Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

International charter on cardiovascular prevention and rehabilitation

Cardiovascular disease remains the leading cause of death in both women and men globally and is a growing epidemic in low-to middle-income countries. Without systematic access to cardiac rehabilitation (CR), these individuals may experience multiple recurrent acute care events and suffer unnecessarily premature death. The 2 aims of this Charter are (1) to bring together national associations from around the world to harmonize efforts in promoting cardiovascular prevention and rehabilitation and (2) to document consensus among national associations globally, regarding the internationally common core elements and benefits of cardiovascular disease prevention and rehabilitation. The Global Charter on CR calls to action those responsible for administering patient care to (a) establish CR as an obligatory, not optional service, and (b) to support countries to establish and augment programs of CR to ensure broad access to these proven services. In addition, the Charter calls for CR organizations and associations in high-income countries to collaborate with those in low-to middle-income countries, to support capacity building and provide tangible toolkits for program development and maintenance. The aim of this Charter is to maintain and grow this global consortium through partnerships with international organizations and to consider and communicate ongoing consensus of evidence-based standards for CR worldwide

International charter on cardiovascular prevention and rehabilitation

Cardiovascular disease remains the leading cause of death in both women and men globally and is a growing epidemic in low-to middle-income countries. Without systematic access to cardiac rehabilitation (CR), these individuals may experience multiple recurrent acute care events and suffer unnecessarily premature death. The 2 aims of this Charter are (1) to bring together national associations from around the world to harmonize efforts in promoting cardiovascular prevention and rehabilitation and (2) to document consensus among national associations globally, regarding the internationally common core elements and benefits of cardiovascular disease prevention and rehabilitation. The Global Charter on CR calls to action those responsible for administering patient care to (a) establish CR as an obligatory, not optional service, and (b) to support countries to establish and augment programs of CR to ensure broad access to these proven services. In addition, the Charter calls for CR organizations and associations in high-income countries to collaborate with those in low-to middle-income countries, to support capacity building and provide tangible toolkits for program development and maintenance. The aim of this Charter is to maintain and grow this global consortium through partnerships with international organizations and to consider and communicate ongoing consensus of evidence-based standards for CR worldwide

A Narrative Review on Women and Cardiac Rehabilitation: Program adherence and preferences for alternative models of care.

Despite the preponderance of evidence on the numerous benefits of CR, it remains largely under-utilized in women. The objective of this narrative review was to summarize and synthesize the literature on women and CR with regard to outcomes, adherence, and preferences for alternative models of CR. Studies of the effectiveness of CR have generally revealed no major differences between men and women. However, female-specific data are lacking on the effect of CR on mortality and morbidity. Research suggests that women and men may be equally likely to prefer home-based to hospital-based CR services. Women’s preferences for and outcomes in, women-only CR are beginning to be uncovered. Discussing program model options with female cardiac patients and referring to preferred types may be the appropriate approach until further evidence is available