Managing High Blood Pressure During the Coronavirus Pandemic

If you have high blood pressure, you know that letting it go unchecked could be deadly, especially if you develop other cardiovascular conditions. You may have also caught wind of some recent theories suggesting that certain blood pressure drugs may increase vulnerability to COVID-19 infection. But experts from three major organizations are cautioning against unnecessarily stopping medications or switching them because of unproven coronavirus concerns.

In a joint statement issued in March, the American College of Cardiology, American Heart Association and Heart Failure Society of America recommended that patients, for whom the benefits of these drugs are known, continue taking the medications. The strong advice comes amid speculation that certain blood pressure medications, called renin-angiotensin system, or RAS, blockers may increase susceptibility to COVID-19 and raise the risk of dying from the disease.

The medications, which are also referred to as renin-angiotensin-aldosterone system (RAAS) antagonists, or blockers, are commonly prescribed to treat high blood pressure and include angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs).

Currently, the organizations note, there's no research demonstrating that taking RAS blockers improves or worsens outcomes for patients with COVID-19. But what is known is that these medications have been clearly shown to be helpful for hypertension, heart failure and ischemic heart disease -- when the heart isn't receiving enough blood -- among other uses.

Older people and individuals with chronic disease tend to be more vulnerable to COVID-19. For example, those with diabetes and heart disease may be more likely to develop a severe COVID-19 infection. Hypertension is a form of cardiovascular disease. Frequently people who have high blood pressure also have other cardiovascular conditions like atherosclerosis, or the narrowing of arteries due to plaque buildup. That increases the risk of death from various causes, including heart attack and stroke.

So clinicians emphasize that it's key to pay attention to heart health and keep blood pressure well-controlled. Having high blood pressure has even been associated with a higher rate of dying from COVID-19. Still, it's not clear whether having hypertension on its own -- without any accompanying forms of cardiovascular disease -- raises the risk of dying from COVID-19. "I just can't answer that question," says Dr. Mariell Jessup, chief science and medical officer for the American Heart Association. Nor is it clear if successfully managing hypertension, by itself, will lower one's risk of death related to the novel coronavirus.

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But experts say that while more research on this subject is needed, there's broad agreement that stopping blood pressure medications isn't wise, given that uncontrolled blood pressure is proven to significantly increase cardiovascular risk and death. "You want to keep in the very best health you can possibly be in, and that means whatever medicines you're on, you continue taking those medicines," Jessup stresses.

The speculation surrounding RAS blockers and any potential impact they may have on vulnerability to COVID-19 is complex. But at its core, it relates to how SARS-CoV-2 -- the virus that causes COVID-19 -- enters the human body.

As noted in the recent joint ACC, AHA, HFSA statement: "Angiotensin converting enzyme 2 (ACE2) receptors have been shown to be the entry point into human cells for SARS-CoV-2." And some animal research has shown that RAS blockers increase the presence of these receptors. But the impact is inconsistent and there's no conclusive research that this affects how a person might respond to COVID-19.

"Importantly no one has shown an increase, by this class of medications, of the presence of ACE2 in the lungs where the coronavirus presumably interacts with ACE2 to enter the body and starts replicating," says Dr. Daniel Batlle, a professor of nephrology and hypertension at the Northwestern University Feinberg School of Medicine, and a kidney specialist at Northwestern Medicine in Chicago. "Therefore, this lack of evidence is reassuring."

Still, there's been speculation that taking medication that increases ACE2 expression might affect how vulnerable a person is to COVID-19. Some researchers hypothesize, as laid out recently in The Lancet Respiratory Medicine, that treating diabetes and hypertension with ACE2-stimulating drugs could increase the risk that a person may develop severe or fatal coronavirus infection. The researchers suggest that for patients with cardiac diseases, high blood pressure or diabetes, another type of blood pressure medication -- namely calcium channel blockers, which work via a different mechanism -- could be a suitable alternative.

But others emphasize that there's just no data to support stopping RAS blockers or switching to another blood pressure medication.

"There is no evidence in human studies that the effect of these drugs on ACE2 expression, if any, have caused increased risk for COVID-19 infection although theoretically this could happen," Batlle says. But he stresses that much more data are needed before patients and health providers make any treatment changes.

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"Based on the currently available evidence there is no reason to consider alternative antihypertensive medications," says Batlle, who co-authored a March article published in the journal Hypertension. "The benefits of RAS blockers on these patients clearly outweigh the risks and there is no evidence of increased risk for COVID 19 infection for people taking RAS blockers," Batlle says.

By contrast, he adds: "There is extensive evidence about the complications of uncontrolled hypertension." Unchecked high blood pressure may lead to severe cardiovascular complications including heart attacks, strokes, pulmonary edema (which is caused by excess fluid in the lungs, usually related to heart problems) and kidney injury, he notes.

Dr. Murray Epstein, professor of medicine emeritus at the University of Miami Miller School of Medicine, and a co-author on the Hypertension article, agrees that patients definitely shouldn't stop taking their blood pressure medication because of an "unsubstantiated notion ... that treatment with RAS blockers might increase the risk of developing a severe and fatal SARS-CoV-2 infection." By contrast, experts say it's clear what will happen if patients who need to be on medicine for hypertension stop taking the drugs. "If patients have high blood pressure and discontinue their antihypertensive medications, their previously controlled BP (is) no longer controlled at an acceptable range," Epstein says.

He adds that there's not always a suitable alternative medication. For some patients, RAS blockers -- used to treat conditions like hypertension in tens of millions of people worldwide -- are a must. The drugs are, for example, a mainstay of treatment for patients with chronic heart failure, Epstein points out.

Experts encourage patients to talk to their doctors about the risks and benefits of any medication. Clinicians say decisions to start, discontinue or switch medications should be made collaboratively, and only after careful discussion between the patient and health provider.

And there's something else in this unprecedented time of pandemic that may be worth considering. People are facing not only the threat of a highly infectious and sometimes deadly disease, but in many cases financial pressures from lost or reduced work and mental health challenges related to staying at home and keeping their distance from others. That's all putting a lot of stress on individuals.

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Exactly how, or to what extent, the stress of dealing with a pandemic may impact a person's blood pressure isn't clear. But what's known, generally, is that "stress can certainly increase BP," Epstein says. That's one more reason, now more than ever, to pay close attention to hypertension and make sure it's carefully controlled.