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While we see with some relief the regress – in our latitudes – of the COVID-19 pandemic, we are still in shock for its brutality, its cost in human lives and the drastic changes it has imposed on our social life. In a recently published article[i]   he calls this event a “Black Swan[ii]“, which caught us all by surprise and therefore unprepared. If, thanks to the mobilization of everyone from the medical community to the patient and citizen, our health care system under strain has managed to cope with this first wave, we are today faced with many new questions and still very few answers. One of these, while epidemiological data clearly indicate that hypertension and cardiovascular disease are the most important risk factor for fatality, is on the role of ACE-inhibitors.

Widely used in particularly on elderly patients, inhibitors of the Angiotensin I conversion enzyme in Angiotensin II (ACE-Is) could, according to Gabriela Kuster from the University Hospital of Basel [iii], facilitate the entry of the virus into cells and thus increase the risk of fatality in patients under ACE-inhibitors. The mechanism presented is that of an up-regulation of ACE2 that the virus uses to fix itself on the membranes of lung cells and penetrate within them. However, it does not rule out a reversal of causation knowing that patients under ACE inhibitors are mostly elderly and have comorbidities. Adrian Voors of the University of Groningen[iv] After a study of 1485 men and 537 women concludes that the use of ACE inhibitors does not increase the vulnerability of COVID-19 patients through an increase in the plasma concentration of ACE2. In fact, our current practice is to maintain treatments with ACE inhibitors, with a particular focus on cases where patients should develop COVID-19.

The pandemic is a challenge at all levels, from the scientific medical to the social economic one, but above all it is a lesson of humility. We must accept that we do not know how and when we will get out of it and we must not forget that our knowledge, and therefore our means, are limited. Current optimism has, of course, quickly replaced pessimism and this is certainly a good thing. But being optimistic does not mean lowering our guard and being convinced that the worst is behind even if   it   is perhaps true. There is no science without experience and there should be no medicine without evidence. We all have to continue to protect ourselves and protect our patients, applying the measures that have proven their effectiveness in the past, informing us about the progress of science and contributing to it through our experience.


[i]  COVID-19: (mis)managing an announced Black Swan, European Heart Journal (2020) 41, 1779-1782 – click here

[ii] Taleb NN. The Black Swan: The Impact of the Highy Improbable. Random House; 2007.

[iii] Kuster et al. SARS-CoV2: should inhibitors of the renin angiotensin system be withdrawn in patients with COVID-19? Eur Heart J 2020;41:1801-1803

[iv] Circulating plasma concentrations of ACE2 in men and women with heart failure and effects of renin-angiotensin-aldosterone inhibitors: potential implications for coronavirus SARS-CoV-2-infected patients.   Eur Heart J 2020;41:1810-1817