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Continued in-hospital ACE inhibitor and ARB Use in hypertensive COVID-19 patients is associated with positive clinical outcomes

Our take —

There had been early concern that patients with hypertension might be at risk for more severe COVID-19 if they continued taking ACE inhibitors or ARBs. However, several studies have failed to show any increased risk associated with the use of these antihypertensive medications. In this single-center study, hyptertensive patients who continued to use ACE inhibitors or ARBs after COVID-19 hospitalization experienced lower mortality and rates of ICU admission compared to those who discontinued their use. Although these patients may not have been comparable in unmeasured ways, this study provides additional support for keeping patients on these medications while in the hospital.

Study design

Retrospective Cohort

Study population and setting

This study included 614 patients with a history of hypertension who were hospitalized with PCR-confirmed SARS-CoV-2 infection in a single hospital in New York State from February 7 to May 23, 2020. Patients were categorized into three groups: 1) those who had not been taking angiotensin-converting enzyme inhibitors (ACEi) or angiotensin II receptor blockers (ARB) at home (n=279), 2) those who had been taking these medications at home but discontinued in the hospital (n=171), and 3) those who continued taking these medications in the hospital (n=164). The primary outcome of interest was death in hospital, and the secondary outcome was ICU admission. Authors extracted demographic and clinical data from medical records at hospital admission. Multivariable logistic regression was used to compare those who continued vs. those who discontinued ACEi and ARB use.

Summary of Main Findings

Among non-users of ACEi and ARB (group A), 62/279 patients died (22%); among those who discontinued ACEi and ARB in the hospital (group B), 48/171 patients died (28%); and among those who continued using ACEi and ARB in the hospital (group C), 10/164 patients died (6%). Adjusting for age, sex, history of heart disease, COPD, and asthma, those in group C had lower odds of mortality than those in group B (OR: 0.22, 95% CI: 0.10-0.46). In adjusted models, those in group B and C combined had no statistically significant difference in odds of mortality compared to those in group A (OR: 0.81, 95% CI: 0.53-1.24). Because those discontinuing ACEi and ARB use had higher incident hypotension and acute kidney disease (AKI), each of which may have indicated discontinuation, analyses were also stratified by hypotension and AKI. In these analyses, continuing ACEi and ARB use was associated with lower mortality relative to discontinuation among patients without hypotension and among patients without AKI. ICU admission rates were also lower in group C relative to group B in both unadjusted and adjusted analyses; the protective association between continued ACEi/ARB use (vs. discontinued ACEi/ARB use) and ICU admission persisted in the subgroup of patients without AKI and moderately in the group with hypotension.

Study Strengths

This study stratified by two important potential confounders, the development of hypotension and acute kidney disease, both of which are reasons for discontinuation of ACEi and ARB medications.

Limitations

There may have been determinants of ACEi and ARB discontinuation that were not adequately controlled in analyses. The timing of discontinuation among patients was not presented or analyzed, though this may have influenced clinical outcomes. ACEi and ARB medications were not disaggregated. The sample sizes, particularly in stratified analyses, were not large.

Value added

This study provides additional evidence that use of ACE inhibitors and ARBs are not associated with more severe COVID-19 outcomes, even when their use is continued after hospitalization.

This review was posted on: 8 September 2020