Saturday, March 14, 2020

ACE inhibitors and statins may reduce mortality

ACE inhibitors and statins may reduce mortality
When any pneumonia can be fatal after age 65?
Dr KK Aggarwal
President CMAAO, HCFI and Past national President IMA

1.     Even with regular community acquired pneumonia the mortality rate higher in patients requiring hospitalization, being as high as 37 percent in patients admitted to the intensive care unit (ICU).
2.     A number of risk factors for mortality have been identified. Having two or three of the following variables have been associated with high risk in several studies: blood urea nitrogen greater than 20 mg/dL, diastolic blood pressure less than 60 mmHg, and/or respiratory rate above 30 per minute. These three variables plus confusion and age greater than 65 years constitute the CURB-65 score; patients with 0 or 1 of these factors are at low risk and can usually be treated as outpatients. Underlying comorbidity and the cause of pneumonia also affect the mortality risk.
3.     CAP has been associated with both short- and long-term risk of cardiac complications. CAP has been associated with acute cardiac events that may result from cardiac stress, hypoxemia, and inflammation.
4.     Most otherwise healthy children with pneumonia recover without sequelae, even if the pneumonia is complicated.
5.     Some people are prone to a severe immune overreaction -— a “cytokine storm” -— that can both sicken and kill patients who are infected with certain strains of flu virus. A cytokine storm is an overproduction of immune cells and their activating compounds (cytokines), which, in a flu infection, is often associated with a surge of activated immune cells into the lungs. The resulting lung inflammation and fluid build up can lead to respiratory distress and can be contaminated by a secondary bacterial pneumonia -- often enhancing the mortality in patients.

This little-understood phenomenon is thought to occur in at least several types of infections and autoimmune conditions, but it appears to be particularly relevant in outbreaks of new flu variants. Cytokine storm is now seen as a likely major cause of mortality in the 1918-20 "Spanish flu" -- which killed more than 50 million people worldwide -- and the H1N1 "swine flu" and H5N1 "bird flu" of recent years.

Drugs for the treatment of cytokine storm can be classified into the following types: OX40 IG, ACE inhibitors and Angiotensin II Receptor Blockers, Corticosteroids, Gemfibrozil, Free radical scavengers, TNF-alpha blockers.

NEJM study: Using Veterans Affairs (VA) databases, the researchers identified 8652 patients (98.6% male) who met the inclusion criteria (age ≥65; hospitalization for community-acquired pneumonia [CAP] or influenza during fiscal year 2000; ≥1 outpatient clinic visit during fiscal year 1999; and ≥1 active and filled prescription ≤90 days before admission). Among these patients, 8.9% were receiving statins and ACE inhibitors, 25.0% were receiving only ACE inhibitors, and 9.2% were receiving only statins. Nearly 10% of the patients died ≤30 days after admission. After adjustment for confounding variables, use of statins alone (odds ratio, 0.58; 95% confidence interval, 0.42–0.80), use of ACE inhibitors alone (OR, 0.84; 95% CI, 0.70–1.00), and use of statins plus ACE inhibitors (OR, 0.45; 95% CI, 0.31–0.66) all were significantly associated with decreased 30-day mortality. Use of nonstatin lipid-lowering agents was not associated with a survival benefit.

Who are high risk patients?

1.     Check SPO2 levels: If with fever. Cough and breathlessness the blood oxygen level SPO2 is low, it’s a sign of anoxia
2.     Check SPO2 levels: If with fever. Cough and breathlessness the blood oxygen level SPO2 drops by 4% on walking it’s a sign of anoxia
3.     Uncontrolled diabetes, blood pressure, asthma and heart failure

Why 65+ pneumococcal vaccination is a must?

People may recover from viral pneumonia but die of secondary pneumococcal pneumonia

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