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Updating the Treatment with
Inhibitors in Covid-19 Patients
Eduardo Rivas Estany*
Chief Cardiac Rehabilitation and Prevention Centre, Institute of Cardiology and Cardiovascular Surgery, Cuba
Submission: June 13, 2020; Published: June 17, 2020
*Corresponding author: Eduardo Rivas Estany, Chief Cardiac Rehabilitation and Prevention Centre, Institute of Cardiology and Cardiovascular Surgery, Cuba
How to cite this article: Rivas Estany E. Updating the Treatment with Renin-Angiotensin-Aldosterone System Inhibitors in Covid-19 Patients. Palliat Med
Care Int J. 2020; 3(4): 555617.
The main objective of this scientific commentary has been to update the behavior and treatment of patients carrying Covid-19 with the drugs known as Renin-Angiotensin-Aldosterone System (RAAS) inhibitors, as well as its effects in these cases. Since the outbreak of pneumonia caused by a new coronavirus occurred in Wuhan, China in December 2019, the disease has spread rapidly throughout the world. After the virus was identified (SARS-CoV-2), the World Health Organization (WHO) named it as coronavirus disease 2019 (Covid-19) and the outbreak was soon declared a Public Health Emergency (pandemic). Since then, an unprecedented challenge has been presented to scientists around the world trying to identify effective drugs for the prevention and treatment of such a disease.
It is suggested that both the virus called SARS-CoV-1 causing the epidemic known to be SARS between 2002 and 2004, and SARS-CoV-2, responsible for the current pandemic, interact with RAAS through the angiotensin-converting enzyme 2 (ACE2) which acts as a receptor for both SARS viruses [1-3]. Such viral and enzymatic interaction is proposed as a factor that increases the infective capacity of the virus, which has raised concerns about the use of RAAS inhibitors that by producing variation in the expression of ACE2 could be responsible for the high virulence of the current pandemic due to Covid-19 [4-6]. Accordingly, it has been stated in some places the discontinuation of treatment
with angiotensin converting enzyme inhibitors (ACEIs) and with angiotensin receptor blockers (ARBs), both in the setting
of suspected Covid-19 and prophylactically. Currently, there are few data to support or refute the mentioned hypothesis and, on the contrary, it is proposed as an alternative that ACE2 may be beneficial in patients with lung damage and that it may also be dangerous to withdraw RAAS inhibitors in high-risk patients with suspected or confirmed Covid-19 .
Initial reports from China drew attention to the high frequency of high blood pressure among patients with Covid-19, with a prevalence of 15%, however other factors that coexisted, such as age, seem to have been more frequent even in those cases with worse evolution, even among those who died. Therefore, age, rather than the probable indication of RAAS inhibitors in these hypertensive cases, seems decisive considering also the low frequency of indication of these drugs in the general population in China [7,8].
After analyzing the effects of the interrelationship between SARS-CoV-2 and RAAS, it was concluded that new human research is needed to better define such effects as current studies offer heterogeneous and sometimes contradictory results [9,10]. It was also noted that ACE inhibitors in clinical use do not directly affect ACE2 activity . It is further argued  that despite the uncertainties related to the pharmacological regulation of ACE2 and its probable influence on the infectivity of SARS-CoV-2, it is risky to withdraw SARS inhibitors in patients who are in a stable clinical condition due to potential damage that can probably occur.
Covid-19 is particularly severe in patients with underlying
cardiovascular disease, who can develop additional myocardial
damage during viral infection. The RAAS inhibitors protect the
myocardium and the kidney; when they are removed there may
be clinical instability, especially in high-risk patients, furthermore
knowing that the prevalence of heart failure in critically ill patients
with Covid-19 can be high (> 40%), as reported in the United
States . It is confirmed that the abrupt withdrawal of RAAS
inhibitors in high-risk patients, including those with myocardial
infarction or heart failure, may result in clinical decompensation
with an evolution with adverse results. Therefore, until new data
becomes available, it is suggested that RAAS inhibitors should be
maintained in stable patients at risk or suspected of Covid-19.
This statement coincides with the recommendation of the
Panel of Experts of the National Institutes of Health (NIH), of the
United States  and of other important international Cardiology
societies  that also recommend maintaining ACEIs or ARBs
in patients with Covid-19 who have them previously prescribed
by suffering cardiovascular disease or some other indication,
however they are not recommended even as a form of Covid-19
The Covid-19 pandemic represents the largest global health
crisis of the current generation. No therapy has been shown
to be effective so far, and the best prevention strategy for
future epidemics would be the development of a vaccine that
produces long-term immune protection, however it still takes
several months to spread it widely . Therefore, the current
recommended management continues to be the application of
prevention and control measures to prevent the outbreak and
its consequences, as well as support measures in the presence of