Should ACEI and ARB be Prescribed During the COVID-19 Pandemic?

Highlights:

ACEI and ARB are recommended for treatment of hypertension
COVID19 pandemic raised doubts about the safety of these drugs
Globally renowned and reputed health organizations have recommended not to stop these drugs as they are safe in these COVID Times

Patients with heart disease are reluctant to seek medical help from hospitals for fear of getting infected with COVID-19 SARS virus. For example, the UK saw a 25 percent reduction in hospital attendance rates following the lockdown. In the US and Spain, there was a 40 percent reduction in hospital admissions for patients suffering from a lethal form of heart attack called ST elevated myocardial infarction (STEMI). Most alarmingly, a 50 percent reduction in hospital attendance in New York was accompanied by an 8-fold increase in out-of-hospital heart attacks during the COVID-19 pandemic.

Telemedicine is now widely available and is being encouraged by health authorities for patients to alleviate their anxiety and fears. One reason for the increase in mortality has been due to many press releases stating that these commonly used drugs for treating hypertension and heart failure could increase their risk of becoming infected by COVID-19 virus. Hence some patients may have stopped the medication for fear of acquiring SARS-CoV-2 infection.

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‘It is presumed that ACEI and ARB could increase the risk of COVID-19 infection and hence thought to be unsafe to use. However, leading global health authorities recommend that these drugs can still be used.’
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What are ACEI and ARB and What is their Function?

‘ACE’ stands for angiotensin-converting enzyme, which converts a substance called angiotensin-I to angiotensin-II. Angiotensin-II acts on the blood vessel walls and causes them to contact, which results in an increase in blood pressure (BP). A class of drugs called ACE inhibitors (ACEI) is capable of preventing the conversion of angiotensin-I to angiotensin-II. Since angiotensin -II is not produced, the blood vessels don’t contract, so BP reduces.

Angiotensin-II acts on the blood vessel walls by binding to its specific protein receptor, called angiotensin receptor (AR). There is another class of drugs called angiotensin receptor blockers (ARB), which bind to these receptors before angiotensin-II has a chance to bind to them. Consequently, the blood vessels don’t contract and so BP is reduced. Since both classes of drugs – ACEI and ARB – lower BP, they significantly reduce the chances of heart failure.

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Are ACEI and ARB Safe to Use During the COVID-19 Pandemic?

In normal times, ACEI and ARB are considered to be the safest and most effective drugs for treating hypertension and heart failure. However, these are not normal times due to the ongoing COVID-19 pandemic. Under these unprecedented circumstances, a controversy has arisen with regard to the safety of ACEI and ARB. The controversy revolves around the possible heightened risk of acquisition of SARS-CoV-2 infections due to use of these drugs, despite the fact that there is no clinching scientific or clinical evidence to support this claim. Only some circumstantial observations have been made that indicate that ACEI and ARB could be unsafe in the context of the COVID-19 pandemic.

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Observations that Support ACEI and ARB are Safe

Only older hypertensive patients develop COVID-19 complications, while other age-groups remain unaffected
No clinical evidence in humans show that ACE2 is upregulated by ACEI or ARB
Since SARS-CoV-2 infection supresses ACE2, it follows that if ACEI and ARB were to upregulate ACE2, the latter would counter the effect produced by the virus, thereby reducing its infectivity
Despite the fact that ACE2 is upregulated in women due to a sex-linked gene on the X-chromosome, they experience less severe disease than men, thereby nullifying the claim that upregulation of ACE2 is directly proportional to increase in infectivity and severity of SARS-CoV-2 illness

Observations that Support ACEI and ARB are Unsafe

Hypertensive patients develop the most severe complications of COVID-19
SARS-CoV-2 enters cells by binding to the ACE2 receptor, which is the same receptor to which angiotensin-II also binds
ACE2 receptors are found in high numbers in the cardiovascular system, besides the gut, kidneys, and lungs
Some animal studies have shown that ACEI and ARB can increase ACE2 levels in heart cells, which can result in more serious SARS-CoV-2 infections

To Prescribe or Not to Prescribe? – Key Recommendation

Leading global health organizations, such as the World Health Organization (WHO), the American Heart Association, the European Society of Cardiology, and the High Blood Pressure Research Council of Australia, have made a collective recommendation with regard to prescribing ACEI and ARB during the COVID-19 pandemic. These world-renowned and highly reputed organizations have collectively recommended that ACEI and ARB should continue to be prescribed during the COVID-19 pandemic, until and unless any solid evidence emerges from clinical trials to the contrary.

Reference:

COVID, ACE Inhibitors/ARBs, and Cardiovascular Diseases - The Medical Journal of Australia - (https://www.mja.com.au/journal/2020/covid-ace-inhibitorsarbs-and-cardiovascular-diseases)

Source-Medindia