The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus responsible for coronavirus disease 2019 (COVID-19), is associated with a high incidence of acute respiratory distress syndrome (ARDS) and death. Hypertension and cardiovascular disease are risk factors for death in COVID-19. Angiotensin converting enzyme 2 (ACE2), an important component of the renin-angiotensin system, serves as the binding site of SARS-CoV-2 and facilitates host cell entry in the lungs. In experimental models, angiotensin converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) have been shown to increase ACE2 expression in several organs, potentially promoting viral cell invasion, although these findings are not consistent across studies. Alternatively, ACEIs and ARBs may actually improve mechanisms of host defense or hyperinflammation, ultimately reducing organ injury. Finally, ACEIs and ARBs may have direct renal, pulmonary and cardiac protective benefits in the setting of COVID-19. Therefore, it is unclear if ACEIs and ARBs may be beneficial or harmful in patients with COVID-19. Given the high prevalence of hypertension, cardiovascular and renal disease in the world, the high prevalence of ACEIs or ARBs in these conditions, and the clinical equipoise regarding the continuation vs. discontinuation of ACEIs/ARBs in the setting of COVID, a randomized trial is urgently needed. The aim of this trial is to assess the clinical impact of continuation vs. discontinuation of ACE inhibitors and angiotensin receptor blockers on outcomes in patients hospitalized with COVID-19.
Other: Discontinuation of ARB/ACEI
The randomized intervention will be the discontinuation of ACEI/ARBs. In all participants randomized to discontinuation, treating clinicians will be reminded about the medication discontinuation upon discharge and will be prompted to consider re-initiation of the medication at that time if appropriate, per the clinician's discretion.
Other: Continuation of ARB/ACEI
The randomized intervention will be the continuation of ACEI/ARBs at the doses previously prescribed for patients during their routine care. Clinicians will be encouraged to continue the randomized treatment but will be allowed to change the dose of ACEI/ARB or discontinue these medications if any compelling clinical reasons are identified (such as hypotension, hyperkalemia, acute kidney injury).
Inclusion Criteria:
1. Age 18 years or older
2. Hospitalization with a suspected diagnosis of COVID-19, based on: (a) A compatible
clinical presentation with a positive laboratory test for SARS-CoV-2, or (b)
Considered by the primary team to be a Person Under Investigation due to undergo
testing for COVID-19 in addition to compatible pulmonary infiltrates on chest x-ray
(mutilobar, intersticial or ground glass opacities).
3. Use of ACEI or ARB as an outpatient prior to hospital admission.
Exclusion Criteria:
1. Systolic blood pressure <100 mmHg.
2. Systolic blood pressure > 180 mmHg or >160 if unable to substitute ACEIs/ARBs for
another antihypertensive class, per the investigator's discretion.
3. Diastolic blood pressure > 110 mmHg
4. Known history of heart failure with reduced ejection fraction (EF <40%) on their most
recent echo and/or clinical heart failure with unknown EF (i.e. no echo in
approximately the past year).
5. Serum K>5.0 mEq/L on admission.
6. Known pregnancy or breastfeeding.
7. eGFR <30 mL/min/1.73m2
8. >50% increase in creatinine (to a creatinine >1.5 mg/dl) compared to most recent
creatinine in the past six months, if available
9. Urine protein-to-creatitine ratio > 3 g/g or proteinuria > 3 g/24-hours within the
past year
10. Ongoing treatment with aliskiren or sacubitril-valsartan.
11. Inability to obtain informed consent from patient.
12. Inability to read and write or lack of access to a smart phone, computer or tablet
device at the time of evaluation.
University of Pennsylvania Health System
Philadelphia, Pennsylvania, United States