describe the evidence collected regarding the two main enzymes of the RAS (i.e., ACE and ACE2) and their principal molecular products (i.e., AngII and Ang1-7) in SARS-CoV-2 infection, with the overarching goal of drawing conclusions on their possible role as clinical markers in association with disease severity, progression, and outcome. Moreover, we will bring into the picture new experimental data regarding the systemic activity of ACE and ACE2 as well as the concentration of AngII and Ang1-7 in a cohort of 47 COVID-19 patients hospitalized at the IRCCS Sacro Cuore-Don Calabria Hospital (Negrar, Italy) between March and April 2020. Finally, we will discuss the possibility of considering this systemic pathway as a clinical marker for COVID-19.

Assessing medication use patterns by clinical outcomes severity among inpatients with COVID-19: A retrospective drug utilization study

PURPOSE

This study assessed medication patterns for inpatients at a central hospital in Portugal and explored their relationships with clinical outcomes in COVID-19 cases.

METHODS

A retrospective study analyzed inpatient medication data, coded using the Anatomical Therapeutic Chemical classification system, from electronic patient records. It investigated the association between medications and clinical severity outcomes such as ICU admissions, respiratory/circulatory support needs, and hospital discharge status, including mortality (identified by ICD-10-CM/PCS codes). Multivariate analyses incorporating demographic data and comorbidities were used to adjust for potential confounders and understand the impact of medication patterns on disease progression and outcomes.

RESULTS

The analysis of 2688 hospitalized COVID-19 patients (55.3% male, average age 62.8 years) revealed a significant correlation between medication types and intensity and disease severity. Cases requiring ICU admission or ECMO support often involved blood and blood-forming organ drugs. Increased use of nervous system and genitourinary hormones was observed in nonsurvivors. Corticosteroids, like dexamethasone, were common in critically ill patients, while tocilizumab was used in ECMO cases. Medications for the alimentary tract, metabolism, and cardiovascular system, although widely prescribed, were linked to more severe cases. Invasive mechanical ventilation correlated with higher usage of systemic anti-infectives and musculoskeletal medications. Trends in co-prescribing blood-forming drugs with those for acid-related disorders, analgesics, and antibacterials were associated with intensive interventions and worse outcomes.

CONCLUSIONS

The study highlights complex medication regimens in managing severe COVID-19, underscoring specific drug patterns associated with critical health outcomes. Further research is needed to explore these patterns.

Immunohistochemical Expression of Angiotensin-Converting Enzyme 2 in the Skin of Patients Affected by COVID-19

BACKGROUND

After many recorded cases of acute pneumonia of unknown cause, the World Health Organization announced COVID-19 as the start of a new coronavirus disease pandemic in 2019. Angiotensin-converting enzyme-2 (ACE2) is reduced by a protease known as transmembrane serine type 2 in the host cell, which then activates the S protein of SARS-CoV-2 regulating coronavirus entry into the host cells.

AIM

The aim of this study was to assess the immunohistochemical expression of ACE 2 in the skin of patients affected by COVID-19 with and without cutaneous manifestations and to correlate ACE2 expression with clinical and pathologic parameters.

METHODS

Skin biopsies were obtained from skin lesions of 25 patients presenting with cutaneous manifestations and from the left forearm of 22 patients without cutaneous manifestations. The specimens were processed for evaluation of histopathologic changes and ACE2 immunohistochemical evaluation.

RESULTS

Positive ACE2 expression was significantly higher in patients without cutaneous manifestations (96%) than those with cutaneous manifestations (72.7%). Positive ACE2 expression in the skin of affected patients was significantly associated with the presence of comorbidities, positive family history, high ABCD score, elevated lactate dehydrogenase, high D-dimer, rapid respiratory rate, and low oxygen saturation.

CONCLUSIONS

The skin could be involved in COVID-19 infection in the form of inflammatory changes, such as pityriasis rosea-like lesions. Patients with COVID-19 who presented with cutaneous manifestations are usually less severe. The presence of ACE2 in the skin of patients with COVID-19 is an indicator of worse status. Patients with COVID-19 without skin manifestations showed higher positivity for ACE2, which may explain the severity of the cases.

Association of antihypertensive drugs with COVID-19 outcomes: a drug-target Mendelian randomization study

Background: Observational investigations have provided conflicting results regarding the effect of antihypertensive drugs on the risk of COVID-19 outcomes. We intended to assess the causal effect of antihypertensive drugs on COVID-19 outcomes using drug-target Mendelian randomization (MR), mainly including angiotensin-converting enzyme inhibitors (ACEIs), β-blockers (BBs) and calcium channel blockers (CCBs). Methods: We used the genetic variants (minor allele frequency >1%, r 2 < 0.30) located within 100 k bases of each drug target gene and associated with lower systolic blood pressure (p < 5 × 10-8) as genetic proxies for antihypertensive drugs. COVID-19 outcomes included COVID-19 susceptibility (122,616 cases and 2,475,240 controls), hospitalization (32,519 cases and 206,2805 controls), and severe illness (13,769 cases and 1,072,442 controls). All studies were conducted on populations of European ancestry. MR estimates were generated using an inverse variance weighted (IVW) model. Results: IVW-MR analysis observed a weak causality between CCBs and COVID-19 susceptibility (OR: 0.993, 95% CI: 0.988-0.999, p = 0.012). Sensitivity analysis suggested that this result was robust. No evidence was found for a link between other antihypertensive drugs and COVID-19 outcomes. Conclusion: The present study suggests that CCBs may reduce COVID-19 susceptibility in European populations.

Prescription of renin-angiotensin system inhibitors in Japan during the COVID-19 pandemic: interrupted time series study

We surveyed changes in angiotensin-converting enzyme inhibitor (ACEIs) and angiotensin II receptor blocker (ARBs) prescription trends during the coronavirus disease 2019 (COVID-19) pandemic in Japan. Data of 1,605,708 outpatients with hypertension were extracted from the Medical Data Vision database. Trends for prescription of ACEIs and ARBs were assessed by analyzing the proportion of these prescriptions in each month, between April 2018 and November 2020. The proportion of ARBs prescriptions changed significantly in trend between the peri-pandemic and pre-pandemic periods (-0.05%/month, P = 0.012). In contrast, the proportion of ACEIs prescriptions did not change significantly in trend in the peri-pandemic period (0.01%/month, P = 0.189). There was no suggestion that the prescribing of ACEIs and ARBs was affected by the COVID-19 pandemic.

STUDY HYPOTHESIS: AGE, GENDER, PRESENCE OF DIABETES MELLITUS OR HYPERTENSION, AND ANTI-HYPERTENSIVE DRUGS ARE INDEPENDENT RISK FACTORS FOR COVID-19 MORTALITY

We aimed to investigate the effects of comorbid diseases and antihypertensive drugs on the clinical outcome of hospitalized patients with COVID-19 infection. A total of 1045 patients whose data could be gathered and confirmed from both hospital files and Turkish National Health Network records were retrospectively screened, and 264 of 1045 patients were excluded because of having more than one comorbid disease. The study population consisted of a total of 781 patients, of which 482 had no comorbid disease, while the remaining 299 patients had only one comorbid disease. The mortality risk was 7.532 times higher in those over 65 years of age compared to cases younger than 30 years (OR: 7.532; 95% CI: 1.733-32.730); the risk of mortality in men was 2.131 times higher than in women (OR: 2.131; 95% CI: 1.230-3.693); and presence of diabetes mellitus (DM) increased mortality risk 2.784 times (OR: 2.784; 95% CI: 1.288-6.019). While hypertension was not found to be an independent risk factor for COVID-19 mortality, age, gender, and presence of DM were independent risk factors for COVID-19 mortality. There was no association between antihypertensive drugs and mortality. Accordingly, age (>65 years), gender (male), and presence of DM were independent risk factors for COVID-19 mortality, whereas hypertension and use of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and their combinations with other antihypertensive drugs were not risk factors for COVID-19 mortality.

Ramipril for the Treatment of COVID-19: RAMIC, a Randomized, Double-Blind, Placebo-Controlled Clinical Trial

INTRODUCTION

Retrospective studies report that angiotensin-converting enzyme inhibitors (ACEIs) may reduce the severity of COVID-19, but prospective data on de novo treatment with ACEIs are limited. The RAMIC trial was a randomized, multicenter, placebo-controlled, double-blind, allocation-concealed clinical trial to examine the efficacy of de novo ramipril versus placebo for the treatment of COVID-19.

METHODS

Eligible participants were aged 18 years and older with a confirmed diagnosis of SARS-CoV-2 infection, recruited from urgent care clinics, emergency departments, and hospital inpatient wards at eight sites in the USA. Participants were randomly assigned to daily ramipril 2.5 mg or placebo orally in a 2:1 ratio, using permuted block randomization. Analyses were conducted on an intention-to-treat basis. The primary outcome was a composite of mortality, intensive care unit (ICU) admission, or invasive mechanical ventilation by day 14.

RESULTS

Between 27 May 2020 and 19 April 2021, a total of 114 participants (51% female) were randomized to ramipril (n = 79) or placebo (n = 35). The overall mean (± SD) age and BMI were 45 (± 15) years and 33 (± 8) kg/m2. Two participants in the ramipril group required ICU admission and one died, compared with none in the placebo group. There were no significant differences between ramipril and placebo in the primary endpoint (ICU admission, mechanical ventilation, or death) (3% versus 0%, p = 1.00) or adverse events (27% versus 29%, p = 0.82). The study was terminated early because of a low event rate and subsequent Emergency Use Authorization of therapies for COVID-19.

CONCLUSION

De novo ramipril was not different compared with placebo in improving or worsening clinical outcomes from COVID-19 but appeared safe in non-critically ill patients with COVID-19.

TRIAL REGISTRATION

Clinicaltrials.gov NCT04366050.

Association of COVID-19 outcomes with diabetes in the Veneto region (north-east italy): Epidemiological insights for the endemic phase?

BACKGROUND AND AIMS

Diabetes mellitus is a prevalent chronic disease in patients who die of COVID-19. The aim of this study was to investigate the clinical and metabolic characteristics of diabetic patients with COVID-19 during the pre-vaccination phase.

METHODS AND RESULTS

A retrospective cohort study was conducted from February 2020 to February 2021 to examine the clinical and metabolic profiles of unvaccinated diabetic patients affected by COVID-19. Data were collected from claim databases, hospital discharge records, and clinical records within a healthcare district located in northeastern Italy with a population of 936,000. Potential prognostic indicators including sex, age, Body Mass Index (BMI), duration and type of diabetes, metabolic control, and the use of antidiabetic, antihypertensive, lipid-lowering, and antiplatelet therapies were investigated. For hospitalized patients, additional variables were recorded, such as length of hospital stay, blood pressure at admission, comorbidities, D-dimer levels, blood glucose (BG), in-hospital insulin and corticosteroid therapies, requirement for mechanical ventilation (i.e., orotracheal or tracheostomy), admission to the Intensive Care Unit (ICU), and mortality. Diabetic patients hospitalized for COVID-19 with a poorer prognosis were characterized by advanced age, longer diabetes duration, hypertension, higher usage of sulfonylureas, and lower usage of dietotherapy alone, metformin, Glucagon-Like Peptide-1 Receptor agonists (GLP1-Ra), and Renin-Angiotensin-Aldosterone System inhibitors (RAAS-i).

CONCLUSION

Considering the potential for COVID-19 to become endemic, special care should be taken in managing older diabetic patients' treatments.

The RAAS Goodfellas in Cardiovascular System

In the last two decades, the study of the renin-angiotensin-aldosterone system (RAAS) has revealed a counterregulatory protective axis. This protective arm is characterized by ACE2/Ang 1-7/MasR and Ang 1-9 that largely counteracts the classic arm of the RAAS mediated by ACE/Ang II/AT1R/aldosterone and plays an important role in the prevention of inflammation, oxidative stress, hypertension, and cardiovascular remodeling. A growing body of evidence suggests that enhancement of this counterregulatory arm of RAAS represents an important therapeutic approach to facing cardiovascular comorbidities. In this review, we provide an overview of the beneficial effects of ACE2, Ang 1-7/MasR, and Ang 1-9 in the context of oxidative stress, vascular dysfunction, and organ damage.

Chronic anticoagulant treatment and risk of mortality in SARS-Cov2 patients: a large population-based study

BACKGROUND

Hypercoagulability is often seen in COVID-19 patients and thromboembolic events appear frequent; antithrombotic treatment has been proposed therefore as part of standard treatment for COVID-19. Under these premises, prior-to-infection antithrombotic treatment may have a protective effect with respect to COVID-19 related thromboembolic events. Aim of the present work was to evaluate the impact of prior-to-infection anticoagulant or antiplatelet treatment on COVID-19 outcomes.

METHODS

Beneficiaries of the Regional Health Service of the Lombardy region of Italy aged ≥40 years with a COVID-19 diagnosis made between February 21st and July 18th, 2020 were included in the present study. The impact on COVID-19 mortality of pre-existing and chronic therapy with anticoagulant drugs (vitamin-K antagonist or new oral anticoagulants) was evaluated. Analyses were repeated with antiplatelets drugs.

RESULTS

Among 79,934 SARS-CoV-2 patients beneficiaries of the Regional Healthcare System of the Lombardy Region who received a diagnosis between February 21st and July 18th, 2020, chronic pre-existing anticoagulant assumption was present in 6.0% and antiplatelets in 12.7%. The overall unadjusted mortality rate was 20.6%, with male sex, age category and comorbidity burden being significantly associated to increased mortality risk. Anticoagulant chronic treatment was not associated with a reduction in mortality. Similar results were observed when repeating the analyses for pre-existing oral antiplatelet treatment.

CONCLUSIONS

In a large population-based study evaluating more than 79,000 COVID-19 patients, pre-existing antithrombotic therapy was not associated to a benefit in terms of mortality. Further studies are needed to evaluate the role of antithrombotic therapy as standard treatment among COVID-19 patients.

Repurposed drug studies on the primary prevention of SARS-CoV-2 infection during the pandemic: systematic review and meta-analysis

OBJECTIVE

Current evidence on the effectiveness of SARS-CoV-2 prophylaxis is inconclusive. We aimed to systematically evaluate published studies on repurposed drugs for the prevention of laboratory-confirmed SARS-CoV-2 infection and/or COVID-19 among healthy adults.

DESIGN

Systematic review.

ELIGIBILITY

Quantitative experimental and observational intervention studies that evaluated the effectiveness of repurposed drugs for the primary prevention of SARS-CoV-2 infection and/or COVID-19 disease.

DATA SOURCE

PubMed and Embase (1 January 2020-28 September 2022).

RISK OF BIAS

Cochrane Risk of Bias 2.0 and Risk of Bias in Non-Randomised Studies of Interventions tools were applied to assess the quality of studies.

DATA ANALYSIS

Meta-analyses for each eligible drug were performed if ≥2 similar study designs were available.

RESULTS

In all, 65 (25 trials, 40 observational) and 29 publications were eligible for review and meta-analyses, respectively. Most studies pertained to hydroxychloroquine (32), ACE inhibitor (ACEi) or angiotensin receptor blocker (ARB) (11), statin (8), and ivermectin (8). In trials, hydroxychloroquine prophylaxis reduced laboratory-confirmed SARS-CoV-2 infection (risk ratio: 0.82 (95% CI 0.74 to 0.90), I2=48%), a result largely driven by one clinical trial (weight: 60.5%). Such beneficial effects were not observed in observational studies, nor for prognostic clinical outcomes. Ivermectin did not significantly reduce the risk of SARS-CoV-2 infection (RR: 0.35 (95% CI 0.10 to 1.26), I2=96%) and findings for clinical outcomes were inconsistent. Neither ACEi or ARB were beneficial in reducing SARS-CoV-2 infection. Most of the evidence from clinical trials was of moderate quality and of lower quality in observational studies.

CONCLUSIONS

Results from our analysis are insufficient to support an evidence-based repurposed drug policy for SARS-CoV-2 prophylaxis because of inconsistency. In the view of scarce supportive evidence on repurposing drugs for COVID-19, alternative strategies such as immunisation of vulnerable people are warranted to prevent the future waves of infection.

PROSPERO REGISTRATION NUMBER

CRD42021292797.

COVID-19 and Acute Cardiac Injury: Clinical Manifestations, Biomarkers, Mechanisms, Diagnosis, and Treatment

PURPOSE OF REVIEW

This review aims to comprehensively explore the clinical characteristics of COVID-19-related cardiac injury and examine the potential mechanisms underlying cardiac injury in patients affected by COVID-19.

RECENT FINDINGS

The COVID-19 pandemic has primarily been associated with severe respiratory symptoms. However, emerging evidence has indicated that a significant number of COVID-19 patients also experience myocardial injury, leading to conditions such as acute myocarditis, heart failure, acute coronary syndrome, and arrhythmias. The incidence of myocardial injury is notably higher in patients with preexisting cardiovascular diseases. Myocardial injury often manifests with elevated levels of inflammation biomarkers, as well as abnormalities observed on electrocardiograms and echocardiograms. COVID-19 infection has been found to be associated with myocardial injury, which can be attributed to several pathophysiological mechanisms. These mechanisms include injury caused by hypoxia, resulting from respiratory compromise, a systemic inflammatory response triggered by the infection, and direct attack on the myocardium by the virus itself. Furthermore, the angiotensin-converting enzyme 2 (ACE2) receptor plays a crucial role in this process. Early recognition, prompt diagnosis, and a comprehensive understanding of the underlying mechanisms are essential for effectively managing and reducing the mortality associated with myocardial injury in COVID-19 patients.

COVID-19 and the Use of Angiotensin II Receptor Blockers in Older Chronic Hypertensive Patients: Systematic Review and Meta-Analysis

Angiotensin II-converting enzyme inhibitors (ACEIs) and selective angiotensin II receptor antagonists (ARAIIs) are widely used antihypertensive agents. Their use has generated controversy due to their possible influence on the health status of chronic patients infected with COVID-19. The objective of this work is to analyze the influence of COVID-19 on chronic hypertensive patients treated with ACEI and ARAII inhibitors. A systematic review and meta-analysis in the databases Pubmed, Pro-Quest and Scopus were carried out. The systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search equation descriptors were obtained from the Medical Subject Headings (MeSH) thesaurus. The search equation was: "Older AND hypertension AND (COVID-19 OR coronavirus) AND primary care" and its equivalent in Spanish. Nineteen articles were obtained, with n = 10,806,159 subjects. Several studies describe the COVID-19 association with ACEI or ARAII treatment in hypertension patients as a protective factor, some as a risk factor, and others without a risk association. In the case of ACEI vs. ARAII, the risk described for the former has an odds ratio (OR) of 0.55, and for ARAII, an OR of 0.59. Some authors talk about mortality associated with COVID-19 and ACEI with a half ratio (HR) of 0.97, and also associated ARAIIs with an HR of 0.98. It is recommended to maintain the use of the renin-angiotensin-aldosterone axis in the context of the COVID-19 disease.

Losartan in hospitalized patients with COVID-19 in North America: An individual participant data meta-analysis

BACKGROUND

Angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers (ARBs) have been hypothesized to benefit patients with COVID-19 via the inhibition of viral entry and other mechanisms. We conducted an individual participant data (IPD) meta-analysis assessing the effect of starting the ARB losartan in recently hospitalized COVID-19 patients.

METHODS

We searched ClinicalTrials.gov in January 2021 for U.S./Canada-based trials where an angiotensin-converting enzyme inhibitors/ARB was a treatment arm, targeted outcomes could be extrapolated, and data sharing was allowed. Our primary outcome was a 7-point COVID-19 ordinal score measured 13 to 16 days post-enrollment. We analyzed data by fitting multilevel Bayesian ordinal regression models and standardizing the resulting predictions.

RESULTS

325 participants (156 losartan vs 169 control) from 4 studies contributed IPD. Three were randomized trials; one used non-randomized concurrent and historical controls. Baseline covariates were reasonably balanced for the randomized trials. All studies evaluated losartan. We found equivocal evidence of a difference in ordinal scores 13-16 days post-enrollment (model-standardized odds ratio [OR] 1.10, 95% credible interval [CrI] 0.76-1.71; adjusted OR 1.15, 95% CrI 0.15-3.59) and no compelling evidence of treatment effect heterogeneity among prespecified subgroups. Losartan had worse effects for those taking corticosteroids at baseline after adjusting for covariates (ratio of adjusted ORs 0.29, 95% CrI 0.08-0.99). Hypotension serious adverse event rates were numerically higher with losartan.

CONCLUSIONS

In this IPD meta-analysis of hospitalized COVID-19 patients, we found no convincing evidence for the benefit of losartan versus control treatment, but a higher rate of hypotension adverse events with losartan.

The effect of COVID-19 on the in-hospital outcomes of percutaneous coronary intervention in patients with acute coronary syndrome: A large scale meta-analysis

Aim

We aimed to study the effect of COVID-19 on the in-hospital outcomes of percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS).

Method

A systematic literature search was performed in 2nd February 2022 updated in 12th December 2022 for recruiting relevant papers. The effect size was computed via the odds ratio (OR) for dichotomous data or standardized mean difference (SMD) for continuous data along with the 95% confidence interval (95%CI).

Results

After the screening of 1075 records, we found 11 relevant papers that included 2018 COVID-19 patients and negative controls 21,207. ACS patients with COVID-19 had a significant higher mortality rate (OR: 4.95; 95%CI: 3.92-6.36; p <0.01), long hospital stay (days) (SMD: 1.17; 95%CI: 0.92-1.42; p <0.01), and reduced post TIMI 3 score (OR: 0.55; 95%CI: 0.41-0.73; p <0.01) rather than controls. However, we found no significant differences in terms of thrombus aspiration prevalence (OR: 1.88; 95%CI: 0.97-3.65; p = 0.06) or door to balloon time (SMD: 0.11; 95%CI: -0.43-0.66; p = 0.7).

Conclusion

Despite that we found a significant association between COVID-19 and high mortality, more length of hospital stay and reduced post TIMI 3 score, in ACS patients after PCI, a rigorous analysis of the adjusted hazard ratio -that was absent in most of the included studies- by further meta-analysis is recommended to confirm this association. However, close monitoring of COVID-19 in patients with a high risk of developing ACS, is recommended due to the associated hypercoagulability of COVID-19 infection.

Interaction of COVID-19 With Common Cardiovascular Disorders

The onset and widespread dissemination of the severe acute respiratory syndrome coronavirus-2 in late 2019 impacted the world in a way not seen since the 1918 H1N1 pandemic, colloquially known as the Spanish Flu. Much like the Spanish Flu, which was observed to disproportionately impact young adults, it became clear in the early days of the coronavirus disease 2019 (COVID-19) pandemic that certain groups appeared to be at higher risk for severe illness once infected. One such group that immediately came to the forefront and garnered international attention was patients with preexisting cardiovascular disease. Here, we examine the available literature describing the interaction of COVID-19 with a myriad of cardiovascular conditions and diseases, paying particular attention to patients diagnosed with arrythmias, heart failure, and coronary artery disease. We further discuss the association of acute COVID-19 with de novo cardiovascular disease, including myocardial infarction due to coronary thrombosis, myocarditis, and new onset arrhythmias. We will evaluate various biochemical theories to explain these findings, including possible mechanisms of direct myocardial injury caused by the severe acute respiratory syndrome coronavirus-2 virus at the cellular level. Finally, we will discuss the strategies employed by numerous groups and governing bodies within the cardiovascular disease community to address the unprecedented challenges posed to the care of our most vulnerable patients, including heart transplant recipients, end-stage heart failure patients, and patients suffering from acute coronary syndromes, during the early days and height of the COVID-19 pandemic.

Patients with COPD hospitalized due to COVID-19 in Spain: a comparison between the first and second wave

OBJECTIVE

This work aimed to compare the characteristics, progress, and prognosis of patients with COPD hospitalized due to COVID-19 in Spain in the first wave with those of the second wave.

MATERIAL AND METHODS

This is an observational study of patients hospitalized in Spain with a diagnosis of COPD included in the SEMI-COVID-19 registry. The medical history, symptoms, analytical and radiological results, treatment, and progress of patients with COPD hospitalized in the first wave (from March to June 2020) versus those hospitalized in the second wave (from July to December 2020) were compared. Factors associated with poor prognosis, defined as all-cause mortality and a composite endpoint that included mortality, high-flow oxygen therapy, mechanical ventilation, and ICU admission, were analyzed.

RESULTS

Of the 21,642 patients in the SEMI-COVID-19 Registry, 6.9% were diagnosed with COPD: 1128 (6.8%) in WAVE1 and 374 (7.7%) in WAVE2 (p = 0.04). WAVE2 patients presented less dry cough, fever and dyspnea, hypoxemia (43% vs 36%, p < 0.05), and radiological condensation (46% vs 31%, p < 0.05) than WAVE1 patients. Mortality was lower in WAVE2 (35% vs 28.6%, p = 0.01). In the total sample, mortality and the composite outcome of poor prognosis were lower among patients who received inhalation therapy.

CONCLUSIONS

Patients with COPD admitted to the hospital due to COVID-19 in the second wave had less respiratory failure and less radiological involvement as well as a better prognosis. These patients should receive bronchodilator treatment if there is no contraindication for it.

Prevalence of Cardiovascular Complications in Coronavirus Disease 2019 adult Patients: A Systematic Review and Meta-Analysis

Background

It has been found that the new coronavirus can affect various parts of the cardiovascular system. Cardiovascular complications caused by coronavirus disease 2019 (COVID-19) are often serious and can increase the mortality rate among infected patients. This study aimed to investigate the prevalence of cardiovascular complications in COVID-19 adult patients.

Methods

A systematic review and meta-analysis of observational studies published in English were conducted between December 2019 and February 2021. A complete search was performed in PubMed (PubMed Central and MEDLINE), Google Scholar, Cochrane Library, Science Direct, Ovid, Embase, Scopus, CINAHL, Web of Science, and WILEY, as well as BioRXiv, MedRXiv, and gray literature. A random effect model was used to examine the prevalence of cardiovascular complications among COVID-19 patients. The I2 test was used to measure heterogeneity across the included studies.

Results

A total of 74 studies involving 34,379 COVID-19 patients were included for meta-analysis. The mean age of the participants was 61.30±14.75 years. The overall pooled prevalence of cardiovascular complications was 23.45%. The most prevalent complications were acute myocardial injury (AMI) (19.38%, 95% CI=13.62-26.81, test for heterogeneity I2=97.5%, P<0.001), arrhythmia (11.16%, 95% CI=8.23-14.96, test for heterogeneity I2=91.5%, P<0.001), heart failure (HF) (7.56%, 95% CI=4.50-12.45, test for heterogeneity I2=96.3%, P<0.001), and cardiomyopathy (2.78%, 95% CI=0.34-9.68). The highest pooled prevalence of cardiac enzymes was lactate dehydrogenase (61.45%), troponin (23.10%), and creatine kinase-myocardial band or creatine kinase (14.52%).

Conclusion

The high prevalence of serious cardiovascular complications in COVID-19 patients (AMI, arrhythmia, and HF) necessitates increased awareness by healthcare administrators.

[Patients with COPD hospitalized due to COVID-19 in Spain: a comparison between the first and second wave]

Objective

This work aimed to compare the characteristics, progress, and prognosis of patients with COPD hospitalized due to COVID-19 in Spain in the first wave with those of the second wave.

Material and methods

This is an observational study of patients hospitalized in Spain with a diagnosis of COPD included in the SEMI-COVID-19 registry. The medical history, symptoms, analytical and radiological results, treatment, and progress of patients with COPD hospitalized in the first wave (from March to June 2020) versus those hospitalized in the second wave (from July to December 2020) were compared. Factors associated with poor prognosis, defined as all-cause mortality and a composite endpoint that included mortality, high-flow oxygen therapy, mechanical ventilation, and ICU admission, were analyzed.

Results

Of the 21,642 patients in the SEMI-COVID-19 Registry, 6.9% were diagnosed with COPD: 1,128 (6.8%) in WAVE1 and 374 (7.7%) in WAVE2 (p = 0.04). WAVE2 patients presented less dry cough, fever and dyspnea, hypoxemia (43% vs 36%, p < 0.05), and radiological condensation (46% vs 31%, p < 0.05) than WAVE1 patients. Mortality was lower in WAVE2 (35% vs 28.6%, p = 0.01). In the total sample, mortality and the composite outcome of poor prognosis were lower among patients who received inhalation therapy.

Conclusions

Patients with COPD admitted to the hospital due to COVID-19 in the second wave had less respiratory failure and less radiological involvement as well as a better prognosis. These patients should receive bronchodilator treatment if there is no contraindication for it.

RAAS inhibition and beyond-cardiovascular medications in patients at risk of or affected by COVID-19

The COVID-19 pandemic led to an enormous burden on healthcare systems worldwide. Causal therapy is still in its infancy. Contrary to initial views that the use of angiotensin-converting enzyme inhibitors (ACEi)/angiotensin II receptor blockers (ARBs) may increase the risk for a deleterious disease course, it has been shown that these agents may actually be beneficial for patients affected by COVID-19. In this article, we provide an overview of the three most commonly used classes of drugs in cardiovascular disease (ACEi/ARB, statins, beta-blockers) and their potential role in COVID-19 therapy. More results from randomized clinical trials are necessary to identify patients that can benefit most from the use of the respective drugs.

Atherosclerosis, Cardiovascular Disease, and COVID-19: A Narrative Review

Atherosclerosis is a chronic inflammatory and degenerative process that mainly occurs in large- and medium-sized arteries and is morphologically characterized by asymmetric focal thickenings of the innermost layer of the artery, the intima. This process is the basis of cardiovascular diseases (CVDs), the most common cause of death worldwide. Some studies suggest a bidirectional link between atherosclerosis and the consequent CVD with COVID-19. The aims of this narrative review are (1) to provide an overview of the most recent studies that point out a bidirectional relation between COVID-19 and atherosclerosis and (2) to summarize the impact of cardiovascular drugs on COVID-19 outcomes. A growing body of evidence shows that COVID-19 prognosis in individuals with CVD is worse compared with those without. Moreover, various studies have reported the emergence of newly diagnosed patients with CVD after COVID-19. The most common treatments for CVD may influence COVID-19 outcomes. Thus, their implication in the infection process is briefly discussed in this review. A better understanding of the link among atherosclerosis, CVD, and COVID-19 could proactively identify risk factors and, as a result, develop strategies to improve the prognosis for these patients.

Clinical and social determinants of health features of SARS-CoV-2 infection among Black and Caribbean Hispanic patients with heart failure: The SCAN-MP Study

Patients with heart failure (HF) often have multiple chronic conditions and are at increased risk for severe disease and mortality when infected by SARS-CoV-2, the virus that causes COVID-19. Furthermore, disparities in outcomes with COVID-19 have been associated with both racial/ethnic identity but also social determinants of health. Among older, urban-dwelling, minority patients with HF, we sought to characterize medical and non-medical factors associated with SARS-CoV-2 infection. Patients with HF living in Boston and New York City over 60 years of age participating in the Screening for Cardiac Amyloidosis with Nuclear Imaging (SCAN-MP) study between 12/1/2019 and 10/15/2021 (n = 180) were tested for nucleocapsid antibodies to SARS-CoV-2 and queried for symptomatic infection with PCR verification. Baseline testing included the Kansas City Cardiomyopathy Questionnaire (KCCQ), assessment of health literacy, biochemical, functional capacity, echocardiography, and a novel survey tool that determined living conditions, perceived risk of infection, and attitudes towards COVID-19 mitigation. The association of infection with prevalent socio-economic conditions was assessed by the area deprivation index (ADI). There were 50 overall cases of SARS-CoV-2 infection (28%) including 40 demonstrating antibodies to SARS-CoV-2 (indicative of prior infection) and 10 positive PCR tests. There was no overlap between these groups. The first documented case from New York City indicated infection prior to January 17, 2020. Among active smokers, none tested positive for prior SARS-CoV-2 infection (0 (0%) vs. 20 (15%), p = 0.004) vs. non-smokers. Cases were more likely to be taking ACE-inhibitors/ARBs compared to non-cases (78% vs 62%, p = 0.04). Over a mean follow-up of 9.6 months, there were 6 total deaths (3.3%) all unrelated to COVID-19. Death and hospitalizations (n = 84) were not associated with incident (PCR tested) or prior (antibody) SARS-CoV-2 infection. There was no difference in age, co-morbidities, living conditions, attitudes toward mitigation, health literacy, or ADI between those with and without infection. SARS-CoV-2 infection was common among older, minority patients with HF living in New York City and Boston, with evidence of infection documented in early January 2020. Health literacy and ADI were not associated with infection, and there was no increased mortality or hospitalizations among those infected with SARS-CoV-2.