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VIEWS ON COVID-19 INFECTION

Are COVID-19 patients with hypertension at higher risk in China?

Wang, Siqia,b; Chen, Yana,b; Wang, Luc; Liu, Huand; Han, Pinga,b

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doi: 10.1097/HJH.0000000000002483
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As of 25 March 2020, the outbreak of COVID-19 caused by SARS-CoV-2 had caused 423 181 confirmed cases and 18 870 dead cases globally, including 194 countries and 6 continents (obtained from Chinese National Health Commission). It poses a great threat to human life and health, especially for those with underlined diseases. Previous studies have reported epidemiological, clinical, and radiological features of COVID-19 patients [1–3]. However, impacts of hypertension on COVID-19 prognosis remain to be determined.

To study the possible effects of hypertension on COVID-19 prognosis, we collected and analysed 147 patients from 2 February 2020 to 1 March 2020 in Union hospital, Wuhan, China. All cases were diagnosed with real-time reverse transcriptase PCR (RT-PCR) tests for COVID-19 nucleic acid in throat swabs or lower respiratory tract and were admitted to hospital. The study was approved by the ethical committee of Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, and the need for informed consent was waived.

On admission, 37 and 110 patients were categorized into hypertension and nonhypertension subgroups. Clinical characteristics and symptoms were collected from electronic medical records. All patients were Wuhan citizens or lived in Wuhan recently. The age differed significantly between hypertension and nonhypertension groups (median, 69 vs. 50, P < 0.001). Dyspnea, shortness of breath, and night sweats were more common in hypertension group than nonhypertension group (P=0.02, P = 0.042, P = 0.049, respectively). Moreover, other comorbidities including diabetes, cardiovascular disease, and hypothyroidism were also significantly more common in hypertension cases than nonhypertension cases (P = 0.001, P = 0.02, P = 0.004, respectively). According to the WHO guideline on admission [4], patients were grouped into severe and nonsevere groups. The patients with severe type in hypertension group were more than those in nonhypertension group (32.4 vs. 19.1%, P = 0.092). Hypertension cases have a higher probability of severe events compared with nonhypertension cases (16.2 vs. 4.6%, P = 0.03).

Severe events were defined as the admission to ICU, or mechanical ventilation, or death [5]. The final date of follow-up was 5 March 2020. A total of 11 patients (7.5%) finally reached the composite endpoint, including being transfered to ICU, requiring mechanical ventilation and death (2.7, 5.4, and 4.8%, respectively). Hypertension cases are more likely to transfer to the ICU and require mechanical ventilation than nonhypertensive cases (8.1 vs. 0.9%, P = 0.049; 13.5 vs. 2.7%, P = 0.025), however, they were less likely to be discharged (21.6 vs. 42.7%, P = 0.022). Kaplan–Meier analysis was used to evaluate the time-dependent hazards of developing severe events, and results showed that patients with hypertension deteriorated more rapidly than patients without hypertension (P = 0.023, Fig. 1).

FIGURE 1
FIGURE 1:
Kaplan--Meier curves of risk group stratification according to hypertension. High risk: hypertension group; low risk: nonhypertension group. Patients with hypertension deteriorated more rapidly than patients without hypertension.

Laboratory findings, including whole blood count, blood chemistry, coagulation test, electrolytes, lymphocytes phenotypic (CD4+, CD8+, CD3+ T cells), and pathogen test were also collected from electronic medical records. For all cases, the mean value of γ-glutamyltransferase, cystatin C, C-reactive protein level, D-dimer, FIB, interleukin-6, Erythrocyte sedimentation rate were higher than normal value, the low-density lipoprotein cholesterol was lower than normal value. Aspartate aminotransferase, lactose dehydrogenase, and erythrocyte sedimentation rate in hypertension group was significantly higher than nonhypertension group (P = 0.026, P = 0.027, P = 0.026, respectively). CD3+ total T lymphocytes and CD8+ T lymphocytes were significantly slightly higher in hypertension cases than in nonhypertension cases (P = 0.043, P = 0.049). More patients use corticosteroid in hypertension group compared with nonhypertension group (29.7 vs. 12.7%, P = 0.017).

Chest computed tomography (CT) has played an important role in the diagnosis and course judgment of COVID-19 [6,7]. To quantify the extent of disease, each case was assigned a CT score according to the involvement of pulmonary abnormalities (1, <5%; 2, 5–25%; 3, 26–50%; 4, 51–75%; and 5, 76–100%). The total CT score was obtained by adding the individual lobar scores and ranged from 0 to 25 [6,8]. Chest CT evaluation was independently reviewed by two radiologists (S.W., Y.C., who had 6 and 15 years of experience in thoracic radiology, respectively) and final scores were determined by consensus. In hypertension group, the lungs were more inclined to be involved with higher CT scores. The CT scores of left upper lobe, right upper lobe, right middle lobe, and right lower lobe in hypertension cases were significantly greater than that of nonhypertension cases (P = 0.015, P = 0.003, P = 0.015, and P = 0.005, respectively). In hypertension group, the total CT score was greater than that of nonhypertension (11.6 ± 7.1 versus 7.8 ± 6.5, P = 0.003).

A recent study showed that 25.2% of COVID-19 patients had at least one underlying disease, including hypertension and chronic obstructive pulmonary disease [9]. We further analysed the clinical characteristics, laboratory data, CT findings, and prognosis differences between hypertensive and nonhypertensive patients after infection with SARS-CoV-2. We found that patients with hypertension might have a higher risk of severe events than nonhypertension patients, and they had poorer outcomes from COVID-19. Our study provides a timely reminder to clinicians that when patients with hypertension are infected with SARS-CoV-2, they should pay more attention and consider more intensive surveillance or treatment to prevent the disease from rapid deterioration.

ACKNOWLEDGEMENTS

Conflicts of interest

There are no conflicts of interest.

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