Hypertension management in outpatient visits by diabetic patients

Management of Hypertension in Patients With Diabetic Kidney Disease: Summary of the Joint Association of British Clinical Diabetologists and UK Kidney Association (ABCD-UKKA) Guideline 2021

Letters26 August 2020Update Alert 3: Risks and Impact of Angiotensin-Converting Enzyme Inhibitors or Angiotensin-Receptor Blockers on SARS-CoV-2 Infection in AdultsFREEKatherine Mackey, MD, MPP, Devan Kansagara, MD, MCR, and Kathryn Vela, MLIS, AHIPKatherine Mackey, MD, MPPVA Portland Health Care System, Portland, Oregon (K.M., D.K., K.V.), Devan Kansagara, MD, MCRVA Portland Health Care System, Portland, Oregon (K.M., D.K., K.V.), and Kathryn Vela, MLIS, AHIPVA Portland Health Care System, Portland, Oregon (K.M., D.K., K.V.)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/L20-1068 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail An update is available for this article.We searched MEDLINE (Ovid) weekly from 7 July to 3 August 2020 using the same search strategy as described in the original review (1). We did not limit the search by language. This search update yielded 67 results (de-duplicated), and after an independent dual-review process, we identified 2 new meta-analyses and 1 reestimated meta-analysis (2–4), interim results from 1 randomized controlled trial (5), and 13 new observational studies (6–18).New EvidenceResults of 2 meta-analyses found that angiotensin-converting enzyme inhibitor (ACEI) and angiotensin-receptor blocker (ARB) use was not associated with coronavirus disease 2019 (COVID-19) disease severity (2, 3). In 1 of these meta-analyses of 9 primary studies with a total of 3936 patients with hypertension, use of ACEIs or ARBs was associated with a lower mortality in COVID-19 (2). In the other meta-analysis of 15 studies of 7410 patients with hypertension, subgroup analysis found that ARB use, but not ACEI use, was associated with lower mortality (3). A third meta-analysis reestimated data from studies included in a prior review and found that exclusion of a retracted study by Mehra and colleagues did not change the prior review's finding of a lack of association with ACEI and ARB use and COVID-19 mortality (4, 19).In addition, interim findings from an ongoing randomized controlled trial (started in 2018) on the use of ramipril among patients with aortic stenosis treated with transcatheter aortic valve replacement found that the use of ramipril was not associated with the incidence or severity of COVID-19 (20). To our knowledge, this is the first study to report findings from a randomized controlled trial on the association between ACEI use and COVID-19.We also identified 13 new observational studies (6–18). One of these observational studies that was based on an analysis of insurance data in Korea addressed our first key question regarding the use of ACEIs and ARBs and COVID-19 risk, finding that increased adherence to ACEI and ARB treatment was associated with a lower incidence of COVID-19 (10). Twelve studies addressed our second key question about ACEI and ARB use and COVID-19 disease severity, and 11 of these studies found a lack of association with ACEIs or ARBs and more severe disease (6–9, 11–13, 15–18). Moreover, 3 of these 11 studies found that use of ACEIs or ARBs was associated with less severe COVID-19 illness (11, 16, 18). The exception was a French study of 149 patients hospitalized with severe COVID-19 illness (defined as an oxygen saturation of 94% or less while the patient was breathing ambient air or receiving oxygen support), 44 of whom were receiving ACEIs or ARBs (14). This study found that ACEI and ARB use was associated with a higher risk for acute kidney injury. However, this study did not examine whether ACEI or ARB use was independently associated with respiratory failure or death.Overall, inclusion of 17 studies from this search update does not change the certainty of evidence rating we reported in the original article for key questions 1 or 2. Although there is a signal toward improved outcomes among patients with COVID-19 who continue use of ACEIs or ARBs, the benefits and harms of initiating ACEIs or ARBs (that is, new users) in COVID-19 treatment remains unclear.Citation UpdateA study by Bean and colleagues that was included in our original manuscript as a preprint has now been published (20).Also of note, we attempted to register our review protocol with PROSPERO, but registration was not accepted given the stage of our review at the time. We followed standard methods and reporting guidelines for systematic reviews (21, 22). We have posted a copy of our protocol to OSF (https://osf.io/qm6h9/).

PCV116 - Hypertension Management In Outpatient Visits By Diabetic Patients

Angiotensin-Converting Enzyme Inhibitors or Angiotensin Receptor Blocker use During Stereotactic Body Radiation Therapy Associated with Decreased Pneumonitis: A Multi-center Analysis

More on isolated systolic hypertension, diabetes, nephropathy and hypertension, and use of low-sodium diets in obese hypertensives.

Objective: Our aim was to assess the evidence for the effects of angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB) on mortality and major cardiovascular events in individuals with hypertension and diabetes. Data Sources: National Guideline Clearinghouse, Guidelines Finder, Canadian Medical Association Practice Guidelines, Cochrane Library, DARE, Bandolier, MEDLINE, Index of Portuguese Medical Journals and General Directorate of Health databases. Methods: The two authors independently performed a search of meta-analyzes (MA), systematic reviews (SR), randomized clinical trials (RCT) and clinical practice guidelines (CPG), published between 31/08/2009 and 31/08/2014 in Portuguese, Spanish, English and French languages. We used the MeSH terms: Diabetes Mellitus AND Hypertension AND Angiotensin-Converting Enzyme Inhibitors OR Angiotensin Receptor Antagonists. The strength of recommendation taxonomy scale was used for the allocation of levels of evidence (LE) and strength of recommendation (SR). Results: Of the 478 articles found, we included five MA and sixCPG in this report. A Cochrane MA showed that ACE inhibitors significantly decreased mortality from all causes (LE 1) and one MA concluded that this class of medications decreased the risk of myocardial infarction (LE 1). The use of ARB was shown to decrease the risk of stroke in one MA. Another MA showed no significant differences between the two classes of drugs. A recent MA found that ACE inhibitors significantly decreased all-cause mortality, cardiovascular mortality, myocardial infarction, and heart failure (LE 1). In the same MA, ARB decreased the risk of heart failure. Most guidelines recommend ACE inhibitors or ARBs as first line therapy for hypertension in diabetic patients. Conclusions: The effects of ACE inhibitors and ARB on mortality and cardiovascular events appear to be different. We found consistent evidence favoring the use of ACE inhibitors as a first option in preventing morbidity and mortality in this population (SR A).

KDOQI US Commentary on the 2012 KDIGO Clinical Practice Guideline for Management of Blood Pressure in CKD

Section 5: Management of Asymptomatic Patients with Reduced Left Ventricular Ejection Fraction

BackgroundCoronavirus disease 2019 (COVID-19) is suspected to mainly be more deleterious in patients with underlying cardiovascular diseases (CVD). There is a strong association between hypertension and COVID-19 severity. The binding of SARS-CoV-2 to the angiotensin-converting enzyme 2 (ACE2) leads to deregulation of the renin-angiotensin-aldosterone system (RAAS) through down-regulation of ACE2 with subsequent increment of the harmful Ang II serum levels and reduction of the protective Ang-(1–7). Both angiotensin receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACEIs) are commonly used to manage hypertension. ObjectiveObjective was to illustrate the potential link between hypertension and COVID-19 regarding the role of angiotensin receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACEIs) in hypertensive patients with COVID-19. MethodsWe carried out comprehensive databases search from late December 2019 to early January 2021 by using online engines of Web of Science, Research gate, Scopus, Google Scholar, and PubMed for published and preprinted articles. ResultsThe present study's findings showed that hypertension is regarded as an independent risk factor for COVID-19 severity. Both ACEIs and ARBs are beneficial in managing hypertensive patients. ConclusionThis study concluded that hypertension increases COVID-19 severity due to underlying endothelial dysfunctions and coagulopathy. COVID-19 might augment the hypertensive complications due to down-regulation of ACE2. The use of ACEIs or ARBs might be beneficial in the management of hypertensive patients with COVID-19.

The Antihypertensive and Lipid-Lowering treatment to prevent Heart Attack Trial (ALLHAT) compared in >30 000 high-risk hypertensive patients the effects on coronary heart disease of 3 treatment strategies: (1) based on the diuretic chlorthalidone, (2) the calcium-channel blocker (CCB) amlodipine, and (3) the angiotensin converting-enzyme (ACE) inhibitor lisinopril, respectively.1 Sponsored by the National Heart, Lung, and Blood Institute, ALLHAT stands out because no differences occurred in the incidence of the primary end point that consisted of the combination of fatal coronary heart disease and acute myocardial infarction.1 Not surprisingly, the attention of the ALLHAT consortium shifted to secondary end points, such as stroke, or to loosely defined2 components of secondary end points, such as heart failure. At the end of the line, the ALLHAT investigators based their main conclusions on events that, at the initiation of the trial, they regarded as “soft data that will at best confirm or supplement the primary endpoint.”3 More importantly, what was not identical in the 3 treatment groups was the on-treatment blood pressure despite vigorous attempts to titrate and combine the study medications to achieve a blood pressure of <140 mm Hg systolic and 90 mm Hg diastolic.1 These salient features of ALLHAT should be kept in mind whenever one attempts to interpret the findings of this landmark trial. In this issue of Hypertension , Leenen et al4 published a post hoc analysis, in which they made a direct comparison of cardiovascular and other outcomes among the 18 102 ALLHAT participants randomly assigned to amlodipine or lisinopril. In line with previous reports,1 the incidence of the primary coronary end point and total and cardiovascular mortality were similar in both groups. However, the patients randomly assigned to lisinopril experienced higher risks of stroke, combined cardiovascular disease, gastrointestinal bleeding, …

Background:Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are commonly used antihypertensives. Recently, these drugs have been associated with a protective effect against pancreatic cancer, but data on this putative association remain limited. Thus, the objective of this study was to determine whether the use of ACEIs and/or ARBs is associated with a decreased risk of pancreatic cancer.Methods:We conducted a population-based cohort study, using a nested case–control analysis within the UK Clinical Practice Research Datalink population. The cohort consisted of all patients newly treated with antihypertensive drugs between 1 January 1995 and 31 December 2009, with follow-up until 31 December 2010. Cases were patients with newly diagnosed pancreatic cancer, which were matched with up to 10 controls on age, sex, calendar year of cohort entry, and duration of follow-up. Conditional logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) of pancreatic cancer incidence associated with ever use of ACEIs and ARBs. A secondary analysis was conducted to assess whether the incidence of pancreatic cancer varied with cumulative duration of use of these drugs.Results:A cohort of 547 566 was assembled. During 3 040 332 person-years of follow-up, a total of 866 patients were newly diagnosed with pancreatic cancer (rate: 3/10 000 per year) and matched to 8636 controls. Overall, when compared with other antihypertensive drugs, the use of ACEIs was not associated with a decreased risk of pancreatic cancer overall (OR: 1.01, 95% CI: 0.86–1.17) or according to cumulative duration of use. The use of ARBs was not associated with a decreased risk of pancreatic cancer overall (OR: 0.93, 95% CI: 0.75–1.15), whereas a cumulative duration of use of 1–3 years was associated with a 38% decrease (OR: 0.62, 95% CI: 0.41–0.94), which returned to the null after >3 years of use (OR: 1.04, 95% CI: 0.74–1.46).Conclusions:The use of ARBs and ACEIs was not associated with an overall decreased risk of pancreatic cancer when compared with patients using other antihypertensive drugs. Additional research is needed to determine whether ARBs may confer a short-term protective effect.

Clinical Challenges in Diagnosis and Management of Diabetic Kidney Disease

The association of renin-angiotensin system blockade use with the risks of cognitive impairment of aging and Alzheimer’s disease: A meta-analysis

Background:Whether angiotensin-converting enzyme (ACE) Inhibitors and angiotensin receptor blockers (ARBs) mitigate or exacerbate SARS-CoV-2 infection remains uncertain. In a national study, we evaluated the association of ACE inhibitors and ARB with coronavirus disease-19 (COVID-19) hospitalization and mortality among individuals with hypertension.Methods:Among Medicare Advantage and commercially insured individuals, we identified 2,263 people with hypertension, receiving ≥1 antihypertensive agents, and who had a positive outpatient SARS-CoV-2 test (outpatient cohort). In a propensity score-matched analysis, we determined the association of ACE inhibitors and ARBs with the risk of hospitalization for COVID-19. In a second study of 7,933 individuals with hypertension who were hospitalized with COVID-19 (inpatient cohort), we tested the association of these medications with in-hospital mortality. We stratified all our assessments by insurance groups.Results:Among individuals in the outpatient and inpatient cohorts, 31.9% and 29.8%, respectively, used ACE inhibitors and 32.3% and 28.1% used ARBs. In the outpatient study, over a median 30.0 (19.0 - 40.0) days after testing positive, 12.7% were hospitalized for COVID-19. In propensity score-matched analyses, neither ACE inhibitors (HR, 0.77 [0.53, 1.13], P = 0.18), nor ARBs (HR, 0.88 [0.61, 1.26], P = 0.48), were significantly associated with risk of hospitalization. In analyses stratified by insurance group, ACE inhibitors, but not ARBs, were associated with a significant lower risk of hospitalization in the Medicare group (HR, 0.61 [0.41, 0.93], P = 0.02), but not the commercially insured group (HR: 2.14 [0.82, 5.60], P = 0.12; P-interaction 0.09). In the inpatient study, 14.2% died, 59.5% survived to discharge, and 26.3% had an ongoing hospitalization. In propensity score-matched analyses, neither use of ACE inhibitor (0.97 [0.81, 1.16]; P = 0.74) nor ARB (1.15 [0.95, 1.38]; P = 0.15) was associated with risk of in-hospital mortality, in total or in the stratified analyses.Conclusions:The use of ACE inhibitors and ARBs was not associated with the risk of hospitalization or mortality among those infected with SARS-CoV-2. However, there was a nearly 40% lower risk of hospitalization with the use of ACE inhibitors in the Medicare population. This finding merits a clinical trial to evaluate the potential role of ACE inhibitors in reducing the risk of hospitalization among older individuals, who are at an elevated risk of adverse outcomes with the infection.

Rate of Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers Use and the Number of COVID-19–Confirmed Cases and Deaths