COVID-19 | science, damage limitation, NO POLITICS

[armand]

Another thing I got to worry about. ACE inhibitors.  ....

The current recommendations is to not stop them if you are already taking them.

[Alan Klein]

Yes, this is quite worrisome. I wonder if any cardiologists and pharmacists are aware of this finding.

You mentioned to me once that cardiologists put their patients on ACE inhibitors as a standard procedure.  My wife was put on them, but she stopped because her regular doctor told her she didn't need it.  Meanwhile I'm still on them because I supposedly had hypertension (high blood pressure) and last year I had a triple bypass.  I'm going to have to move to a cave before this is over, if it ever ends.

[Alan Klein]

The current recommendations is to not stop them if you are already taking them.

That makes sense.  Thanks for the input.  I have a call out to my cardiologist.  I suspect he will confirm that.  It's just that it adds another risk factor and I have enough of them.  I'm starting to feel like Bubble Boy from Seinfeld.

[armand]

Yes, this is quite worrisome. I wonder if any cardiologists and pharmacists are aware of this finding.

Probably but as I said above it doesn't really matter right because the recommendation is not to stop them (because of fear of corona). The benefit of taking them outweighs the risks, at least with the current info that we have. Even if this virus uses ACE2 to enter the cells, it's not clear that taking the ACEI will change your clinical course.

[LesPalenik]

The current recommendations is to not stop them if you are already taking them.

The current recommendation is most likely based on the old data preceding this new finding about C19 and ACE2.

[armand]

That makes sense.  Thanks for the input.  I have a call out to my cardiologist.  I suspect he will confirm that.  It's just that it adds another risk factor and I have enough of them.  I'm starting to feel like Bubble Boy from Seinfeld.

You're welcome.
Talking to your cardiologist it's obviously the best course. ACEI are one of the few drugs that made pretty large differences in outcomes of heart failure and hypertension. So far your chances to have cardiovascular events, particularly if you stop them, are higher than having the corona and being seriously affected by it.

[armand]

The current recommendation is most likely based on the old data preceding this new finding about C19 and ACE2.

No, it's based exactly on this finding. That's why there is a comment about it.

There are actually 2 schools of thought, both based on some theoretical models and not so great quality studies.

1. ACEI are bad
- it's because ACEI inhibit the ACE receptor and the body, trying to compensate, overregulates the expressions of ACE2 which is used by SARS-Cov-2 to enter the cells

2. ACEI are good
- many of these patients that don't do well, have cardiovascular comorbidities, for which ACEI are beneficial.


There is no good data if any of these is more important than the other or they just balance out.

https://jamanetwork.com/journals/jama/fullarticle/2763803
https://www.ahajournals.org/doi/10.1161/JAHA.120.016509
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7154066/
https://www.nejm.org/doi/full/10.1056/NEJMsr2005760


Again, once we know more these recs might change but with the current data the safest it's to just continue the course. Particularly if you are at home, because even then the chances are in your favor.
If there is a question mark it's for patients sick enough to come to the hospital, at which point the physicians there will be involved in the decision.

[Alan Klein]

You're welcome.
Talking to your cardiologist it's obviously the best course. ACEI are one of the few drugs that made pretty large differences in outcomes of heart failure and hypertension. So far your chances to have cardiovascular events, particularly if you stop them, are higher than having the corona and being seriously affected by it.

Every case is different.  The article mentioned that if a person is getting ACE inhibitors for marginal reasons, then it might be worse.  In my case, although I had triple bypass, I;ve had no heart attacks and its very strong and in good shape.  It's just that my arteries were clogged.  But that's been taken care of with bypass.  The high blood pressure is rather mild in my case.  My cardiologist likes prescribing drugs in his tool kit.  But, For a change I'll listen to what he says and not second guess him like I do most experts.   I've got a call out to him.  Meanwhile, I'm going to wash my hands.

[armand]

Interesting op-ed piece from the NYT - 'silent hypoxia'.

https://www.nytimes.com/2020/04/20/opinion/coronavirus-testing-pneumonia.html?action=click&module=Opinion&pgtype=Homepage

That's a good article. I recommend that you look at the comments also, particularly from other physicians.

[Alan Klein]

That's a good article. I recommend that you look at the comments also, particularly from other physicians.

I just ordered a pulse oximeter that measure oxygen in your blood and gives your pulse.  It's amazing how they're all backordered.  I won't get mine until May, and that's with special priced shipping. I called Walgreens, and they have none in stock, even for prescription order.

[armand]

I just ordered a pulse oximeter that measure oxygen in your blood and gives your pulse.  It's amazing how they're all backordered.  I won't get mine until May, and that's with special priced shipping. I called Walgreens, and they have none in stock, even for prescription order.

I wonder if he had any stocks in pulseox making companies, this is just the cynical in me.
I though about getting one for myself some time ago but I gave up on that.

If you have a newer Samsung phone you can get your pulse oximetry with it, I don't know about iPhones. Likely not the most calibrated but good enough.

Every case is different.  The article mentioned that if a person is getting ACE inhibitors for marginal reasons, then it might be worse.  In my case, although I had triple bypass, I;ve had no heart attacks and its very strong and in good shape.  It's just that my arteries were clogged.  But that's been taken care of with bypass.  The high blood pressure is rather mild in my case.  My cardiologist likes prescribing drugs in his tool kit.  But, For a change I'll listen to what he says and not second guess him like I do most experts.   I've got a call out to him.  Meanwhile, I'm going to wash my hands.

I have no intention on giving you medical advice on the internet (if it sounds like I'm giving medical advice, it's not my intention and you should disregard it). That and the fact that while I know a good amount about cardiology and HTN, this is mostly for inpatient and I'm not a cardiologist.

[LesPalenik]

https://jamanetwork.com/journals/jama/fullarticle/2763803
https://www.ahajournals.org/doi/10.1161/JAHA.120.016509
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7154066/
https://www.nejm.org/doi/full/10.1056/NEJMsr2005760

Again, once we know more these recs might change but with the current data the safest it's to just continue the course. Particularly if you are at home, because even then the chances are in your favor.

Thank you for posting those links, armand

Those articles describe situations for people with hypertension which is the most frequent condition for using ACEI. How about effect of C19 on people with reduced Ejection Fraction who are taking ACEI?

[armand]

Thank you for posting those links, armand

Those articles describe situations for people with hypertension which is the most frequent condition for using ACEI. How about effect of C19 on people with reduced Ejection Fraction who are taking ACEI?

There is some info regarding heart failure in there also.

Strictly on theoretical reasoning, stopping the ACEI/ARBs for heart failure can be more dangerous than stopping them for HTN. It's easier to add a different drug to control the blood pressure than to deal with decompensated heart failure. So if anything I would be very reluctant to stop them for heart failure if they have Covid19. Now, some of these patients will be in shock (with very low BP) or have significant kidney injury that we have to stop these medications anyway.

[LesPalenik]

Every case is different.  The article mentioned that if a person is getting ACE inhibitors for marginal reasons, then it might be worse.  In my case, although I had triple bypass, I;ve had no heart attacks and its very strong and in good shape.  It's just that my arteries were clogged.  But that's been taken care of with bypass.  The high blood pressure is rather mild in my case.  My cardiologist likes prescribing drugs in his tool kit.  But, For a change I'll listen to what he says and not second guess him like I do most experts.   I've got a call out to him.  Meanwhile, I'm going to wash my hands.

Alan, you don't get a lifetime warranty with the bypass surgery. If the arteries were clogged and patients don't change their eating habits, they can get clogged again.
That is the reason why some patients need a second bypass surgery. Unless they follow Bill Clinton example and become vegans. Regardless of their political affiliation.

As you mention, prescribing ACEI is now a standard routine by most cardiologists. Dilation of the arteries and veins can't hurt, but I don't know if there are also negative side effects.

[Jeremy Roussak]

Breaking Radio Silence -  of course I am masking up when I go to the store to stock up on provisions.

Glad to hear that. When did you start?

Jeremy

[armand]

Glad to hear that. When did you start?

Jeremy

+1

[Alan Klein]

New York antibody study estimates 13.9% of residents have had the coronavirus, Gov. Cuomo says.  That's 2.7 million people out of 19.4 residents.
https://www.cnbc.com/2020/04/23/new-york-antibody-study-estimates-13point9percent-of-residents-have-had-the-coronavirus-cuomo-says.html

Note that NYC had the highest rates with upstate the lowest. 

[armand]

The current recommendation is most likely based on the old data preceding this new finding about C19 and ACE2.

And here is another one that was sent to me. Still not the best study but better than anecdotal or theoretical.
https://www.ahajournals.org/doi/abs/10.1161/CIRCRESAHA.120.317134

[armand]

Some succint guidelines for treatment of Covid19
https://covid19treatmentguidelines.nih.gov/

[LesPalenik]

And here is another one that was sent to me. Still not the best study but better than anecdotal or theoretical.
https://www.ahajournals.org/doi/abs/10.1161/CIRCRESAHA.120.317134

Thank you!
It's interesting that their conclusion is contradictory with that first report.