Coronavirus disease 2019 (COVID-19) is a pandemic infection caused by a virus called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Because SARS-CoV-2 is known to require the angiotensin-converting enzyme 2 (ACE-2) receptor for uptake into the human body, there have been questions about whether medications that upregulate ACE-2 receptors might increase the risk of infection and subsequent complications. One such group of medications are anti-hypertensives that block the renin-angiotensin system, including both angiotensin converting enzyme inhibitors (ACEi) and angiotensin II receptor blockers (ARB). Both ACEi and ARB are widely used for the treatment of hypertension. Early reports from China and Italy suggest that many of those who die from COVID-19 have a coexisting history of hypertension. Consequently, there have been questions raised as to whether these 2 types of blood pressure medication might increase the risk of death among patients with COVID-19. However, it is well known that the prevalence of hypertension increases linearly with age. Therefore, it is possible that the high prevalence of hypertension and ACEi/ARB use among persons who die from COVID-19 is simply confounded by age (older people are at risk of both a history of hypertension and dying from COVID-19). Whether these commonly prescribed blood pressure medications increase the risk of COVID-19 or not remains unanswered. Statements from professional cardiology societies on both sides of the Atlantic have called for urgent research into this question. Our study aims to randomize patients with primary (essential) hypertension who are already taking ACEi/ARB to either switch to an alternative BP medication or continue with the ACEi/ARB that they have already been prescribed. Adults with compelling indications for ACEi/ARB will not be enrolled.
Drug: Thiazide or Thiazide-like diuretics
Anti-hypertensive (Active Arm)
Other Name: Hydrochlorothiazide, metolazone, chlorthalidone, chlorothiazide, bendroflumethiazide, indapamide
Drug: Calcium Channel Blockers
Anti-hypertensive (Active Arm)
Other Name: Amlodipine, diltiazem, felodipine, nicardipine, nifedipine, nimodipine, nitrendipine, verapamil
Drug: ACE inhibitor
Anti-hypertensive (Control Arm)
Other Name: Benazepril, captopril, enalapril, fosinopril, lisinopril, perindopril, quinapril, ramipril, trandolapril
Drug: Angiotensin receptor blocker
Anti-hypertensive (Control Arm)
Other Name: Candesartan, eprosartan, irbesartan, losartan, olmesartan, telmisartan, valsartan
Inclusion Criteria:
- Men and non-pregnant women aged 60 or over
- Known diagnosis of hypertension
- Current use of ACEi or ARB for the treatment of hypertension
- COVID-19 naïve (i.e. not known to be infected)
- English speaker
Exclusion Criteria:
- Known diabetic nephropathy
- Known heart failure with reduced ejection fraction
- Resistant hypertension (defined as blood pressure that remains above goal despite
concurrent use of three anti-hypertensive agents of different classes, one of which
should be a diuretic, or as blood pressure that is controlled with four or more
medications)
- Contraindications or allergies to CCB or Thiazide
- Unconscious patients
- Current psychiatric in-patients
- Patients in an emergency medical setting
- Inability to consent
University Hospital Galway
Galway, Ireland
John William McEvoy, MBBCh MHS, Principal Investigator
National University of Ireland, Galway, Ireland