ImportanceCoronavirus disease 2019 (COVID-19), the disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been declared a global pandemic with significant morbidity and mortality since first appearing in Wuhan, China, in late 2019. As many countries are grappling with the onset of their epidemics, pharmacotherapeutics remain lacking. The window of opportunity to mitigate downstream morbidity and mortality is narrow but remains open. The renin–angiotensin–aldosterone system (RAAS) is crucial to the homeostasis of both the cardiovascular and respiratory systems. Importantly, SARS-CoV-2 utilises and interrupts this pathway directly, which could be described as the renin–angiotensin–aldosterone–SARS-CoV (RAAS–SCoV) axis. There exists significant controversy and confusion surrounding how anti-hypertensive agents might function along this pathway. This review explores the current state of knowledge regarding the RAAS–SCoV axis (informed by prior studies of SARS-CoV), how this relates to our currently evolving pandemic, and how these insights might guide our next steps in an evidence-based manner.ObservationsThis review discusses the role of the RAAS–SCoV axis in acute lung injury and the effects, risks and benefits of pharmacological modification of this axis. There may be an opportunity to leverage the different aspects of RAAS inhibitors to mitigate indirect viral-induced lung injury. Concerns have been raised that such modulation might exacerbate the disease. While relevant preclinical, experimental models to date favour a protective effect of RAAS–SCoV axis inhibition on both lung injury and survival, clinical data related to the role of RAAS modulation in the setting of SARS-CoV-2 remain limited.ConclusionProposed interventions for SARS-CoV-2 predominantly focus on viral microbiology and aim to inhibit viral cellular injury. While these therapies are promising, immediate use may not be feasible, and the time window of their efficacy remains a major unanswered question. An alternative approach is the modulation of the specific downstream pathophysiological effects caused by the virus that lead to morbidity and mortality. We propose a preponderance of evidence that supports clinical equipoise regarding the efficacy of RAAS-based interventions, and the imminent need for a multisite randomised controlled clinical trial to evaluate the inhibition of the RAAS–SCoV axis on acute lung injury in COVID-19.

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aortic dissections was the critical care unit in the majority (n = 12, 67%) of centres, with 5 centres preferring theatre (28%). There was agreement from respondents that guidelines regarding the transfer of acute Type A aortic dissection patients would be beneficial.Discussion: This survey of UK cardiac centres shows that the majority of centres already centralise treatment of Type A aortic dissection patients by sharing responsibilities. Furthermore, it reflects the observation by the majority of ACTACC link persons that there may be room for improvement of a timely diagnosis, transfer times, monitoring, and training and experience of escorting personnel. In the future a national prospective audit of acute Type A dissection cases in the UK will be necessary to further assess timely diagnoses and quality of transfer-related variables in individual patients with the view of elucidating how to potentially reduce the high incidence of pre-hospital deaths of patients with acute Type A aortic dissection. This survey was conducted before the COVID-19 pandemic. A future audit would help to assess NHS treatment of acute Type A aortic dissections after the pandemic peak.References: Mahase E. Half of patients with acute aortic dissection in England die before reaching a specialist centre. Brit Med J 2020; 368:m304.

important impact on mortality and morbidity after cardiac surgery: in the Euroscore2 renal function is appreciated by the glomerular filtration rate (GFR) calculated by Cockgroft and Could (CC), divided in 4 different categories. Recent studies suggested that different equation will predict more accurately postoperative AKI. The aim of this study was to evaluate if more recent ways to assess renal function (CKD-EPI, MDRD, Mayo-Clinic equation) or the simple preoperative creatinine level (SCr) would improve the accuracy of the euroscore2.Methods: We used data of a cohort using our prospective database from September 2012-Juin 2019 of patients undergoing cardiac surgery. We excluded emergent surgery and left heart assistance devices. GFR was calculated with the different equations. We then calculated the Euroscore2 without the weight of the GFR and used statistic regression to build 4 new Euroscore2 including the different GFR (CKD-EPI, MDRD, Mayo-Clinic equation) in a logistic regression as a continuous variable or creatinine level. The area under the ROC curve (AUC) for the to the different Euroscore2 to predicted mortality, for AKI and for hospital stay. AKI was classed with RIFLE criteria.

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