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:

• SARS-CoV-2
• COVID-19
• blood pressure
• hypertension
• hypertensive emergencies
• hypertensive urgencies
• treatment
• blood pressure lowering drugs
• outcome

Article highlights

• Among established risk factors associated with severe coronavirus disease 2019 (COVID-19), hypertension is one of the most common comorbidities.

• Acute elevations in blood pressure and unstable in-hospital blood pressure may be associated with in-hospital mortality, intensive care unit admission and heart failure, with acute end-organ damage and a worse outcome in these patients.

• The pathophysiologic mechanisms involved in the acute target-organ dysfunction during a severe elevation of blood pressure are still undefined.

• The direct invasion of endothelial cells by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) promotes cell injury, microvascular inflammation, endothelial exocytosis, and endothelitis. Furthermore, some observations support a direct effect of SARS-CoV-2 invasion on the homeostatic regulation of the vascular system and blood pressure as mediated by the interaction with angiotensin-converting enzyme 2 (ACE2) receptors.

• For hypertensive emergencies in COVID-19, the site of organ damage mostly drives the choice of blood pressure-lowering drugs, target blood pressure, and timeframe by which reduction in blood pressure should achieved.

• In hypertensive urgencies, blood pressure should be reduced over a period of hours to days, usually requiring oral drug administration. Among common blood pressure lowering drugs, beta-blockers, renin-angiotensin-aldosterone system inhibitors, and calcium channel blockers could offer benefits in treating COVID-19 patients.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Additional information

Funding

This manuscript was not funded.