It is not cholera. It is not a love story set in uncertain times in the Caribbean. It is a real pandemic. The novel coronavirus, SARS-CoV-2, causes a unique illness with many manifestations called COVID-19. Older patients and those with pre-existing conditions such as high blood pressure (hypertension) and cardiovascular disease are especially vulnerable. How has COVID-19 affected the treatment of hypertension and where have all of the heart attacks gone?
Older patients and men are much more prone to COVID-19 compared to women and children. Why is that? SARS-CoV-2 infects the body by entering cells through a protein called ACE2. ACE2 is found throughout the body and is especially concentrated in the lungs and the heart, which may account for the severity of respiratory problems with COVID-19. Elevated levels of ACE2 theoretically make more targets available for the coronavirus to infect. ACE2 also interacts with another protein called ADAM-17. It is hypothesized that the coronavirus activates ADAM-17, which then stimulates the hormonal system and worsens cardiovascular disease. It also causes a severe inflammatory response, causing damage to tissue throughout the body. It has been shown that men have higher concentrations of ACE2 than women. This may explain why men have worse outcomes with the virus compared to women. Similarly, older patients have worse outcomes while children have a low rate of infection. Studies have shown that ACE2 concentration was low in children and increased with advancing age. Certain blood pressure medications can affect ACE2 and early in the pandemic there was a question whether these medications may make a patient more prone to the virus.
ACE inhibitors (such as lisinopril or ramipril) and ARBs (such as losartan, valsartan or olmesartan) are pharmacologic mainstays in the treatment of hypertension and congestive heart failure. ACE and ARB medications work by increasing ACE2 in the body. As a result of the increased ACE2 do these medications increase the risk of COVID-19 infection? Are these medications associated with worse outcomes with the virus? Now, after months of pandemic and millions of infections, the data is in. Studies from China, Italy and New York City show that ACE and ARB medications are not associated with an increased likelihood for SARS-CoV-2 infection. In addition, ACE and ARB medications are not associated with worse outcomes. In fact, patients who were on an ACE or ARB had a lower risk of dying in the hospital than patients who weren’t on these meds. What about other hypertensive agents? Data from New York City showed that patients on beta blockers (such as metoprolol), calcium channel blockers (such as amlodipine or diltiazem) or diuretics (such as hydrochlorothiazide) had no increased risk for a positive test or severe COVID-19 infection. Even before this information became available, the American College of Cardiology encouraged patients to continue their blood pressure medications. Now, with more data in, this is prudent advice.
Staying on cardiac medications is especially important, as the global pandemic has caused stress levels to go up worldwide. Stress is caused by worrying about catching the virus and becoming severely ill. The quarantine keeps people away from family and friends and increases social isolation. Then there is the economic impact. Job loss and worry over how to pay the rent and bills all raise anxiety levels. Normally when psychological stress is increased, there is a concomitant increase in the number of heart attacks. That has not been the case with the current pandemic. Studies from Italy, California and Boston show that heart attacks have gone down 48% during the pandemic as compared to a similar period a year ago. This is not a local phenomenon; it has been felt globally. In addition, about half of Americans have skipped or delayed medical treatment during the pandemic. On the other hand, cardiac arrests at home have soared since COVID-19 arrived (in New York City it was estimated that cardiac arrests at home increased 800% compared to the previous year). So, are people having fewer heart attacks? Or are they ignoring symptoms for fear of catching COVID-19 in the hospital and then subsequently dying at home?
There are several lessons to be learned here. First, ACE2 and ADAM-17 are fun names for proteins. Second, take your blood pressure medication. Blood pressure medications are safe and they may have a protective effect against the detrimental cardiac effects of COVID-19. Lastly, don’t ignore symptoms such as chest pain or shortness of breath. Don’t “wait it out” at home; call your doctor or head to the Emergency Room. It could save your life.