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The Beat:
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Caring For Patients During a Pandemic

Written by John Steuter, MD

Every day we learn more and more about how SARS-CoV-2 virus impacts the health of infected individuals. The following diagram is an effort to explain the current understanding of how the virus changes cell signaling pathways and leads to clinical compromise. It also looks to identify methods of treatment.

sars diagram

The mechanism for SARS-CoV-2 infection is the requisite binding of the virus to the membrane-bound form of angiotensin-converting enzyme 2 (ACE2) and internalization of the complex by the host cell.

As a result there is:

  • Increased endothelial apoptosis
  • Decreased fibrinolysis
  • Increased cytokine levels
  • All leading to microangiopathy

At the same time there is an increase in:

  • Nitric oxide
  • Pulmonary vasodilation
  • Fibrinous and edematous insult that lead to lung injury that is seen clinically as the ground glass appearance pattern on lung imaging and hypoxia in patients

ACEIs/ARBs May Increase Risk of SARS‐CoV‐2 Infection

Angiotensin‐converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs) are widely used in the treatment of these cardiovascular diseases. Interestingly, several studies have shown that ACEIs/ARBs exhibit ability to upregulate ACE2 expression. Therefore, some have suggested that patients should discontinue ACEIs/ARBs to avoid the potential increased risk of SARS‐CoV‐2 infection.

Elevated Level of Angiotensin II, Potential Cause for Lung Injury 

At the same time there is evidence demonstrating that the activation of the renin‐angiotensin system (RAS) and the downregulation of ACE2 expression are involved in the pathological process of lung injury after SARS‐CoV infection.  It has been reported that serum level of angiotensin II is significantly elevated in COVID‐19 patients and exhibits a linear positive correlation to viral load and lung injury. Activation of the RAS can cause widespread endothelial dysfunction and varying degrees of multiple organ (heart, kidney and lung) injuries. Thus, intake of ACEIs/ARBs might probably relieve the lung injury and absolutely decrease heart and renal damage resulting from the RAS activation.

Future Findings

For now the jury is out about ACE/ARBs in COVID-19, overtime new data will hope to shed further guidance on this issue. We are committed at Bryan Heart and Bryan Health to staying on the leading edge of understanding the current pandemic and providing top level care for your patients during these times as further demonstrated by our actions with clinic visits detailed next.

Caring For Our Patients & Communities  

Over the past six weeks, the COVID-19 pandemic forced Bryan Heart to restructure the ways in which we were caring for patients. As of March 18, Bryan Heart suspended physician travel to our 38 outreach locations, in addition we started to scale back the number of in-person patient visits taking place at our Lincoln, Columbus and Hastings offices.  While this was a difficult decision, our main priority was and continues to be patient safety.

steuter telemedicine

John Steuter, MD, Bryan Heart cardiologist, provides a virtual visit

We know that cardiac patients are part of the high-risk population that need to practice social distancing and limit possible exposure to COVID-19. By offering our patients different avenues to conduct their regularly scheduled appointment via telephone, virtual/video and when acuity dictates, an in-person visit, we hope to do our part in keeping those patients as safe as possible at home.

We have been overwhelmed by the positive response received from our patients while modifying the appearance of their visits. Most patients have smartphones, tablets or computers and are able to complete a virtual/video visit. 

If you have questions, please contact Bryan Heart at 402-483-3333.


steuter john

About John Steuter, MD

John Steuter, MD, is a cardiologist at Bryan Heart. Steuter is a graduate of The University of Nebraska Medical Center College of Medicine and joined Bryan Heart in 2015 after completing his residency and fellowship at The University of Nebraska Medical Center. He is certified with the American Board of Internal Medicine.

View Dr. Steuter’s physician profile


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