ACE inhibitors and ARBs not associated with severity of Coronavirus

Researchers have found ACE inhibitors (a type of blood pressure medicine commonly used in patients with high blood pressure or diabetes) and ARBs (used to treat heart failure and high blood pressure) did not increase the severity of COVID-19 disease in patients in two hospitals.

The researchers from King’s College London, King’s College Hospital, NIHR Maudsley Biomedical Research Centre and the London Medical Imaging and Artificial Intelligence Centre for Value Based Healthcare, tested for an association between a patient’s treatment with blood pressure drugs (Angiotensin-converting enzyme inhibitors (ACE Inhibitors) or Angiotensin receptor blockers (ARBs)) and their severity of Coronavirus disease.

The study used CogStack, an information retrieval and extraction platform, to review the electronic health records of COVID-19 patients. They looked at the data of 1,200 patients with COVID-19 admitted to two hospitals at the King’s College Hospital NHS Foundation Trust with Coronavirus symptoms from 1 March to 13 April 2020.

Researchers identified severe cases by detecting patients who were either transferred to a critical care unit or who died and compared data for those treated with and without ACE inhibitors and ARBs. Of the 1,200 patients, 415 patients died or required critical care support within 21 days of symptoms and 33% were taking ACE inhibitors or ARBs. The average age was 68 and 74% of patients had at least one comorbidity. The patients were of diverse ethnicities with over 30% from minority ethnic groups.

ACEi and ARB medications are used to treat chronic illnesses such as hypertension and diabetes. The drugs inhibit Angiotensin-converting enzyme 1 (ACE1) and lower blood pressure to help manage these diseases but may also increase the related ACE2 enzyme which is attached to the outer surface of cells within the body.

ACE2 is of particular interest to COVID-19 researchers because the virus binds with these receptors for cell entry to infect the human body. Because of this association, it was thought that ACEi and ABE medications might increase the severity of COVID-19, however, the current finding shows no evidence to support this theory.

Their findings indicated that the likelihood of severe disease was similar in individuals on ACE inhibitors or ARBs compared to those not on these drugs.

Professor Ajay Shah, BHF Chair of Cardiology & James Black Professor of Medicine Director, King’s BHF Centre of Excellence, King's College London and King’s College Hospital, said, “ This study has addressed a very important clinical question since a large proportion of the UK population takes these cardiovascular drugs. Our study indicates that it is perfectly safe to continue taking these agents and that people's concerns about them can be alleviated. "

Dr Daniel Bean, lead author and UKRI Innovation Fellow with Health Data Research UK and King’s College London said, “The CogStack platform was key to this study as it allowed us to very quickly retrieve relevant clinical data and address urgent medical questions about drug safety in coronavirus patients. We’re able analyse medical notes to identify pre-existing conditions and factor these into our analysis. We couldn’t do that so quickly without CogStack. ”

Professor Richard Dobson, Professor of Medical Bioinformatics, King's College London said, “Near real time access to hospital data has never been more important as during the Covid-19 pandemic, as we continue to learn about the virus and respond each day.”

Dr James Teo, Clinical Director of Data Science at King's College Hospital NHS Foundation Trust said, "This work was possible through the use of open technologies working on real-time health data through Health Data Research UK and the guidance and support from the expert patients of the King’s Electronic Records Research Interface (KERRI)."

Professor Sir Nilesh Samani, Medical Director at the British Heart Foundation, said, “The use of ACE inhibitors and ARBs has been a hot topic of debate since the start of the coronavirus pandemic. This left millions of people living with heart and circulatory conditions questioning whether they should continue to take their heart medications.

“This UK study, which is the first to include significant proportions of people from both white and minority ethnic backgrounds, adds to other recent evidence confirming these medications do not increase the risk of severe Covid-19 infections. These drugs are very effective for heart failure, and to control high blood pressure to help prevent a heart attack or stroke. This study provides further reassurance that their use is safe and that it is important that patients continue to take them as prescribed to protect cardiovascular health.”

Patient data included demographics, emergency department letters, discharge summaries, clinical notes, radiology reports, medication orders, lab results and was retrieved from the structured and unstructured components of the electronic health record (EHR) and analysed using CogStack, an information retrieval and extraction platform.

CogStack was developed by researchers at the NIHR Maudsley Biomedical Research Centre and uses enterprise search, natural language processing, analytics and visualisation technologies to unlock health records to assist in clinical decision making and research. 

CogStack implements new data mining techniques within NHS Trusts – specifically, the ability to search any clinical data source (unstructured and structured), and natural language processing (NLP) applications developed to automate the extraction of medical concepts. These tools allow clinical text to be searched for specific terms using simple or complex syntax, rapidly retrieving the data needed to answer complex queries such as “find all patients with coronavirus symptoms” or “find all coronavirus patients prescribed ARBs. ”

Angiotensin-converting enzyme (ACE) inhibitors reduce a person's blood pressure by relaxing their blood vessels. They are commonly used for people with high blood pressure or diabetes. Angiotensin receptor blockers (ARB) work in a similar way to ACE inhibitors. They are often recommended to patients if ACE inhibitors cause them unwanted side effects.

The findings have been published today (7 July 2020) in European Journal of Heart Failure.