April 24, 2020

ACEIs/ARBs do not affect outcomes of patients with COVID-19, dipyridamole for severe COVID-19, and unexpected findings of COVID-19 at the lung bases on abdominopelvic CT

By Denise Baez

NEW YORK -- April 24, 2020 -- In today’s DG Alert, we cover the association of renin-angiotensin system inhibitors with severity or risk of death in patients with hypertension and coronavirus disease 2019 (COVID-19), potential therapeutic effects of dipyridamole in severely ill patients with COVID-19, and unexpected findings of COVID-19 at the lung bases on abdominopelvic CT.

A single-centre study published in JAMA Cardiology showed that angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) had no effect on the severity or outcome of patients with hypertension hospitalised for COVID-19.

Juyi Li, MD, Tongji Medical College, Wuhan, China, and colleagues analysed data from 1,178 patients with COVID-19 hospitalised at the Central Hospital of Wuhan from January 15 to March 15, 2020. Of the patients, 362 (30.7%) had hypertension (median age, 66 years, 52.2% male), and of these, 115 (31.8%) were taking ACEI/ARBs. 

The in-hospital mortality for the overall population was 11.0%. The in-hospital mortality for patients with hypertension was 21.3%. 

The percentage of patients with hypertension taking ACEIs/ARBs did not differ between those with severe and nonsevere infections (32.9% vs 30.7%; P = 0.65) nor did it differ between nonsurvivors and survivors (27.3% vs 33.0%; P = 0.34). Similar findings were observed when data were analysed for patients taking ACEIs and those taking ARBs.

“In this single-centre case series involving 362 patients with hypertension hospitalised with COVID-19 infection, there was no difference in severity of the disease, complications, and risk of death in those who were taking ACEIs/ARBs compared with those not treated with these medications,” the authors concluded. “These data support current guidelines and societal recommendations for treating hypertension during the COVID-19 pandemic.”

The researchers said their findings "also confirm data in these prior reports that patients with hypertension have more severe illness and higher mortality rates than those without hypertension.”

Another study published in Acta Pharmaceutica Sinica B showed that supplementation with dipyridamole was associated with markedly improved clinical outcomes in patients with COVID-19, particularly in patients with severe disease. 

Xiaoyan Liu, MD, Zhongnan Hospital of Wuhan University, Wuhan, and colleagues conducted an open label study involving 31 patients with COVID-19 treated at Dawu County People’s Hospital (1st hospital, 12 patients and 10 controls) and Huangpi Chinese Medicine Hospital (2nd hospital, 2 patients and 7 controls),  from February 3, 2020 to March 8, 2020. 

D-dimer concentrations were elevated in 50% of patients in the dipyridamole group and in 42% of patients in the control group. 

Patients in the dipyridamole group received 50 mg oral tablets 3 times daily (total 150 mg) for 14 consecutive days. All patients received ribavirin, glucocorticoids, and oxygen therapy, but none received antifungal treatment. 

Dipyridamole adjunctive therapy was associated with markedly improved clinical cure and remission rates in both the non-severe and severely ill patients. In particular, for the 8 severely ill patients in the dipyridamole group, 7 (87.5%) patients achieved clinical cure and were discharged from the hospitals, and the remaining 1 patient was in clinical remission. In contrast, for the 12 severely ill patients in the control group, 4 (33.3%) patients were discharged, 2 (16.7%) were in remission, and 2 (16.7%) died.

“It should be mentioned that due to the urgent situation and the lack of resources to perform viral RNA detection by the participating hospitals, we were unable to accurately determine the effects of dipyridamole to viral clearance,” the authors wrote. “However, according to the qualitative RT-PCR result of SARS-CoV-2 RNA provided by local Centers for Disease Control and Prevention, the average time for virus clearance was shortened by 1.6 days for the severe cases in the dipyridamole-treated group compared with the control group.”

Lastly, a study published in the American Journal of Roentgenology showed that unsuspected COVID-19 may be strongly suggested on the basis of lung findings on abdominopelvic CT.

Bari Dane, MD, New York University Langone Medical Center, New York, New York, and colleagues identified reports from abdominal (with a pelvic component) CT examinations of patients who underwent imaging from March 16, 2020, through March 26, 2020, and for whom the terms “COVID” or “pneumonia/pneumonitis” AND “atypical” appeared in the report impression. 

The search identified 23 patients with unanticipated lung base findings on abdominopelvic CT that were concerning for COVID-19. Of the patients, 17 had positive COVID-19 test results. The remaining 6 patients did not have available COVID-19 test results or additional clinical information.

For the 17 patients who had positive COVID-19 test results, the most common lung base findings on abdominopelvic CT were ground-glass opacities (n = 13), which were most commonly multilobar (n = 9), peripheral (n = 8), or peribronchovascular (n = 8) in distribution. Other patients had consolidation (n = 4) or ground-glass nodules (n = 3). No patients had any pleural effusion.

“All the patients included in the present study underwent abdominopelvic CT for primary abdominal signs, symptoms, or both,” the authors wrote. “Because this subset of patients does not present with respiratory symptoms typical of COVID-19, COVID-19 is often unsuspected by the referring clinician, as was found to be the case in our series on retrospective review of imaging reports and electronic medical records, and by the general public, rendering this an underreported cohort. Similarly, these patients may not be identified by departmental screening measures before CT unless they have a fever. Consequently, many of these patients may not be subject to departmental or hospital protective measures, including wearing a surgical mask or being placed in patient isolation. This raises substantial concern about the spread of COVID-19 from this patient subset to health care personnel or other patients in the vicinity.”

SOURCE: JAMA Cardiology, Acta Pharmaceutica Sinica B, American Journal of Roentgenology