The American College of Cardilology (American College of Cardiology ACC)” next to “The American Heart Association (American Heart Association (AHA) ”issued a joint statement to address concerns about the coronavirus and a group of drugs called antagonists renin angiotensin aldosterone system (RAAS), They are often recommended for patients with high blood pressure or heart failure.
The statement is especially important for heart disease patients, because people with heart disease appear to be more likely to get COVID-19.
RAAS is a hormonal system that regulates blood pressure, the extracellular body volume and the balance of sodium and potassium in our body. It is an elegant cascade of vasoactive peptides that orchestrates key processes in human physiology. When blood pressure drops (to systolic, to 100 mm Hg or less), the kidneys release the enzyme renin into the bloodstream.
Coronaviruses of severe acute respiratory syndrome 1 (SARS-CoV-1) and 2 (SARS-CoV-2), responsible for the SARS epidemic in 2002-2004 and the most recent coronavirus disease pandemic 2019 (Covid-19), respectively, interact with SARS through the angiotensin-converting enzyme 2 (ECA2 or ACE2) , which physiologically counteracts SARS activation but also functions as a receptor for both viruses.
The interaction between the SARS and ACE2 viruses has been proposed as a potential factor in their infectivity, and There is concern about the use of SARS inhibitors that may alter ACE2 and be partly responsible for the virulence of Covid-19 disease. In fact, some scientists and doctors have recently called for the suspension of ACE inhibitors (IACE) and angiotensin II receptor antagonists (ARA II), both prophylactically and in the context of Covid’s clinical suspicion. -19.
In an analysis by Dr. Muthiah Vaduganathan of the Cardiovascular Division, Brigham and Women’s Hospital, and Harvard Medical School, Boston, in the scientific journal New England Journal of Medicine, He claims that human data is too limited to support or refute these hypotheses and concerns.
“Specifically, we discussed the uncertain effects of RAAS blockers on ACE2 levels and activity in humans, and we propose an alternative hypothesis that ACE2 may be beneficial rather than harmful in patients with lung injury. We also expressly express concern that withdrawal of RAAS inhibitors may be harmful in certain high-risk patients with Covid-19 known or suspected ”, specifies the specialist.
Covid-19 and older adults with coexisting conditions
Initial reports have drawn attention to possible excessive hypertension in patients with Covid-19. In one of the largest Chinese studies published during the Covid-19 pandemic, the hypertension was the most frequent coexisting condition in 1099 patients, with an estimated prevalence of fifteen%; however, this estimate appears to be less than the estimated prevalence of hypertension observed with other viral infections 10 and in the general population in China.
Coexisting conditions, including hypertension are more common among patients with Covid-19 who have had a serious illness, were admitted to the intensive care unit, received mechanical ventilation or died than among patients who had a mild illness.
There is concern that medical treatment of these coexisting conditions, including the use of RAAS inhibitors, may have contributed to the observed adverse health outcomes. However, these conditions seem to follow closely with advancing age, which is emerging as the strongest predictor of Covid-19 related death. Unfortunately, reports to date have not rigorously considered age or other key factors contributing to health as potential confounders in predicting risk. With other infectious diseases, coexisting conditions such as hypertension have been key prognostic determinants, 10 and this also appears to be the case with Covid-19.
“It is important to note that despite inferences about the use of background RAAS inhibitors, specific details were lacking in the studies. Population-based studies have estimated that only 30 to 40% of patients in China who have hypertension are treated with some antihypertensive therapy. RAAS inhibitors are used alone or in combination in 25 to 30% of these treated patients. Given these estimates, only a fraction of Covid-19 patients, at least in China, are expected to have been previously treated with RAAS inhibitors. Data are needed that show patterns of use of RAAS inhibitors and associated health outcomes that rigorously explain the indication of treatment and the severity of the disease among patients with Covid-19, “the expert said.
And he added: “Despite these theoretical uncertainties about whether pharmacological regulation of ACE2 can influence the infectivity of SARS-CoV-2, There is a clear potential for harm related to the withdrawal of RAAS inhibitors in patients under stable conditions.. Covid-19 is particularly severe in patients with underlying cardiovascular disease, and in many of these patients, active myocardial injury, myocardial stress, and cardiomyopathy develop during the course of the disease. SRAA inhibitors have established benefits in protecting the kidney and myocardium, and their withdrawal may lead to clinical decompensation in high-risk patients.
Conclusion, Dr. Vaduganathan stated that “based on the available evidence, we believe that, despite theoretical concerns and uncertainty regarding the effect of SARS inhibitors on RCTs2 and how these drugs may affect propensity or severity of Covid-19, SARS inhibitors should be continued in patients in stable conditions who are at risk, are being reevaluated, or diagnosed with Covid-19”
And he recommended that while additional data may better inform treatment of high-risk patients with Covid-19, clinicians should be aware of the unintended consequences of prematurely stopping proven therapies in response to hypothetical concerns that may be based on incomplete experimental evidence.
Key points of the scientific article:
• ACE2, an enzyme that physiologically counteracts RAAS activation, is the functional receptor for SARS-CoV-2, the virus responsible for the Covid-19 pandemic
• Selected preclinical studies have suggested that RAAS inhibitors may increase ACE2 expression, raising questions about its safety in patients with Covid-19.
• There is insufficient data available to determine whether these observations translate easily into humans, and no study has evaluated the effects of RAAS inhibitors on Covid-19.
• Clinical trials are underway to evaluate the safety and efficacy of RAAS modulators, including recombinant human ACE2 and losartan ARB in Covid-19
• Abrupt withdrawal of RAAS inhibitors in high-risk patients, including those with heart failure or myocardial infarction, can lead to clinical instability and adverse health outcomes.
• Until more data becomes available, we believe that RAAS inhibitors should be continued in patients in stable conditions who are at risk of evaluation or with Covid-19.
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