Angiotensin II Administration in Patients With COVID-19 Shock

Abstract

Purpose: To understand the hemodynamic effect of angiotensin II as a vasopressor in patients with shock secondary to COVID-19 infection. Methods: A retrospective analysis was performed on all patients at a single center with COVID-19 infection and shock who were treated with angiotensin II. The hemodynamic response to angiotensin II was estimated by recording the mean arterial pressure, norepinephrine equivalent dose (NED) and urine output. Results: Ten patients with COVID-19 related shock were treated with angiotensin II. Over the initial 6 hours, the average the NED decreased by 30.4% (from 64.6 to 44 µg/min) without a significant change in the mean arterial pressure (0.7% decrease). Six patients experienced at least a 25% reduction in NED by 6 hours, and 2 experienced at least a 50% reduction. Conclusions: On average, the hemodynamic response to angiotensin II in COVID-19 related shock was favorable. Two patients had a marked rapid improvement. Given the relationship of SARS-CoV-2 with the renin-angiotensin-aldosterone system, further evaluation of angiotensin II for the treatment of COVID-19 related shock is warranted.

Association of vasopressors with mortality in critically ill patients with COVID-19: A systematic review and meta-analysis

“…patients who did not receive vasopressors [20-37,39-48,50,52]. Moreover, three studies included patients who received angiotensin-II [38,49,51] and, out of those, two compared the use of angiotensin-II with other vasopressors [49,51] (Appendix C2). Table 1 summarizes the main characteristics of the included studies.…”

“…Four studies provided data on mortality based on the specific vasopressor(s) administered [38,43,49,51]. The highest mortality rate was observed in patients treated with vasopressin or epinephrine (78% and 76%, respectively) [43].…”

Clinical update on COVID-19 for the emergency clinician: Airway and resuscitation

“…A study of 31 ICU patients on norepinephrine found aerosolized milrinone did not have a positive impact on right ventricular (RV) function or afterload [ 16 ]. One retrospective study of 10 patients found adding angiotensin II reduced the norepinephrine equivalent dose by 30.4%; however, 50% of patients died after care was withdrawn and the other 50% of patients remained hospitalized [ 17 ]. In patients with severe or refractory septic shock, corticosteroids are recommended with consideration for dexamethasone or hydrocortisone as primary options (e.g., hydrocortisone 200 mg daily) [ 7 ].…”

Multifunctional angiotensin converting enzyme 2, the SARS-CoV-2 entry receptor, and critical appraisal of its role in acute lung injury

“…On the other hand, plasma levels of DPP4, the entry receptor for MERS-CoV, were reported to be decreased in COVID-19 patients [ 285 ] and in patients infected with MERS-CoV [ 286 ]. Interestingly, in small cohorts of COVID-19 patients, Ang-II has been used to treat COVID-19-induced vasodilatory shock [ [287] , [288] , [289] ].…”