The drugs neither help nor hurt

In the early days of the Covid-19 pandemic, concerns were raised about the safety of RAAS inhibition because SARS-CoV-2 binds to ACE2 (membrane-bound angiotensin-converting enzyme 2), and ACE2 is expressed in the lungs and in the endothelial linings of blood vessels. Initially, that concern led some patients to stop taking ACEi and ARBs, even as cardiologists warned against doing so.

A number of early reports based on observational studies concluded that RAAS inhibition did not increase the risk of infection, nor did it worsen the course of disease, and some clinicians suggested that ACEi/ARB therapy might be beneficial; however, randomized trial date were lacking.

The findings from BRACE CORONA — the first randomized clinical trial to investigate the issue in patients hospitalized with Covid-19—reinforced clinicians’ suspicions.

Renato Lopez, MD, of the Duke Clinical Research Institute in Durham, North Carolina, reported results from the 659-patient trial as a Hot Line presentation at the European Society of Cardiology, ESC 2020: The Digital Experience.

“In patients hospitalized with Covid-19, suspending ACE inhibitors and ARBs for 30 days did not impact the number of days alive and out of hospital,” Lopez said.

The patients were recruited from March through June, and the data were locked down in early August, Lopez explained in his presentation, noting that the pandemic forced the researchers to recruit patients quickly and report findings fast.

All of the patients were taking ACEi or ARBs chronically, he said, but he noted that patients taking more than three antihypertensive medications and those taking sacubitril/valsartan were excluded from the trial. The patients were randomized to either stopping their ACEi/ARB medications for 30 days or continuing to take the drugs while hospitalized.

The primary outcome measure was number of days alive and out of the hospital at 30 days.

Among the findings:

  • Average number of days alive were 21.9 for those who stopped ACEi/ARB therapy and 22.9 for those who continued.
  • Average ratio of days alive and out of hospital between the suspending and continuing groups was 0.95 (95% confidence interval [CI] 0.90 to 1.01, P=0.09).
  • The average difference between groups was −1.1 days (95% CI −2.33 to 0.17).
  • At 30 days, 91.8% of those in the ACEi/ARB suspension group were alive versus 95% of those who continued the medications.
  • The 30-day mortality rate was virtually the same — 2.8% for those who continues versus 2.7% for those who suspended the drugs.

Lopez concluded the data “indicate that there is no clinical benefit from routinely interrupting these medications in hospitalized patients with mild to moderate Covid-19, [and] they should generally be continued for those with an indication.”

Peggy Peck, Editor-in-Chief, BreakingMED™

Cat ID: 204

Topic ID: 74,204,204,914,926,192,927,925,934,203