Editorial note
COVID-19 and cardiovascular comorbidities: An update
COVID-19 e comorbilidades cardiovasculares: uma atualização
a Serviço de Cardiologia, Hospital Geral, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
b Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal
c Serviço de Cardiologia, Hospital Santo António, Centro Hospitalar Universitário do Porto, Porto, Portugal
d Faculdade de Medicina da Universidade do Porto, Porto, Portugal
e Centro Cardiovascular, Hospital dos Lusíadas, Lisboa, Portugal
f Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
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The series, as expected, differ in terms of demographics, the definition of comorbidities such as chronic cardiovascular disease, and clinical outcomes. Nevertheless, some observations can be made regarding the interaction between cardiovascular comorbidities and COVID-19 infection.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Hypertension, diabetes, and cardiovascular disease were the most frequent comorbidities in infected patients requiring hospitalization, compared to other chronic diseases such as cancer, chronic kidney disease and even chronic obstructive pulmonary disease. In a meta-analysis that included six Chinese studies and 1527 COVID-19 patients, the overall prevalence of hypertension, cardiovascular and cerebrovascular disease, and diabetes were 17.1%, 16.4% and 9.7%, respectively.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">9</span></a> More recent studies from Italy<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">7</span></a> and the US<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">8</span></a> which included older patients, the majority of whom were male, report higher proportions of hypertension (over 50%) and diabetes (25%) among COVID-19 patients, which is similar to the last coronavirus pandemic, Middle East respiratory syndrome (MERS), which mainly affected the Arabian Peninsula. A systematic analysis of 637 MERS cases showed that the prevalence of hypertension and diabetes was over 50% and cardiac diseases were present in 30% of cases.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">10</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Consistently, the severity of the disease and case fatality rates have tended to be higher in COVID-19 patients with cardiovascular comorbidities. Another recent pooled analysis showed that hypertension and a history of cardiovascular disease conferred a 2.4 (95% confidence interval [CI] 1.5-3.8) and 3.4 (95% CI 1.9-6.2) times higher risk of severe COVID-19 disease, respectively.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">11</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The exact mechanisms underlying the worse prognosis of hypertensive COVID-19 patients remain unknown. One current hypothesis is that the excessive activation of the renin-angiotensin system (RAS) typical of the hypertensive patient may contribute to the progression of COVID-19 lung injury by promoting an inflammatory response (cytokine storm), smooth muscle cell contraction and vasoconstriction.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">12</span></a> Moreover, some authors speculate that the use of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), commonly used to treat patients with cardiovascular disease, could explain their worse outcomes.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">13</span></a> In animal studies, ACEIs/ARBs increase the expression of angiotensin-converting enzyme 2 (ACE2), the receptor which SARS-CoV-2 uses for viral entry and propagation in host cells.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">14</span></a> On the other hand, the upregulation of ACE2 expression by ACEIs/ARBs may mitigate the deleterious ACE2 downregulation associated with COVID-19 infection, conferring pulmonary (and cardiac) protection.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">15</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">At the beginning of the pandemic, all published guidelines recommended continuing ACEIs/ARBs in patients with COVID-19.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">14</span></a> In a recently published retrospective analysis of 1128 adult patients with hypertension diagnosed with COVID-19 from Hubei province, the use of ACEIs or ARBs was associated with a lower risk of both non-adjusted and adjusted all-cause mortality.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">16</span></a> Two randomized phase II clinical trials in outpatient (ClinicalTrials.gov identifier: NCT04311177) and inpatient (ClinicalTrials.gov identifier: NCT04312009) settings are currently being planned to study the effect of losartan in the context of COVID-19 infection.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">14</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">At the end of March 2020, the Centers for Disease Control and Prevention (CDC) reported data on underlying health conditions in COVID 19 patients in the US.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">17</span></a> Among 122 653 US COVID-19 cases, 7162 (5.8%) patients had data available on underlying health conditions and other potential risk factors for severe outcomes from respiratory infections, and similarly to other series, a higher proportion of patients with comorbidities were admitted to the hospital and to intensive care. On the other hand, the prevalence of common clinical conditions in the US is similar to that described in this CDC report. For example, in 2018 the prevalence of diabetes among US adults was 10.1%, similar to the COVID 19 patients (10.9%). Regarding all types of heart disease (excluding hypertension), the US prevalence in 2017 was 10.6%, comparable to that observed in the CDC data, and the findings are similar regarding chronic obstructive pulmonary disease and asthma.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">17</span></a> Moreover, data from China are also in agreement: according to the Summary of the 2018 Report on Cardiovascular Diseases in China, the prevalence of hypertension and diabetes was 23.2% and 10.9%, respectively, which is in line with the above-mentioned pooled prevalence.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">18</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In summary, a higher prevalence of hypertension, diabetes, and chronic heart disease compared to other chronic conditions has been reported among COVID-19 patients. The prevalence of these comorbidities may nevertheless be similar to that in the general population, and these patients may not be more susceptible to COVID-19 infection. Hypertension can function as a proxy for older age and cardiovascular and non-cardiovascular comorbidities, and hence for the association in these patients with more aggressive COVID-19 disease. There is no evidence to support the idea that ACEIs or ARBs could be harmful by increasing SARS-CoV-2 infectivity. It is as yet unknown whether the severity or level of control of underlying health conditions affects the risk for severe disease in COVID-19. Nonetheless, given the limited data and potential hazard to individual and public health, a precautionary approach should be followed by carefully protecting from infection and more closely monitoring patients with multiple comorbidities, in particular those with hypertension and cardiovascular disease.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:18 [ 0 => array:3 [ "identificador" => "bib0095" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72314 cases from the Chinese Center for Disease Control and Prevention" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Z. Wu" 1 => "J.M. 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| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 8 | 4 | 12 |
| 2024 Outubro | 57 | 42 | 99 |
| 2024 Setembro | 54 | 32 | 86 |
| 2024 Agosto | 51 | 38 | 89 |
| 2024 Julho | 51 | 34 | 85 |
| 2024 Junho | 46 | 34 | 80 |
| 2024 Maio | 54 | 15 | 69 |
| 2024 Abril | 52 | 36 | 88 |
| 2024 Maro | 56 | 27 | 83 |
| 2024 Fevereiro | 43 | 24 | 67 |
| 2024 Janeiro | 36 | 30 | 66 |
| 2023 Dezembro | 34 | 22 | 56 |
| 2023 Novembro | 55 | 53 | 108 |
| 2023 Outubro | 34 | 18 | 52 |
| 2023 Setembro | 41 | 22 | 63 |
| 2023 Agosto | 33 | 10 | 43 |
| 2023 Julho | 33 | 9 | 42 |
| 2023 Junho | 38 | 20 | 58 |
| 2023 Maio | 47 | 31 | 78 |
| 2023 Abril | 35 | 3 | 38 |
| 2023 Maro | 58 | 18 | 76 |
| 2023 Fevereiro | 37 | 16 | 53 |
| 2023 Janeiro | 34 | 15 | 49 |
| 2022 Dezembro | 46 | 25 | 71 |
| 2022 Novembro | 63 | 30 | 93 |
| 2022 Outubro | 46 | 26 | 72 |
| 2022 Setembro | 43 | 50 | 93 |
| 2022 Agosto | 35 | 37 | 72 |
| 2022 Julho | 33 | 32 | 65 |
| 2022 Junho | 43 | 32 | 75 |
| 2022 Maio | 32 | 29 | 61 |
| 2022 Abril | 40 | 40 | 80 |
| 2022 Maro | 46 | 47 | 93 |
| 2022 Fevereiro | 31 | 22 | 53 |
| 2022 Janeiro | 30 | 25 | 55 |
| 2021 Dezembro | 34 | 37 | 71 |
| 2021 Novembro | 45 | 49 | 94 |
| 2021 Outubro | 30 | 34 | 64 |
| 2021 Setembro | 50 | 26 | 76 |
| 2021 Agosto | 48 | 35 | 83 |
| 2021 Julho | 17 | 29 | 46 |
| 2021 Junho | 32 | 33 | 65 |
| 2021 Maio | 61 | 56 | 117 |
| 2021 Abril | 54 | 36 | 90 |
| 2021 Maro | 62 | 34 | 96 |
| 2021 Fevereiro | 29 | 23 | 52 |
| 2021 Janeiro | 38 | 30 | 68 |
| 2020 Dezembro | 47 | 31 | 78 |
| 2020 Novembro | 62 | 30 | 92 |
| 2020 Outubro | 59 | 30 | 89 |
| 2020 Setembro | 124 | 83 | 207 |
| 2020 Agosto | 197 | 102 | 299 |
| 2020 Julho | 12 | 9 | 21 |
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