Patients With COVID-19 Should Stay on ACE Inhibitors, ARBs, Study Finds

Patients with heart conditions that require angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) can safely keep taking them if hospitalized with coronavirus disease 2019 (COVID-19), based on findings from the first randomized trial to examine this issue.

Data from the BRACE CORONA trial, presented today during the European Society of Cardiology 2020 Congress, show no difference in outcomes between patients who kept taking their ACE inhibitors or ARBs and those who stopped taking them for 30 days following a COVID-19 diagnosis.

Investigators found that the average number of days alive and out of hospital was 21.9 for patients who stopped ACE inhibitors/ARBs and 22.9 for patients who continued these medications, for a mean ratio of 0.95 (95% CI, 0.90-1.01; P = .09). The average difference in clinical status at 30 days between groups was -1.1 days (95% CI, -2.33 to 0.17).

“This is the first randomized data assessing the role of continuing versus stopping ACE inhibitors and ARBs in patients with COVID-19,” said principal investigator Renato Lopes, MD, PhD, of Duke Clinical Research Institute, Durham, North Carolina. “Because these data indicate that there is no clinical benefit from routinely suspending these medications in hospitalized patients with mild to moderate COVID-19, they should be generally continued for those with an indication.”

BRACE CORONA randomized 659 patients at 29 sites in Brazil, which has been hit hard by the pandemic. The trial examined the conflicting theories that have stymied clinicians since the pandemic began.

On the one hand, early links between COVID-19 deaths and hypertension worried public health clinicians, due to associations between angiotensin-converting enzyme 2 (ACE2) and SARS-CoV-2. ACE2 was seen as a port of entry for the virus that causes COVID-19, and thus could make COVID-19 more dangerous in some patients. Yet other evidence suggested that renin-angiotensin-aldosterone system inhibitors could actually reduce acute lung damage from COVID-19.

Patients who were using more than 3 antihypertensive drugs, or sacubitril/valsartan, or who were hemodynamically unstable at hospital admission were excluded from the study.

The trial also examined several secondary end points, Lopes said, including myocardial infarction and stroke and how far the disease had progressed, as measured by whether a patient was intubated or in the intensive care unit. “Basically, the results are very consistent,” he said. “We do not see any significant difference between treatment strategies in any of the key secondary end points that were also assessed in the trial.”

Lopes said the results confirm early guidance from professional societies to keep patients on their medication in most cases. Subgroup analyses, which will examine whether there are any differences by age or obesity status or other factors, will be forthcoming.

Reference

Lopes R, on behalf of the BRACE CORONA Investigators. Continuing versus suspending ACE inhibitors and ARBs: impact of adverse outcomes in hospitalized patients with COVID-19—the BRACE CORONA Trial. Presented at the European Society of Cardiology 2020 Congress, September 1, 2020.