Pharmacotherapy for hypertensive urgency and emergency in COVID-19 patients

Abstract

Introduction: Hypertension is a common chronic disorder in patients hospitalized for coronavirus disease 2019 (COVID-19). Furthermore, an exaggerated cardiovascular response with persistently raised blood pressure during hospitalization seems independently associated with in-hospital all-cause mortality, intensive care unit admission and heart failure. However, the real burden of elevated blood pressure during the acute phase of COVID-19 remains undefined.

Areas covered: The authors review the available evidence on the pharmacotherapy for the treatment of acute elevations in blood pressure (including hypertensive urgency and emergency) in COVID-19 patients.

Expert opinion: Acute elevations in blood pressure and unstable in-hospital blood pressure may be associated with organ damage and worse outcome in patients with COVID-19. In this setting, hypertensive emergencies require immediate reduction in blood pressure through intravenous treatment according to specific features and goals. Conversely, hypertensive urgencies usually require solely oral treatment. Diuretics, beta-blockers, renin-angiotensin-aldosterone system inhibitors, and calcium channel blockers may be of benefit in treating COVID-19 patients with elevated blood pressure values.

Keywords: COVID-19; SARS-CoV-2; blood pressure; blood pressure lowering drugs; hypertension; hypertensive emergencies; hypertensive urgencies; outcome; treatment.

Figure 1.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) interaction with angiotensin converting enzyme 2 (ACE2) receptors. After the invasion of SARS-CoV-2, the binding to membranal ACE2 is associated with the phenomenon of downregulation and progressive loss of catalytic activities. The process leads to a marked imbalance between angiotensin II overactivity and angiotensin_1-7 deficiency, triggering rise in BP (see text for details)

Figure 2.

A 70-year old white man, with a history of coronary artery bypass graft, hospitalized for COVID-19 pneumonia. At admission, he reported fever and cough. Anteroposterior chest radiograph showed vague hazy densities and lung opacities (a). During hospitalization, he developed a hypertensive emergency (systolic blood pressure > 200 mmHg) with acute ischemic heart disease (b) and elevated high-sensitivity troponin I levels. Treatment with infusion of nitroglycerin and labetalol lowered heart rate and BP values with consequent normalization of electrocardiographic examination (c)