Characteristics of Patients with Hypertension Admitted for COVID-19 Treatment in Khulna: Single-Centre Cross-Sectional Study

Background: The outbreak of coronavirus disease 2019 (COVID-19) has become a large threat to global health due to its high contagious nature and varied mortality. Arterial hypertension repre-sents one of the most common comorbidities in patients with COVID-19. Close connections be-tween inflammation and blood pressure (BP) have been described, and inflammation plays a key role in the outcome for patients with COVID-19. Objective: This study aims to investigate the clinical characteristics of patients with hypertension admitted for COVID-19 treatment in Gazi Medical College Hospital (GMCH), Khulna, Bangladesh. Methods: This was a cross-sectional type of observational study on patients with hypertension who were diagnosed with COVID-19 based on laboratory and/or radiological findings and admitted to Gazi Medical College Hospital, Khulna, Bangladesh, from July 1 to July 31, 2021. In that timeframe, overall, 215 patients with COVID-19 were admitted. Among them, 37 patients having hypertension fulfilled the inclusion criteria for the study. Demographic, clinical, laboratory and radiological data of those 37 patients were recorded and analyzed. Results: Among 37 study subjects, 54.1% were female. The mean age of the patients was 59.6±13.9 years. Among the study subjects, diabetes (56.8%) was the most common comorbidity. Regarding laboratory parameters, the mean Hb of the patients was 11.4±1.9 g/dl. In addition, the mean random blood sugar (RBS) level was 11.6±2.9 mmol/l. Neutrophilia and lymphocytopenia were observed in 86.5% and 83.8% cases, respectively. The mean D-dimer (2.4 mg/l) and CRP (72.5 mg/l) levels were well above their normal limits. In high resolution CT scan of the chest (HRCT chest), bilateral lung involvement was present in 89.2% cases. Ground-glass appearance was the most frequent (91.9%) radiologic pattern. Among antihypertensive drugs, losartan potassium was the most frequently used category (29.7%). Total 7 (18.9%) pa-tients were severely affected with COVID-19 and admitted to the ICU, requiring mechanical venti-lation. During our study, 2 patients (5.4%) died either due to multiple organ dysfunction syndrome or cardio-respiratory failure. Conclusion: The study provides key information to better understand the clinical characteristics of patients with hypertension admitted for COVID-19 treatment, which may help physicians to identify the factors associated with adverse outcomes in this disease.


Introduction
Towards the end of December 2019, pneumonia cases with no identifiable cause began to appear in Wuhan and quickly spread to most of China.The genetic makeup of the virus isolated from these patients revealed that it is one of the members of the Coronaviridae family; as a result, it was given the names "severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)" and "coronavirus disease 2019" (COVID- 19) to describe the illness it causes. 1Since the World Health Organization (WHO) designated this sickness a pandemic in early March 2020, it has already spread to several nations worldwide. 2The management of COVID-19 patients is extremely difficult in countries like Bangladesh since the little medical resources are soon exhausted.IEDCR, the nation's epidemiology institute, released information about the first three instances on March 8th, 2020.Since then, the epidemic has progressively spread over the entire country, and the number of victims has been rising. 3angladesh has experienced a threefold increase in coronavirus incidence during the previous several months.The specialized beds in many other hospitals are likewise filled, as are all COVID-19 hospitals in the capital and other cities. 4 As of June 2021, it has been noted that Sylhet has the lowest confirmed cases rate (9.75%) out of all eight divisions in Bangladesh, while Khulna division possesses the highest known cases rate (19.94%). 5veral underlying medical conditions are associated with increasing the risk of COVID-19 severity and are associated with a higher mortality rate. 6Hypertension (HTN) is a major disease that increases the risk of acute respiratory failure, hospital admission and mortality rate among patients with COVID-19. 7It is a main co-morbidity among patients with COVID-19 and management of HTN in COVID-19 is an essential for reduction of mortality and morbidity.Older hypertensive patients are more vulnerable to severe COVID-19 outcomes and may experience large fluctuations in BP along with psychological stress such as anxiety, depression, or other negative emotions. 8 this study, we sought to better understand the clinical characteristics of patients with hypertension who were admitted to Gazi Medical College Hospital in Khulna, Bangladesh, for COVID-19 management.

Study design
This was a cross-sectional, observational study of patients with diabetes who were diagnosed with COVID-19 based on laboratory and/or radiological findings and admitted to Gazi Medical College Hospital, Khulna, Bangladesh, from July 1 to July 31, 2021.In that timeframe, overall, 215 patients with COVID-19 were admitted.Among them, 51 patients had hypertension.Thus, 23.7% (51/215) of all patients admitted with COVID-19 had coexistent hypertension. 9Among them, 37 patients who fulfilled the inclusion criteria, were selected for the study.

Data collection
We looked through each study participant's medical records, nursing notes, test results, and HRCT chest report.From patients' case files and electronic medical records, the information on demographic, clinical, biochemical, and radiological characteristics, treatments, as well as outcomes was collected and then put into standardized data collecting forms.Up to July 31, 2021, clinical outcomes (such as discharges, death, and readmission) were monitored.

Data analysis
For descriptive explanations, the clinical and demographic parameters of the patients were collated.According to the situation, continuous variables were either reported as means ± standard deviations (SDs) or medians (with interquartile ranges, IQR).We computed the frequencies and proportions of patients in each group for categorical variables.Microsoft Excel and Jamovi Open Statistical Software Version 2.4.8.0 for Windows were used for all analyses.

Results
The demographic characteristics, laboratory findings, information about comorbidities and HRCT chest reports of the 37 study subjects are described below.

Pattern of antihypertensive drugs used:
Survey of the treatment regimen of the patients showed that, different classes of antihypertensive medications were prescribed to the patients.Among those, followed by a β-blocker, bisoprolol [8 (21.65)].The list of antihypertensives used in our study subjects is shown in Table 04.During the study period, 2 patients (5.4%) died either due to multiple organ dysfunction syndrome or cardio-respiratory failure-all of whom were in the ICU (Table 05).

Discussion
This is a single center study conducted at Gazi Medical College Hospital, Khulna, Bangladesh on the patients with COVID-19 with hypertension (HTN).In our study, 23.7% of all patients admitted with COVID-19 had coexistent hypertension.Previous researches have documented that comorbid hypertension can exacerbate COVID-19 in all age patients.Hypertension had a more pronounced effect on in-hospital death in the present study, when compared to previous studies that focused on patients of all ages. 9,10The cellular entry of SARS-CoV-2 depends on its recognition of angiotensin-converting enzyme 2 (ACE2), and leads to the activation of T cell proliferation and differentiation into Th1 cells 11 , which secretes proinflammatory cytokines and eventually triggers immune hyperresponsiveness, and this is referred to as a "cytokine storm". 12There is substantial evidence that human circulating T cells are activated in hypertension, and inflammation has been considered to have a significant role in the promotion and maintenance of hypertension. 13eractivated circulating T cells in pre-existing hypertension may amplify the cytokine storm of COVID-19, and thereby exacerbate the condition.The present study revealed that elderly patients with hypertension had significantly higher NLRs, indicating their overall inflammatory status.In addition, the levels of LDH, hs-CRP and D-dimer were higher in the hypertension group, which usually increase after the onset of inflammation, cell damage, or tissue injury, and this may be associated with the more serious tissue damage led by the cytokine storm magnified by hypertension. 14Another possible explanation for the correlation between severe COVID-19 and hypertension is that the end-organ damage from chronic hypertension may have led to some degree of immune dysfunction in the elderly. 15milar to previous findings, 16,17 the lymphocyte count of patients was significantly lower, suggesting that immune cell depletion and immune system dysregulation were more severe in the hypertensive patients.In addition, the higher chest CT score denotes the further involvement of lung infection.This also indirectly supports the notion that hypertensive patients are more likely to develop immune dysfunction.

Limitations and conclusion
It is important to consider the present study's limitations.First off, because we conducted the study at just one center, our sample size was rather small.Therefore, the current study does not accurately reflect the COVID-19 burden in the Khulna area.Our study's lack of a control group of individuals without hypertension to compare the outcomes to is another drawback.Additionally, most of our patients lacked information on how accurately they might be classified as overweight or obese, despite the fact that obesity is associated with a more severe disease and a higher death risk.This is because during a short period of time, a rising number of new patients presented to our healthcare institution with COVID-19 symptoms.
Despite these drawbacks, we think our study offers important insights into the characteristics of hypertensive patients hospitalized for COVID-19 management.This study may aid medical professionals in determining the causes of unfavorable outcomes in hypertensive individuals hospitalized with COVID-19 by using clinical and laboratory data.

Figure 01 :
Figure 01: Lung field involvement of the study subjects reported by HRCT of chest HTN was defined clinically as systolic blood pressure (SBP) 140 mmHg or greater or diastolic blood pressure (DBP) 90 mmHg or greater averaged over two or more readings on two or more occasions following an initial screening.•Laboratory tests ordered within 24 hours after hospital admission were referred to as initial tests.• When patients were clinically healthy and were negative on two consecutive nasopharyngeal swab tests (laboratory tests) for COVID-19 RT-PCR, they were released from the hospital.
(for example, ground-glass opacity), were required to confirm a diagnosis of COVID-19.•