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Ramipril in High-Risk Patients With COVID-19
Quick Takes
- Use of RAAS inhibitors was associated with neither risk for infection nor poorer outcomes with COVID-19 patients after TAVR.
- Patients who died due to the infection presented with higher BMI or obesity as a unique and characteristic feature.
- Based on available data, RAAS inhibitors should be maintained or initiated in patients with new-onset heart failure, hypertension, or myocardial infarction according to current ACCF/AHA guidelines, irrespective of presence of COVID-19 disease.
Study Questions:
What is the impact of the coronavirus disease 2019 (COVID-19) pandemic in high-risk patients from the RASTAVI trial who were randomly assigned to receive ramipril or standard care?
Methods:
The investigators performed a non–prespecified interim analysis to evaluate its impact on COVID-19 risk in this vulnerable population in the ongoing RASTAVI (NCT03201185; Renin-Angiotensin System Blockade Benefits in Clinical Evolution and Ventricular Remodeling After Transcatheter Aortic Valve Implantation) clinical trial, which is randomly allocating ramipril or control after successful transcatheter aortic valve replacement (TAVR) at 14 centers in Spain. A Cox regression analysis was performed for investigating the effect of ramipril administration on the time symptoms of COVID-19 developed in the study patients.
Results:
As of April 1, 2020, 102 patients (50 ramipril and 52 controls) were included in the trial. Mean age was 82.3 ± 6.1 years, and 56.9% were men. Median time of ramipril treatment was 6 months (interquartile range, 2.9-11.4). Eleven patients (10.8%) had been diagnosed with COVID-19 (six in control group and five receiving ramipril; hazard ratio, 1.150; 95% confidence interval, 0.351-3.768). The risk of COVID-19 was increased in older patients (p = 0.019), and those with atrial fibrillation (p = 0.066), lower hematocrit (p = 0.084), and more comorbidities, according to Society of Thoracic Surgeons score (p = 0.065). Admission and oxygen supply were required in 4.9% (two patients in the ramipril and three in control), and four of them died (two in each randomized group). A higher body mass index (BMI) was the only factor increasing the mortality rate (p = 0.039).
Conclusions:
The authors concluded that in a high-risk population of older patients with cardiovascular disease, randomization to ramipril had no impact in the incidence or severity of COVID-19.
Perspective:
This study reports that the use of renin-angiotensin-aldosterone system (RAAS) inhibitors was associated with neither risk for symptomatic infection nor poorer outcomes with COVID-19 disease in a subset of patients with hypertension after TAVR. Of note, patients who died due to the infection presented with higher BMI as a unique and characteristic feature. Given the overwhelming evidence of mortality reduction in cardiovascular disease and the lack of harm found in several recent studies of COVID-19 patients, RAAS inhibitors should be maintained or even initiated in patients with new-onset heart failure, hypertension, or myocardial infarction according to current American College of Cardiology Foundation/American Heart Association (ACCF/AHA) guidelines, irrespective of presence of COVID-19 disease.
Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Cardiovascular Care Team, COVID-19 Hub, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Valvular Heart Disease, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Interventions and Structural Heart Disease, Hypertension
Keywords: Atrial Fibrillation, Body Mass Index, Coronavirus, COVID-19, Geriatrics, Heart Failure, Heart Valve Diseases, Hematocrit, Hypertension, Myocardial Infarction, Obesity, Ramipril, Renin-Angiotensin System, Risk, Secondary Prevention, Transcatheter Aortic Valve Replacement, Ventricular Remodeling, Vulnerable Populations
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