LAUSR

The coronavirus disease 2019 (COVID-19) pandemic is precipitating the global health crisis of our time, as stated by the World Health Organization (WHO). Since its surge in December 2019, in Wuhan, Hubei province, China, the virus has spread to every continent except Antarctica. The main clinical manifestation of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is severe respiratory infection, which yields to inflammatory reaction and alveolar fluid floading, ultimately impairing gas exchange.1–3 Reports have clearly established that hypertension, diabetes, and cardiovascular diseases are the most frequent comorbidities in affected patients, and these individuals are exposed to the highest mortality rates.4,5 Most of these patients suffer from pre-existing or rapidly evolving heart failure (HF)6,7 and are commonly treated with renin–angiotensin system inhibitors, such as angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs), according to guideline class I, level of evidence A.8 However, there is an ongoing debate about the use of ACEIs/ARBs in patients with COVID-19 or at risk of SARS-CoV-2 infection which may not be beneficial or even harmful.9 Vaduganathan et al.10 have recently reported an elegant and comprehensive review on the controversial aspects of this topic, providing the most updated evidence. We gained previous experience on the effects of renin–angiotensin system inhibition on the pulmonary function of HF patients showing a protective effect on the perturbed gas exchange and lung fluid handling, i.e. alveolar–capillary stress failure, an effect especially observed with enalapril treatment, with a positive but not statistically significant trend for losartan11,12. Based on this, we outline how renin–angiotensin inhibitors may interact with lung fluid handling and gas diffusion process in patients with HF infected by SARS-CoV-2, and propose areas for further research.