Hypertension, Medications, and COVID-19 Risks

Harlan M. Krumholz, MD, SM reviewing Mehra MR et al. N Engl J Med 2020 May 1 Reynolds HR et al. N Engl J Med 2020 May 1 Mancia G et al. N Engl J Med 2020 May 1

More observational data show that two common antihypertensive medication classes do not increase COVID-19 infectivity or severity.

The relationship between cardiovascular disease (CVD), CV treatment, and the risk for adverse outcomes in patients with COVID-19 has been receiving much attention. Three other research groups now provide more insights.

To investigate CVD as a risk factor for patients with COVID-19 and the association between CVD pharmacotherapy and COVID-19 outcomes, Mehra and colleagues used a large, de-identified, international database that included 8910 people hospitalized with COVID-19 who either died or were discharged. Angiotensin-converting–enzyme (ACE) inhibitors were more common among survivors than those who died. 

In a multivariable model, higher risks for death were associated with age >65, coronary artery disease, congestive heart failure, cardiac arrhythmia, chronic obstructive pulmonary disease, and current smoking. Being a woman, using ACE inhibitors, and using statins were associated with lower death risks. No associations were found for angiotensin-receptor blockers (ARBs).

Reynolds and colleagues examined diagnoses and medications via electronic health record codes in 12,594 people tested for COVID-19 in New York City; 5894 patients had positive results. The accuracy of coding was not reported. Of 2573 patients with hypertension and positive COVID-19 tests, 634 had severe COVID-19 disease (i.e., intensive care unit admission, mechanical ventilation, or death). 

In analyses requiring differences of 10 percentage points for statistical significance, no medication class was associated with a lower risk for severe disease, although ACE inhibitors had an absolute difference of 3.3%; no other class showed benefits ≥1.5%. The investigators acknowledged that smaller effects could be meaningful.

Mancia and colleagues studied 6272 people (age, ≥40) with SARS-CoV-2 infection from the Lombardy region of Italy and 30,759 uninfected controls matched by age, sex, and residence. Infected patients more commonly used ACE inhibitors and ARBs than controls. However, after multivariable adjustment, these medications were not associated with infection or severe disease.