The heart of the angiotensin controversy amid COVID-19: The safety of inhibitors and receptor blockers amid a global pandemic

June 8, 2020

Our editorial team is working from home to bring you a series of articles about the coronavirus. This article, about a study into the safety of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers in hypertensive patients with COVID-19, is the third in the series.

Angiotensin is the common name given to hormones in the body that may be small but play an outsized role on our health and blood pressure regulation. Too much of angiotensin II can result in higher blood volume, blood pressure, and sodium content – a particularly dangerous combination for patients with cardiovascular disease.

A hotly debated topic in the health community is the safe use of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) – two common classes of medications used to treat patients with hypertension, heart failure, coronary artery disease and other disorders by targeting angiotensin – in patients with COVID-19.

At the heart of the angiotensin controversy is the fear these medications may cause more harm than good.

- Dr. Peter Liu, UOHI

“At the heart of the angiotensin controversy is the fear these medications may cause more harm than good,” explains Dr. Peter Liu, chief scientific officer and vice-president of research at the University of Ottawa Heart Institute (UOHI). Do ACEIs and ARBs increase a patient’s susceptibility to coronavirus SARS CoV-2 (the viral agent that causes COVID-19)? The question is enough for scientists like Liu to consider the safety of these medications in patients with hypertension.

Dr. Peter Liu has been recognized with numerous awards, including both the Research Achievement Award and the Life Time Achievement Award of the Canadian Cardiovascular Society, the Rick Gallop Award of the Heart & Stroke Foundation, the Institute of Circulatory and Respiratory Health Distinguished Lecture Award of the Canadian Institutes of Health Research, and the Margolese Award from the University of British-Columbia, among others.

Dr. Liu is a principal investigator of a recent study published in Circulation Research, a leading scientific journal of the American Heart Association. Liu and his international colleagues sought to more clearly understand the relationship between in-hospital use of ACEIs and ARBs and all-cause mortality in COVID-19 patients with hypertension.

Liu says the retrospective, multi-centre study included over one-thousand adults with hypertension who were diagnosed with COVID-19 and treated at nine hospitals in Hubei Province, China, between December 31, 2019 and February 20, 2020. In one study arm, 188 patients who received either ACEI or ARB medication. In the other arm, 988 patients who did not.

“Our retrospective analysis of a Wuhan cohort demonstrated a potential 63% reduction in mortality in the ACEI/ARB group, which was similar to the observations of another major international cohort,” says Liu. “From these results we can hypothesize these medications may actually be beneficial and not harmful as originally thought.” Dr. Liu notes that the retrospective studies have unknown confounding factors, thus “a prospective trial is urgently needed.”

Dr. Liu and his colleagues at the UOHI have just launched a large international randomized clinical trial (COVID-RASi) to validate these findings.

COVID-19 resources

Hospitals in cities around the world are moving to cancel or postpone elective surgeries and procedures to prevent the potential spread of the virus. Patients, too, are turning to telehealth alternatives for treatment or advice, avoiding hospitals for fear of catching COVID-19 or unknowingly passing it on to others themselves. It has been reported that heart attack and stroke patients have all but disappeared, part of an unprecedented shift in the demand for hospital services imposed by the pandemic.

On its website, the University of Ottawa Heart Institute is cautioning all who may experience heart-related symptoms not to delay seeking emergency medical assistance. A delay in seeking care could have a lasting impact on the outcome of your treatment.

Download and share this infographic (PDF) developed by the UOHI, and visit this website for helpful COVID-19 updates and resources, tips to keep safe and healthy during the pandemic, and for answers to your frequently asked questions about the virus’s implications on your heart health.