Antihypertensives do not increase risk of COVID-19 infection or its severity

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Antihypertensive medications acting on the renin-angiotensin-aldosterone system were not found to increase the risk of either testing positive for coronavirus disease 2019 (COVID-19) or experiencing a more severe disease course, according to the findings of an observational analysis.

Since the viral receptor for COVID-19 is angiotensin-converting enzyme 2 (ACE2), researchers have questioned whether patients receiving antihypertensive drugs acting on the renin-angiotensin-aldosterone hormonal system have worse outcomes if exposed to the virus.

The study, which began in mid-March, aimed to determine the association between previous use of ACE inhibitors, angiotensin-receptor blockers, beta-blockers, calcium-channel blockers, or thiazide diuretics with the likelihood of a positive COVID-19 test result as well as the risk of experiencing severe illness (intensive care, mechanical ventilation, or death).

The study utilised the New York University (NYU) Langone Health electronic health record to obtain the medical histories of patients who had been tested for COVID-19. “Using Bayesian methods, we compared outcomes in patients who had been treated with these medications and in untreated patients, overall and in those with hypertension, after propensity-score matching for receipt of each medication class,” the authors explained. A difference of ≥10 percentage points was considered to be a substantial difference in the likelihood of the outcome.

Of the total patients who were tested f or COVID-19 (N=12,594), 46.8% (n=5894) tested positive and 17.0% (n=1002) of the positive cases were considered to be severe. Among all the patients, 34.6% (n=4357) had a history of hypertension, and of these patients, 59.1% (n=2573) tested positive for COVID-19 and 24.6% (n=634) experienced severe illness.

“There was no association between any single medication class and an increased likelihood of a positive test,” the study authors reported. They added, “None of the medications examined was associated with a substantial increase in the risk of severe illness among patients who tested positive.”

The study was conducted to add to the body of evidence related to the optimal care of cardiovascular disease patients diagnosed with COVID-19. In a joint statement, the American Heart Association (AHA), the Heart Failure Society of America (HFSA), and the American College of Cardiology (ACC) highlighted the need for obtaining this additional research.

“With nearly half of American adults having high blood pressure, and heart disease patients more vulnerable to COVID-19, understanding the relationship between these commonly used medications and COVID-19 was a critical public health concern,” said lead investigator Dr Harmony Reynolds, associate director of the Cardiovascular Clinical Research Centre at NYU Langone Health. “Our findings should reassure the medical community and patients about the continued use of these commonly prescribed medications, which prevent potentially severe heart events in their own right.”

Abstract
Background: There is concern about the potential of an increased risk related to medications that act on the renin–angiotensin–aldosterone system in patients exposed to coronavirus disease 2019 (Covid-19), because the viral receptor is angiotensin-converting enzyme 2 (ACE2).
Methods: We assessed the relation between previous treatment with ACE inhibitors, angiotensin-receptor blockers, beta-blockers, calcium-channel blockers, or thiazide diuretics and the likelihood of a positive or negative result on Covid-19 testing as well as the likelihood of severe illness (defined as intensive care, mechanical ventilation, or death) among patients who tested positive. Using Bayesian methods, we compared outcomes in patients who had been treated with these medications and in untreated patients, overall and in those with hypertension, after propensity-score matching for receipt of each medication class. A difference of at least 10 percentage points was prespecified as a substantial difference.

Results: Among 12,594 patients who were tested for Covid-19, a total of 5894 (46.8%) were positive; 1002 of these patients (17.0%) had severe illness. A history of hypertension was present in 4357 patients (34.6%), among whom 2573 (59.1%) had a positive test; 634 of these patients (24.6%) had severe illness. There was no association between any single medication class and an increased likelihood of a positive test. None of the medications examined was associated with a substantial increase in the risk of severe illness among patients who tested positive.
Conclusions: We found no substantial increase in the likelihood of a positive test for Covid-19 or in the risk of severe Covid-19 among patients who tested positive in association with five common classes of antihypertensive medications.

Authors
Harmony R Reynolds, Samrachana Adhikari, Claudia Pulgarin, Andrea B Troxel, Eduardo Iturrate, Stephen B Johnson, Anaïs Hausvater, Jonathan D Newman, Jeffrey S Berger, Sripal Bangalore, Stuart D Katz, Glenn I Fishman, Dennis Kunichoff, Yu Chen, Gbenga Ogedegbe, Judith S Hochman

Infectious Disease Advisor material

NEJM abstract

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