AHA/ACC/HFSA Joint Statement on ACE Inhibitors and ARBs

The American Heart Association, the American College of Cardiology, and the Heart Failure Society of America have issued a joint statement urging patients with COVID-19 infection to continue taking ACE inhibitors and ARBs.

They have categorically emphasized that "Patients of novel coronavirus disease (COVID-19) having hypertension, heart failure, or ischemic heart disease concomitantly should continue taking their angiotensin-converting-enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs)."

This statement may give clinicians comfort and confidence to continue the use of RAAS blockers during these strange and difficult times.

This is in response to correspondence in Lancet Respiratory Medicine, proposing that ACE-inhibitors and ARBs may increase the risk for developing severe COVID-19. This is because the coronavirus binds to target cells through ACE 2, the expression of which is increased when patients take these drugs.

This implied that patients with cardiac diseases, hypertension, or diabetes, who are treated with ACE2-increasing drugs, are at higher risk for severe COVID-19 infection and, therefore, should be monitored for ACE2-modulating medications, such as ACE inhibitors or ARBs.

The AHA, the HFSA, and the ACC recommend continuation of angiotensin-converting enzyme inhibitors (ACE-i) or angiotensin receptor blocker (ARB) medications for all patients already prescribed for indications such as heart failure, hypertension, or ischemic heart disease. Cardiovascular disease patients who are diagnosed with COVID-19 should be fully evaluated before adding or removing any treatments, and any changes to their treatment should be based on the latest scientific evidence and shared-decision making with their physician and health care team.

"We understand the concern – as it has become clear that people with cardiovascular disease are at much higher risk of serious complications including death from COVID-19. However, we have reviewed the latest research – the evidence does not confirm the need to discontinue ACE-i or ARBs, and we strongly recommend all physicians to consider the individual needs of each patient before making any changes to ACE-i or ARB treatment regimens," said Robert A. Harrington, M.D., FAHA, president of the American Heart Association, Arthur L. Bloomfield Professor of Medicine and chair of the department of medicine at Stanford University.

"While the primary symptoms of COVID-19 include respiratory symptoms, the latest evidence demonstrates some patients with COVID-19 may also have severe cardiovascular damage. We must ensure we fully evaluate and treat patients with cardiovascular disease," continued Biykem Bozkurt, M.D., Ph.D., HFSA president, professor of cardiology, the Mary and Gordon Cain Chair of Medicine in the Winters Center for Heart Failure Research and the W.A. "Tex" and Deborah Moncrief Chair in Cardiology at Baylor College of Medicine in Houston.

"The continued highest standard of care for cardiovascular disease patients diagnosed with COVID-19 is our top priority, but there are no experimental or clinical data demonstrating beneficial or adverse outcomes among COVID-19 patients using ACE-i or ARB medications. We urge urgent, additional research that can guide us to optimal care for the millions of people worldwide with cardiovascular disease and who may contract COVID-19. These recommendations will be adjusted as needed to correspond with the latest research," concluded Richard J. Kovacs, M.D., president of the American College of Cardiology and Q.E. and Sally Russell Professor of Cardiology at Indiana University School of Medicine.

These theoretical concerns and findings of cardiovascular involvement with COVID-19 deserve much more detailed research, and quickly. As further research and developments related to this issue evolve, we will update these recommendations as needed.

AHA/ACC/HFSA statement