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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. Eur Heart J Cardiovasc Pharmacother 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] [What about the content of this article? (0)] [Affiliation(s)] [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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Nakamura A, Kagaya Y, Saito H, Kanazawa M, Miura M, Kondo M, Sato K, Endo H. Effects of switching from sacubitril/valsartan to valsartan alone on plasma levels of natriuretic peptides and myocardial remodeling in heart failure with reduced ejection fraction. BMC Cardiovasc Disord 2023; 23:39. [PMID: 36681789 PMCID: PMC9862569 DOI: 10.1186/s12872-023-03077-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 01/18/2023] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND We examined the effect of switching from angiotensin receptor-neprilysin inhibitor (ARNI) to angiotensin-receptor blocker (ARB) on plasma levels of natriuretic peptides and myocardial remodeling. METHODS This is a prospective study that included 11 patients with heart failure (HF) treated with ARNI. The patients were divided into two groups: 5 patients who continued treatment with sacubitril/valsartan 194/206 mg/day (ARNI-continue group) and 6 patients who were switched to valsartan 160 mg/day (ARB-switch group). The primary endpoint was percent change (%Change) in plasma A-, B-, and N-terminal pro-B-type natriuretic peptide (ANP, BNP, and NT-proBNP) levels from the baseline to week 24. The secondary endpoint was the change in echocardiographic parameters related to myocardial remodeling from the baseline to week 24. RESULTS ANP levels in the ARB-switch group significantly decreased (from 1155.7 ± 592.6 pg/mL to 231.6 ± 233.8 pg/mL, p = 0.035), whereas those in the ARNI-continue group were not significant (p = 0.180). The %Change of decrease in ANP levels was significantly greater in the ARB-switch group than the ARNI-continue group (- 76.9% vs. -9.1%, p = 0.009). BNP levels were not significantly different between the baseline and week 24 in both groups. NT-proBNP levels in the ARB-switch group increased from 1185.3 ± 835.6 pg/mL to 1515.2 ± 1213.5 pg/mL, although the changes were not statistically significant (p = 0.345). The %Change of increase in NT-proBNP levels was significantly greater in the ARB-switch group than the ARNI-continue group (57.9% vs. 17.3%, p = 0.016). In the ARB-switch group, there was a significant increase in left ventricular (LV) end-systolic volume (from 41.3 ± 24.1 mL/m2 to 71.4 ± 8.8 mL/m2, p = 0.043) and LV peak-systolic wall stress (from 187.0 ± 42.7 × 103 dynes/cm2 to 279.7 ± 34.1 × 103 dynes/cm2, p = 0.012) from the baseline to week 24 and a trend toward a decrease in LV ejection fraction (p = 0.080). In the ARNI-continue group, no differences in echocardiographic parameters were observed from the baseline to week 24. CONCLUSION Switching from ARNI to ARB may worsen HF due to returning to myocardial remodeling induced by a sustained decline in ANP levels.
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Affiliation(s)
- Akihiro Nakamura
- Department of Cardiology, Iwate Prefectural Central Hospital, 1-4-1 Ueda, Morioka, Iwate, 020-0066, Japan.
| | - Yuta Kagaya
- Department of Cardiology, Iwate Prefectural Central Hospital, 1-4-1 Ueda, Morioka, Iwate, 020-0066, Japan
| | - Hiroki Saito
- Department of Cardiology, Iwate Prefectural Central Hospital, 1-4-1 Ueda, Morioka, Iwate, 020-0066, Japan
| | - Masanori Kanazawa
- Department of Cardiology, Iwate Prefectural Central Hospital, 1-4-1 Ueda, Morioka, Iwate, 020-0066, Japan
| | - Masanobu Miura
- Department of Cardiology, Iwate Prefectural Central Hospital, 1-4-1 Ueda, Morioka, Iwate, 020-0066, Japan
| | - Masateru Kondo
- Department of Cardiology, Iwate Prefectural Central Hospital, 1-4-1 Ueda, Morioka, Iwate, 020-0066, Japan
| | - Kenjiro Sato
- Department of Cardiology, Iwate Prefectural Central Hospital, 1-4-1 Ueda, Morioka, Iwate, 020-0066, Japan
| | - Hideaki Endo
- Department of Cardiology, Iwate Prefectural Central Hospital, 1-4-1 Ueda, Morioka, Iwate, 020-0066, Japan
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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. Int J Cardiol Heart Vasc 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] [What about the content of this article? (0)] [Affiliation(s)] [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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Desai AS, McMurray JJV, Packer M, Swedberg K, Rouleau JL, Chen F, Gong J, Rizkala AR, Brahimi A, Claggett B, Finn PV, Hartley LH, Liu J, Lefkowitz M, Shi V, Zile MR, Solomon SD. Effect of the angiotensin-receptor-neprilysin inhibitor LCZ696 compared with enalapril on mode of death in heart failure patients. Eur Heart J 2015; 36:1990-7. [PMID: 26022006 DOI: 10.1093/eurheartj/ehv186] [Citation(s) in RCA: 298] [Impact Index Per Article: 33.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 04/23/2015] [Indexed: 11/13/2022] Open
Abstract
AIMS The angiotensin-receptor-neprilysin inhibitor (ARNI) LCZ696 reduced cardiovascular deaths and all-cause mortality compared with enalapril in patients with chronic heart failure in the prospective comparison of ARNI with an Angiotensin-Converting Enzyme Inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure (PARADIGM-HF) trial. To more completely understand the components of this mortality benefit, we examined the effect of LCZ696 on mode of death. METHODS AND RESULTS PARADIGM-HF was a prospective, double-blind, randomized trial in 8399 patients with chronic heart failure, New York Heart Association Class II-IV symptoms, and left ventricular ejection fraction ≤40% receiving guideline-recommended medical therapy and followed for a median of 27 months. Mode of death was adjudicated by a blinded clinical endpoints committee. The majority of deaths were cardiovascular (80.9%), and the risk of cardiovascular death was significantly reduced by treatment with LCZ (hazard ratio, HR 0.80, 95% CI 0.72-0.89, P < 0.001). Among cardiovascular deaths, both sudden cardiac death (HR 0.80, 95% CI 0.68-0.94, P = 0.008) and death due to worsening heart failure (HR 0.79, 95% CI 0.64-0.98, P = 0.034) were reduced by treatment with LCZ696 compared with enalapril. Deaths attributed to other cardiovascular causes, including myocardial infarction and stroke, were infrequent and distributed evenly between treatment groups, as were non-cardiovascular deaths. CONCLUSIONS LCZ696 was superior to enalapril in reducing both sudden cardiac deaths and deaths from worsening heart failure, which accounted for the majority of cardiovascular deaths. CLINICAL TRIAL REGISTRATION https://clinicaltrials.gov/, NCT01035255.
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Affiliation(s)
- Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Center, University of Glasgow, Glasgow, UK
| | - Milton Packer
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, USA
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden National Heart and Lung Institute, Imperial College, London, UK
| | - Jean L Rouleau
- Institut de Cardiologie, Université de Montréal, Montreal, Canada
| | - Fabian Chen
- Novartis Pharmaceuticals Corporation, East Hanover, USA
| | - Jianjian Gong
- Novartis Pharmaceuticals Corporation, East Hanover, USA
| | | | - Abdel Brahimi
- Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Brian Claggett
- Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Peter V Finn
- Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Loren Howard Hartley
- Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Jiankang Liu
- Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | | | - Victor Shi
- Novartis Pharmaceuticals Corporation, East Hanover, USA
| | - Michael R Zile
- Medical University of South Carolina and Ralph H. Johnston Veterans Administration Medical Center, Charleston, USA
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
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Capoulade R, Clavel MA, Mathieu P, Côté N, Dumesnil JG, Arsenault M, Bédard E, Pibarot P. Impact of hypertension and renin-angiotensin system inhibitors in aortic stenosis. Eur J Clin Invest 2013; 43:1262-72. [PMID: 24117162 DOI: 10.1111/eci.12169] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Accepted: 08/29/2013] [Indexed: 12/24/2022]
Abstract
BACKGROUND Experimental studies revealed that renin-angiotensin system (RAS) could play a crucial role in the pathophysiology of aortic stenosis (AS). The objectives of this study were to examine (i) the impact of hypertension on AS progression and clinical events and (ii) the effect of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin-receptor blockers (ARBs). MATERIALS AND METHODS In this observational study, we retrospectively analysed clinical and Doppler echocardiographic data prospectively collected in 338 patients with AS. Patients were separated into four groups: patients without hypertension and not treated by RAS medication (Ctrl group), patients with hypertension but not treated by RAS medication (HTN group), patients treated with ACEIs, and patients treated with ARBs. AS progression rate was assessed by the annualized increase in peak aortic jet velocity. RESULTS Compared with Ctrl group, patients in HTN group had faster stenosis progression (P = 0·01). Patients on ARBs had slower AS progression compared with Ctrl (trend P = 0·10) and HTN (P = 0·002) groups, whereas patients on ACEIs had similar progression rate compared with Ctrl group (P = NS) but lower compared with HTN group (P = 0·02). On multivariable analysis, compared with Ctrl group, HTN group was associated with faster AS progression rate (P = 0·002), whereas ARBs with slower progression (P = 0·0008). During a mean follow-up of 6·2 ± 2·4 years, HTN (hazard ratio [HR] = 2·45; P = 0·006) and ACEI (HR = 2·30; P = 0·01) groups were associated with a significant increase in all-cause mortality compared with Ctrl group, whereas ARB group (HR: 0·89; P = 0·80) not. In multivariable analysis, HTN and ACEI groups remained associated with increased mortality. CONCLUSIONS Hypertension is associated with significantly faster stenosis progression and higher incidence of clinical events in patients with AS. ARBs but not ACEs were found to abolish the increased risk of mortality associated with hypertension.
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Affiliation(s)
- Romain Capoulade
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec city, QC, Canada
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Rodríguez-Mañero M, Abu-Assi E, López MJV, de Blas Abad P, Fernández GG, Alcalde CC, Loureiro MS, García-Seara J, Pérez RCV, González-Juanatey JR. Left bundle branch block in atrial fibrillation patients without heart failure. Int J Cardiol 2013; 168:5460-2. [PMID: 24007968 DOI: 10.1016/j.ijcard.2013.07.250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Accepted: 07/25/2013] [Indexed: 11/18/2022]
Affiliation(s)
- Moisés Rodríguez-Mañero
- Servizo de Cardioloxía, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS), SERGAS, Santiago de Compostela, Spain.
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