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A Plaque for the Ages
continued from page 9
by which ACE2 receptors are upregulated. Even though
physiological models of SARS-CoV infection show a theoretical
benefit of ACEI/ARB, these findings cannot be extrapolated
to SARS-CoV-2 causing COVID-19. Major cardiology
scientific associations, including ACC, HFSA, AHA, and ESC
Hypertension Council, have rejected these correlation hypotheses.
Recognition that ACE2 is the coreceptor for
the coronavirus has led to new approaches to block
the enzyme or reduce its expression to prevent the
cellular entry and SARS-CoV-2 infection in tissues
that express ACE2 including lung, heart, kidney,
brain, and gut. However, ACE2 is a key component
of the renin-angiotensin-aldosterone system (RAAS).
ACE2 degrades ANG II, a peptide with multiple
actions that promote CVD, and generates Ang-(1-7),
which antagonizes the effects of ANG II. Moreover,
experimental evidence suggests that RAAS blockade by
ACE inhibitors, ANG II type 1 receptor antagonists,
mineralocorticoid antagonists, and statins enhance
ACE2 which, in part, contributes to the benefit of
these regimens. Many patients with hypertension or
other cardiovascular diseases are routinely treated with
RAAS blockers and statins, and new clinical concerns
have developed regarding whether these patients are at greater risk
for SARS-CoV-2 infection, whether RAAS and/or statin therapy
should be discontinued, and the potential consequences of RAAS
blockade to COVID-19-related pathologies such as acute and
chronic respiratory disease.
John McMurray, MD, professor of medical cardiology,
University of Glasgow, UK, spoke on a study from Wuhan
about ACEI/ARBs. He commented that the data available at
this time is not concerning, so the recommendations from many
medical societies to continue ACEI/ARBS seems wise. However,
McMurray pointed out that the patient size was small, which
limits the data's reliability.
While studies have looked at possible consequences of using
statins and RAAS medications during the COVID-19 pandemic,
even more studies are looking at possible therapeutic options and
vaccines to treat patients infected with the virus. The medical
research community has responded to the pandemic remarkably
in order to try and fill in the gaps of knowledge that we lack about
treating this new virus. One medical regimen that has been the
focus of many studies thus far has been the hydroxycholorine
and azithromycin combination use in COVID-19 patients.
Hydroxycholoquine is used widely as an antimalarial drug and
has long been used as an effective treatment of chronic rheumatic
diseases, such as rheumatoid arthritis and systemic lupus
erythematosus. In addition, earlier research on this drug suggested
that it had potential antiviral properties. Azithromyocin, on the
other hand, is an antibiotic commonly used to treat pneumonia,
which is a common complication seen in COVID-19 patients.
However, each have potential serious implications for people
with existing cardiovascular disease. Complications include severe
electrical irregularities in the heart such as arrhythmia (irregular
heartbeat), polymorphic ventricular tachycardia (including
10 CHESTER COUNT Y Medicine | SPRING 2020

Torsades de Pointes), long QT syndrome, and increased risk
of sudden death. The effect on QT or arrhythmia of these two
medications combined has not yet been fully studied, but a journal
article from members of Northshore University Hospital in
Manhasset, New York describes an algorithm for managing QT in
hospitalized COVID-19 patients, in whom this combination may
be used in (outlined in Figure 4 below).

Figure 4: The FDA is currently recommending to not use
this combination out of the hospital. Also, U.S. Veterans Affairs
(VA) medical centers showed no apparent benefit to hospitalized
COVID-19 patients treated with hydroxychloroquine. The
FDA has recently approved the use of Remdesivir in COVID-19
infections.
The FDA is currently recommending to not use this
combination out of the hospital. Also, U.S. Veterans Affairs
(VA) medical centers showed no apparent benefit to hospitalized
COVID-19 patients treated with hydroxychloroquine.
In summary, coronavirus (COVID-19) is a devastating
infection, which is as dangerous as any plague from the Middle
Ages with no treatment or vaccine available at this time. In
addition to multiple complications that we have listed, it can
have cardiovascular complications and its treatments may lead
to potentially dangerous cardiac arrhythmias. Further research is
being conducted in large numbers at this time, and we anxiously
await more information and signs of progress in treating/
preventing infection of COVID-19.
This article was written in
collaboration between Mian
A. Jan, M.D., Chairman
Department of Medicine,
Penn Medicine Chester
County Hospital, and Seamus
Winters, MHS, PA-C, Class
of 2019 graduate of Lock
Haven University's Physician
Assistant Program.
http://www.chestercms.org
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