At IDOVEN, our main objective is to improve people's heart health both when doing any sport activity and in the course of their day-to-day life.
This article seeks to answer the questions of many of you (fellow doctors, friends, and clients) who have written to us concerned about the relationship of the coronavirus with hypertension, heart problems, and some of its most frequent treatments. The alarm has grown after it was learned, just a few hours ago, that the French Minister of Health, Olivier Véran, has warned that ibuprofen and other anti-inflammatory drugs can worsen coronavirus infection. Many of you are now considering whether to change the treatment of your friends, patients, or family.
The pandemic situation we are currently experiencing due to the coronavirus (COVID-19) is not simple. Data from China and Italy show that people with high blood pressure, diabetes, or heart problems are more likely to develop complications from the coronavirus.
From IDOVEN we have studied and reviewed all the news and scientific publications that reach us about the virus and its relationship with hypertension or heart problems. We will try to explain the conclusions we have drawn and how they can affect patients with heart problems:
The coronavirus enters the cell of the pulmonary alveolus through a receptor called ACE2. When it binds to it, it overexpresses it and kills the alveolar cell. Hence all that it produces: fever (83%), cough (82%), respiratory distress (30%), bilateral pneumonia (75%), unilateral pneumonia (25%).
Patients who develop more severe symptoms are usually male, older, smokers, and those with comorbidities such as hypertension, diabetes, or heart disease. In these people, symptoms worsen in 2-6 days, appearing respiratory insufficiency (choking sensation and lack of air).
It should be noted that men have more ACE2 receptors than women, Asians more than Caucasians, and that people taking antihypertensive drugs to control blood pressure of the·Angiotensin converting enzyme inhibitors (ACE inhibitors) and especially Angiotensin II receptor blockers (ARBs) have a very high over-expression of this receptor, and are therefore more susceptible to infection and, if so, more severe symptoms.
What is the solution?
Cardiologists and other medical colleagues are still assessing the need to change the medication of hypertensive patients taking drugs from the ACE inhibitors·family and the ARBs·family in order to minimize the risks, as this may have been the reason for the worse prognosis of hypertensive patients in China. The conclusions drawn could affect millions of people who take these drugs today to control their diseases.
Examples of Angiotensin converting enzyme inhibitors (ACE inhibitors) include
- Ramipril (Acovil®)
- Enalapril (Renitec®)
- Lisinopril (Prinivil®; Zestril®)
- Benazepril (Lotensin®)
Some examples of Angiotensin II receptor blockers (ARBs family) are as follows:
- Irbesartán (Aprovel®; CoAprovel®; Karvea®; Avapro®)
- Candesartán (Atacand®)
- Eprosartán (Tevetens®)
- Losartán (Cozaar®)
- Olmesartán (Ixia®; Openvas®; Olmetec®; Capenon®; Benicar®)
- Telmisartán (Micardis®; Pritor®)
- Valsartán (Diovan®; Co-Diovan®)
In principle, diuretic drugs, drugs of the Calcium Antagonist family and Beta-blocker drugs, which do not appear to be related to the clinical worsening of patients affected by coronavirus (COVID-19), would be safe to control the stress.
Some examples of these drugs without possible added risk are Amlodipine (Norvas®; Astudal®), Diltiazem (Angiodrox®; Carreldon®; Diltiwas®; Dinisor®; Lacerol®; Masdil®), Felodipine (Plendil®), Nicardipine (Vasonase®; Nerdipine®; Lincil®), Nifedipine (Adalat®), Nisoldipine (Sular®; Syscor®), Verapamil (Manidon®).
The European Society of Cardiology (ESC) has sent us a statement informing on the subject and insisting that at present the scientific evidence is not sufficient, so they strongly recommend that doctors and patients continue with the usual antihypertensive treatment, insisting on the importance of not stopping the treatment of high blood pressure in case of infection by COVID-19.
While waiting for possible new recommendations, we therefore advise you to remain calm, maintain the current treatment, avoid contagion and take extreme hygiene measures, following in any case the recommendations of the health authorities.
We end this post by quoting a paragraph from the article published by Lei Fang et al. in the Lancet according to which:
"We suggest that patients with cardiac diseases, hypertension, or diabetes, who are treated with ACE2-increasing drugs, are at higher risk for severe COVID-19 infection and, therefore, should be monitored for ACE2-modulating medications, such as ACE inhibitors or ARBs. Based on a PubMed search on Feb 28, 2020, we did not find any evidence to suggest that antihypertensive calcium channel blockers increased ACE2 expression or activity, therefore these could be a suitable alternative treatment in these patients."
Below you will find links to some of the articles reviewed by our scientific-medical team:
- Fang L, Karakiulakis G, Roth M. Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection? Lancet Respir Med 2020 Published Online March 11, 2020.
- Sommerstein R. Re: Preventing a covid-19 pandemic: ACE inhibitors as a potential risk factor for fatal Covid-19. BMJ 2020;368:m810.
- Yang X, Yu Y, Xu J, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med 2020; published online Feb 24. DOI:10.1016/S2213- 2600(20)30079-5.
- Guan W, Ni Z, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med 2020; published online Feb 28. DOI:10.1056/NEJMoa2002032.
- Zhang JJ, Dong X, Cao YY, et al. Clinical characteristics of 140 patients infected by SARS-CoV-2 in Wuhan, China. Allergy 2020; published online Feb 19. DOI:10.1111/ all.14238.
- Wan Y, Shang J, Graham R, Baric RS, Li F. Receptor recognition by novel coronavirus from Wuhan: An analysis based on decade-long structural studies of SARS. J Virology 2020; published online Jan 29. DOI:10.1128/ JVI.00127-20.
- Li XC, Zhang J, Zhuo JL. The vasoprotective axes of the renin-angiotensin system: physiological relevance and therapeutic implications in cardiovascular, hypertensive and kidney diseases. Pharmacol Res 2017; 125: 21–38.
- Dong E, Du H, Gardner L. An interactive web-based dashboard to track COVID-19 in real time. Lancet Infect Dis 2020.
- The Novel Coronavirus Pneumonia Emergency Response Epidemiology Team. The Epidemiological Characteristics of an Outbreak of 2019 Novel Coronavirus Diseases (COVID-19) — China, 2020[J]. China CDC Weekly, 2020, 2(8): 113-122.
- Jackson, Edwin K. (2006). "Chapter 30. Renin and Angiotensin". In Brunton, Laurence L.; Lazo, John S.; Parker, Keith (eds.). Goodman & Gilman's The Pharmacological Basis of Therapeutics (11th ed.). New York: McGraw-Hill. ISBN 978-0-07-142280-2.
- Hoffmann M, Kleine-Weber H, Krüger N, Müller M, Drosten C, Pöhlmann S. The novel coronavirus 2019 (2019-nCoV) uses the SARS-coronavirus receptor ACE2 and the cellular protease TMPRSS2 for entry into target cells. bioRxiv 2020:2020.01.31.929042.
- Ferrario CM, Jessup J, Chappell MC, et al. Effect of angiotensin-converting enzyme inhibition and angiotensin II receptor blockers on cardiac angiotensin-converting enzyme 2. Circulation 2005;111:2605-10.