What is the recommended management for patients with hypertension and COVID-19?

Management of Hypertension in Patients with COVID-19

Continue all antihypertensive medications, particularly RAAS inhibitors (ACE inhibitors and ARBs), in patients with hypertension who develop COVID-19, as these medications do not increase infection risk or worsen outcomes and may provide protective benefits. 1, 2

Medication Management During COVID-19 Infection

RAAS Inhibitors (ACE Inhibitors and ARBs)

• Do not discontinue ACE inhibitors or ARBs in hypertensive patients with COVID-19, despite initial theoretical concerns about angiotensin-converting enzyme 2 receptor expression 1
• Clinical groups have recommended continued use of RAAS inhibitors based on growing evidence that allays safety concerns 1
• Studies suggest potential protective effects of RAAS inhibitors in COVID-19 patients with or without hypertension, though evidence is limited beyond recommending continuation 1
• The American Heart Association recommends adding an ACE inhibitor or ARB (such as lisinopril or losartan) as foundational therapy for heart failure and hypertension, as these agents do not increase COVID-19 risk 2

Other Antihypertensive Medications

• Continue all cardiovascular medications including beta-blockers, diuretics, and calcium channel blockers during and after COVID-19 infection 2
• Anti-hypertensive drugs do not affect prognosis in COVID-19 patients 3
• Monitor for medication-specific considerations during acute illness (see below for diabetes medications that may require adjustment) 1

Blood Pressure Control During COVID-19

Importance of BP Control

• Poor blood pressure control is independently associated with higher risks of adverse COVID-19 outcomes, including heart failure, ICU admission, and mortality 4
• Average systolic blood pressure and pulse pressure are significant predictors of heart failure in hypertensive COVID-19 patients 4
• Blood pressure variability (standard deviations of systolic and diastolic BP) is independently associated with mortality and ICU admission 4

Monitoring Strategy

• Implement telemedicine-based home blood pressure monitoring to maintain good BP control while maintaining social distancing 1, 5
• The American Heart Association recommends telehealth visits include remote monitoring and transmission of blood pressure readings using connected home monitors 6
• Monitor daily weights and volume status, particularly in patients with heart failure 2

Risk Stratification and Monitoring

Hypertension as a Comorbidity

• Hypertension is a common comorbidity in hospitalized COVID-19 patients, though insufficient evidence exists to establish it as an independent risk factor after accounting for age, obesity, and diabetes 1
• Hypertensive patients with COVID-19 have higher risk of severe disease, hospitalizations, ICU admissions, and mortality compared to non-hypertensive patients, though this may be confounded by demographic and socioeconomic factors 7

Biomarker Monitoring

• Monitor troponin, N-terminal pro-B-type natriuretic peptide, D-dimer, and serum creatinine for complications including myocardial injury, heart failure, thrombosis, and kidney injury 5
• Check platelet count, coagulation parameters, and liver and renal function before starting antithrombotic medications 1

Special Considerations for Comorbid Conditions

Diabetes Management in Hypertensive COVID-19 Patients

• Metformin should be stopped if patients are dehydrated due to risk of lactic acidosis; follow sick day rules and monitor renal function carefully 1
• SGLT2 inhibitors (canagliflozin, dapagliflozin, empagliflozin) should be stopped during respiratory illness due to risk of dehydration and diabetic ketoacidosis 1
• The American Diabetes Association recommends adding SGLT2 inhibitors for dual benefit of glycemic control and heart failure management in stable patients 2
• DPP-4 inhibitors are generally well tolerated and can be continued 1
• Never stop insulin therapy; encourage regular self-monitoring of blood glucose every 2-4 hours 1

Atrial Fibrillation Management

• In outpatients with COVID-19 and new-onset AF, start a DOAC if CHA2DS2-VASc score is ≥1 in males or ≥2 in females 1
• In hospitalized patients with COVID-19 and new-onset AF, start therapeutic-dose parenteral anticoagulation irrespective of CHA2DS2-VASc score 1
• Continue rivaroxaban or other anticoagulants for stroke prevention, monitoring for drug interactions with COVID-19 treatments 2

Post-COVID Cardiovascular Monitoring

Follow-up Strategy

• Schedule follow-up at 2-4 weeks post-discharge to reassess medication regimen and volume status 2
• The American College of Cardiology recommends ECG, echocardiogram, and ambulatory rhythm monitor at 3-6 months post-infection to assess for persistent cardiac dysfunction or arrhythmias 2
• Monitor for post-acute COVID-19 cardiovascular sequelae including persistent dyspnea, chest pain, palpitations, or exercise intolerance 2
• Consider cardiac MRI if symptoms persist or worsen, particularly with concern for myocarditis 2

Healthcare Delivery Considerations

Telemedicine Implementation

• The COVID-19 pandemic has demonstrated telemedicine as an indispensable resource for continuity of care in vulnerable patients with chronic diseases including hypertension 1
• Telehealth visits should include blood pressure review, medication management, lifestyle factors assessment, and plan development 6
• Remote consultations using Connected Health models should be utilized to reduce exposure wherever possible 1

Common Pitfalls to Avoid

• Do not discontinue RAAS inhibitors based on theoretical concerns about ACE2 receptor expression 1
• Do not use antiplatelet therapy alone for thromboembolism prevention in patients with new-onset AF 1
• Recognize that reduced contact with healthcare services during pandemic may delay hypertension diagnosis and disrupt treatment 1
• Consider socioeconomic factors including patients' delay of healthcare due to fear of COVID-19 and barriers to accessing primary care 7