Skip to main content

Clinical outcomes in COVID-19 among patients with hypertension in the Philippine CORONA Study



To describe the association between hypertension and clinical outcomes in a cohort of patients with coronavirus disease 2019 (COVID-19).


Retrospective cohort study.


Thirty-seven (37) hospitals in the Philippines.


10,881 patients admitted for COVID-19 from February to December 2020.

Measurements and main results

Among the 10,881 patients included in the Philippine CORONA Study, 3647 (33.5%) had hypertension. On regression analysis adjusted for confounders (age group, sex, smoking history, diabetes, chronic cardiac disease, chronic kidney disease, chronic respiratory disease, chronic neurologic disease, chronic liver disease, HIV/AIDS, and malignancy), patients with hypertension had significantly greater odds of in-hospital mortality (OR 1.33, 95% CI 1.17–1.52), respiratory failure (OR 1.99, 95% CI 1.75–2.28), ICU admission (OR 2.16, 95% CI 1.90–2.45) and severe/critical disease (OR 1.57, 95% CI 1.41–1.75), compared to patients without hypertension. The time-to-event analysis with confounder adjustment also showed that hypertension was significantly associated with shorter time-to-event outcomes of in-hospital mortality (HR 1.13, 95% CI 1.01–1.26), respiratory failure (HR 1.86, 95% CI 1.65–2.10), and ICU admission (HR 1.99, 95% CI 1.76–2.23).


Our analysis of nationwide data confirmed previous findings that hypertension is an independent risk factor for worse clinical outcomes among patients hospitalized for COVID-19, with increased odds of in-hospital mortality, respiratory failure, ICU admission, and severe/critical COVID-19. More specific studies should be done to elucidate the impact of hypertension characteristics, such as chronicity, severity, drug therapy, and level of control on these clinical outcomes.


Since December 2019, a novel coronavirus SARS-CoV-2 has swept all across the world. Globally, it has infected 500 million individuals, leading to more than 6 million deaths [1]. In the Philippines, more than 4 million people have been infected, with 64 thousand individuals expiring from the disease [2]. The COVID-19 pandemic continues to strain the healthcare system in terms of cost, resources, and workforce. Because of its impact on public health, there is an ongoing need to elucidate the pathophysiology of COVID-19 and the risk factors that may impact its transmission, virulence, and associated clinical outcomes. COVID-19 commonly presents with fever, cough, dyspnea, fatigue, headache [3], and disturbances of olfactory and gustatory function [4]. Rarely, it may also present with vasculitis-like skin lesions [5].

Early studies among patients with COVID-19 have identified hypertension as the most common comorbidity, suggesting that it may be an independent risk factor for increased severity and mortality among patients with COVID-19 [6, 7]. According to the latest National Nutrition Survey done by the Food and Nutrition Research Institute (FNRI) in 2018, among Filipinos 20–59 years of age, the prevalence of hypertension was 19.2%. Among adults aged 60 years and above, it was pegged at 35% [8]. These hypertensive individuals, constituting a sizeable bulk of the Filipino population, may be at higher risk for COVID-19 infection and disease progression.

Despite this, many earlier studies did not account for the confounding effect of comorbidities, such as diabetes mellitus, obesity, and coronary artery disease, that often cluster around hypertension. Succeeding studies since have shown heterogeneous results. Some studies showed that hypertension was an independent predictor of severity and mortality [9, 10]. Others discovered that it was only a predictor when combined with another comorbidity [11], while some investigators surmised that it was not a predictor at all [12,13,14]. There is still a continuing controversy on the effect of hypertension on the COVID-19 disease process. To help address this knowledge gap and contribute to the growing fund of knowledge on COVID-19, we performed an analysis of data from the Philippine COVID-19 outcomes: a retrospective study of neurological manifestations and associated symptoms (Philippine CORONA Study) [15] to elucidate the association between hypertension and clinical outcomes among Filipino patients hospitalized for COVID-19.

Materials and methods

Study design and source population

The Philippine CORONA Study was a multi-center retrospective cohort study that described the neurologic characteristics and clinical outcomes of patients hospitalized for COVID-19. It involved patients admitted to 37 participating hospitals in the Philippines from February to December 2020 [15]. The study protocol was reviewed and approved by the research ethics boards of participating sites and was registered with (NCT04386083) [16]. To meet the objective of our study, we gathered hypertension data from the Philippine CORONA Study cohort and analyzed the association between hypertension and relevant clinical outcomes, such as COVID-19 disease severity, neurological outcomes, respiratory failure, dependence on mechanical ventilator (MV) > 5 days, need for ICU admission, prolonged ICU stay > 7 days, prolonged length of hospital stay > 14 days, and mortality.


The cohort of 10,881 patients was divided into groups with and without hypertension. The diagnosis of hypertension was determined by clinicians through past medical history and/or a physical examination finding of blood pressure greater than or equal to 140/90 during admission. Thus, the group with hypertension included both individuals with a prior diagnosis of hypertension and those patients who were newly diagnosed upon admission. No data were available on the control of hypertension or anti-hypertensive medications started prior to or during the admission.


The primary outcomes of interest were in-hospital mortality, respiratory failure, and ICU admission. Secondary outcomes examined included COVID-19 disease severity at nadir (mild/moderate versus severe/critical COVID-19), neurological outcome (no improvement in neurologic symptoms versus partial or complete resolution of neurologic symptoms), prolonged mechanical ventilator (MV) dependence (defined as > 5 days on MV), prolonged ICU stay (defined as > 7 days), and prolonged hospital stay (defined as > 14 days).

Statistical analysis

Baseline patient characteristics and outcomes were summarized using descriptive statistics. Data were assessed by the Shapiro–Wilk test to evaluate normality. Normally distributed continuous variables were described with means and standard deviations. Medians and interquartile ranges (IQR) were used to describe continuous variables that were not normally distributed. Categorical variables were described using counts and proportions. Baseline characteristics and clinical outcomes were compared between groups with and without hypertension. Significant differences in these groups were determined by Student’s t test for normally distributed continuous data, and Mann–Whitney U test for non-normally distributed variables. For categorical variables, heterogeneity of the proportions between the two groups was determined by the Chi-square test.

The associations between hypertension and the dichotomous outcomes of interest were determined by multivariable binary logistic regression. Survival analysis was also done for time-to-event data on mortality, respiratory failure, and admission to ICU. The time-to-event data were right-censored, using time-to-discharge as the exit from the analysis among those who did not experience the event of interest (e.g., mortality, respiratory failure, admission to ICU) during the hospital stay. The associations between hypertension and the different time-to-event outcomes of interest were determined by univariate Cox proportional hazards regression analysis. The logistic and Cox proportional hazards regression models used were adjusted for the following predetermined confounders: age group, sex, smoking status, diabetes, chronic cardiac disease, chronic respiratory disease, chronic kidney disease, chronic neurologic disease, chronic liver disease, HIV/AIDS, and malignancy. Kaplan–Meier curves adjusted to the different confounding variables of interest were constructed to compare the time-to-event curves of the groups with and without hypertension.

All statistical tests were two-tailed, and p < 0.05 was set as the threshold for statistical significance. All analyses were carried out in Stata Version 15.1 (StataCorp LLC, TX, USA).


Baseline characteristics of analytic cohort

Among the 10,881 patients included in the Philippine CORONA Study, 3647 (33.5%) had hypertension (see Table 1). The median age of patients was 54 years (IQR 28 years), with 64.8% of patients aged less than 60 years. Patients in the hypertension group were more likely to be 60 years of age or more (55.6%, p < 0.001) and ever-smokers (15.6%, p < 0.001), but less likely to be female (46.9%, p < 0.001). Several comorbidities were significantly more common among the group with hypertension, such as diabetes mellitus (45.1%, p < 0.001), chronic cardiac disease (11.3%, p < 0.001), chronic respiratory disease (8.61%, p < 0.001), chronic kidney disease (13.0%, p < 0.001), chronic liver disease (0.80%, p = 0.015), and malignancy (0.08%, p < 0.001). There were significantly fewer patients with HIV/AIDS (p = 0.001) among the hypertensive group. Among neurologic comorbidities, cerebrovascular disease (7.95%, p < 0.001), neurodegenerative disease (0.93%, p < 0.001), and peripheral nerve and muscular disease (0.25%, p = 0.03) were more common among the hypertensive group.

Table 1 Baseline characteristics of patients in groups with and without hypertension

Baseline data also showed that hypertensive patients who were admitted for COVID-19 were more likely to be symptomatic than their non-hypertensive counterparts. Symptoms such as fever (55.8%, p < 0.001), cough (63.5%, p < 0.001), dyspnea (42.1%, p < 0.001), rhinorrhea (6.33%, p = 0.015), sputum production (10.0%, p < 0.001), sore throat (8.06%, p = 0.001), diarrhea (7.73%, p < 0.001), and fatigue (10.5%, p < 0.001) were all more common in the hypertensives. Patients with hypertension also more often presented with nausea and vomiting (2.36%, p < 0.001), seizure (1.56%, p < 0.001), altered mental state (8.61%, p < 0.001), olfactory and taste dysfunction (6.58%, p = 0.018), motor (4.77%), and bulbar (2.50%), and sensory (1.01%) symptoms (p < 0.001). Neurologic diagnoses of encephalopathy (10.9%, p < 0.001), status epilepticus (2.06%, p < 0.001), and stroke (6.99%, p < 0.001) were also more often made among the hypertensive group compared to the non-hypertensive group. Regarding treatments received, a significantly more significant proportion of patients in the hypertension group were given glucocorticoids (47.1%, p < 0.001), tocilizumab (18.4%, p < 0.001), antiviral (e.g., remdesivir, lopinavir/ritonavir) (32.3%, p < 0.001), and antibiotics (91.6%, p = 0.001) than their non-hypertensive counterparts.


A total of 4061 patients (37.3%) were classified as severe or critical cases of COVID-19 at nadir and 1702 patients (15.6%) expired during admission (see Table 2). The group with hypertension had a significantly higher percentage of severe/critical cases (52.4%) than the group without hypertension (30.4%). There was also a significantly greater mortality rate in the group with hypertension (23.96%) than without (11.45%), with a median time-to-mortality of 16 days for hypertensives and 14 days for non-hypertensives.

Table 2 Clinical outcomes of COVID-19 patients with and without hypertension

Overall, 1608 patients (14.8%) developed respiratory failure requiring MV and 1740 patients (16.0%) required admission to the ICU. There was a significantly greater proportion of hypertensives who developed respiratory failure (27.6%, p < 0.001) and who were admitted to the ICU (30.8%, p < 0.001), but there was no significant difference between the groups in terms of time-to-respiratory failure, prolonged MV dependence (> 5 days), time-to-ICU admission, or prolonged ICU stay (> 7 days). More hypertensive patients had a prolonged hospital stay (> 14 days) (p < 0.001). There was a negative association between hypertension and partial or full neurologic recovery (p < 0.001).

Logistic regression analysis

Logistic regression analysis of hypertension with the outcomes of interest was performed and adjusted for predetermined confounding variables, including age group, sex, smoking history, diabetes mellitus, chronic cardiac disease, chronic kidney disease, chronic respiratory disease, chronic neurologic disease, chronic liver disease, HIV/AIDS, and malignancy (see Table 3). Hypertension was associated with greater odds of severe/critical COVID-19 at nadir (adjusted OR 1.57, [95% CI 1.41–1.75], p < 0.001), neurologic complications (adjusted OR 1.54, [95% CI 1.37–1.73], p < 0.001), in-hospital mortality (adjusted OR 1.33, [95% CI 1.17–1.52], p < 0.001), respiratory failure (adjusted OR 1.99, [95% CI 1.75–2.28], p < 0.001), and ICU admission (adjusted OR 2.16, [95% CI 1.90–2.45], p < 0.001). There was no sufficient evidence to suggest an association of hypertension with full/partial neurologic improvement, prolonged ICU stay > 7 days, or prolonged hospital stay > 14 days.

Table 3 Association of having hypertension with the different outcomes of interest

Time-to-event analysis

Univariate multiple Cox proportional hazards regression analysis was done to determine the association of hypertension with time-to-event of clinical outcomes, including in-hospital mortality, respiratory failure, and ICU admission (see Fig. 1). After adjusting for predetermined confounding variables, hypertension was significantly associated with shorter time-to-event outcomes of in-hospital mortality (HR 1.13, [95% CI 1.01–1.26], p = 0.038), respiratory failure (HR 1.86, [95% CI 1.65–2.10], p < 0.001), and ICU admission (HR 1.99, [95% CI 1.76–2.23], p < 0.001).

Fig. 1
figure 1

Comparison of Kaplan–Meier curves for in-hospital mortality (A), respiratory failure (B), and ICU admission (C) between hypertensive and non-hypertensive COVID-19 patients, adjusted for the different confounding variables of interest


The Philippine CORONA Study data paved the way for sub-studies that elucidated the impact of comorbidities on the outcomes of COVID-19, including studies on body mass index [17], diabetes mellitus [18], malignancy [19], and stroke [20]. Our findings from the Philippine CORONA Study data were consistent with the findings of past observational studies [6, 7, 9, 10] showing that hypertension is an independent risk factor for worse clinical outcomes among patients hospitalized for COVID-19. In our analysis, hypertension was shown to have a significant association with in-hospital mortality, respiratory failure, ICU admission, severe/critical COVID-19 at nadir, and neurologic complications.

Since it is the most common comorbidity among patients with COVID-19, several studies were done to determine the relationship between hypertension with poor clinical outcomes in this patient population. These studies were heterogeneous in their findings, with some showing a positive association [9, 10], while others showed no association with outcomes such as mortality or severity of COVID-19 [12,13,14]. Due to its complexity, the impact of hypertension on the COVID-19 disease course (and vice-versa) has been difficult to characterize. An early study on hospitalized patients suggested that elevated systolic blood pressure and blood pressure variability were associated with higher mortality, ICU admission, and COVID-induced heart failure [21]. Another observational study showed a similar association but found no significant difference in outcomes among the different grades of hypertension (i.e., grade 1 hypertension versus grade 2 or 3 hypertension) [22]. Further study needs to be done among the hypertensive population to determine if the severity of hypertension and level of control has any effect on COVID-19 clinical outcomes. Data are also scarce on comparisons of outcomes between hypertensive patients who are chronically hypertensive versus newly diagnosed.

The pathophysiologic mechanisms to explain the poorer outcomes observed in hypertensive patients with COVID-19 are also under investigation. It is suggested that chronically hypertensive patients have greater endothelial dysfunction and hypertension-mediated organ damage, increasing their susceptibility to cardiovascular complications if they are infected with COVID-19 [23]. It is also hypothesized that hypertension and SARS-CoV-2 interact with the ACE/Angiotensin II/AT1R axis, which promotes vasoconstriction and RAAS upregulation, as well as the vasodilatory ACE2/Ang (1–7)/AT2R axis, to promote viral entry, replication, and organ damage [24, 25]. Recent studies on hypertension and atherosclerosis have shown that immune cell infiltration and cytokine production play a role in sustaining elevated blood pressure and target organ damage [26]. As such, the pro-inflammatory cascade brought about by COVID-19 infection may compound the existing chronic inflammation in hypertensive patients. Supporting this hypothesis, findings of a study also demonstrated that the immune cells in the airways of COVID-19 patients with hypertension exhibited inflammatory signals, which correlated with COVID-19 disease progression [27]. To date, no studies have yet specifically explored the association of hypertension with COVID-19-related cytokine storm.

Hypertension is a well-known and prevalent risk factor for cardiovascular disease. Hypertension occurs in conjunction with several modifiable and non-modifiable factors that often cluster and work in synergy, such as in metabolic syndrome. We confirmed this clustering of comorbidities in our analysis of the Philippine CORONA Study data. Earlier studies that showed an association of hypertension with poor clinical outcomes did not consider these comorbidities, which are likely to confound the observations. In one study, hypertension alone did not affect mortality or ARDS in COVID-19, but there was an association if considered together with diabetes [11]. In another study, neither hypertension nor diabetes mellitus affected the clinical outcomes in critically ill COVID-19 patients [12]. We adjusted our regression and time-to-event analyses for these predetermined confounders and found that the positive association of hypertension with poor outcomes remains significant.

The burden of hypertension and its interaction with COVID-19 is not only limited to the comorbid itself but also the medications used to treat the condition. In particular, animal studies have shown that renin–angiotensin–aldosterone system (RAAS) inhibitors increase the expression of ACE2 receptors, which constitute one of the initial steps in COVID-19 viral entry into cells [28]. These findings led to succeeding studies investigating the association of using these anti-hypertensive medications on clinical outcomes, such as worsening severity and mortality. Although initially thought to increase the risk of COVID-19 infection, using RAAS inhibitors did not significantly increase the risk of infection or mortality from COVID-19 in several observational studies [29,30,31]. A large study involving 16866 cases of COVID-19 in the United Kingdom showed that using RAAS blockers, calcium channel blockers, and thiazides among hypertensives were associated with a lower risk of infection and no effect on mortality [32]. More recently, a randomized clinical trial BRACE CORONA involving 659 patients hospitalized for COVID-19 showed that continuing RAAS inhibitors during COVID-19 hospitalization versus discontinuing them did not affect days alive and out-of-hospital in 30 days, mortality, cardiovascular death, or COVID-19 progression [33]. The European Society of Cardiology, Italian Society of Hypertension, and British Cardiovascular Society have also released their official statements on the safety of continuing RAAS inhibitors among patients who have conditions for which these are indicated [34,35,36]. There is also a hypothesis that beta-blockers, unlike RAAS blockers, may improve outcomes in COVID-19 patients, as they were found to reduce the expression of ACE2 receptors and interleukin-6 [37]. In the UK study, beta-blocker use was even initially associated with higher odds of COVID-19 infection, but this effect was attenuated after adjusting for confounders. Succeeding studies on the association of different classes of anti-hypertensives with outcomes discovered no significant impact on the risk of COVID-19 infection, need for MV, and mortality [9, 38, 39].

Currently, several therapeutics have been shown to prevent disease progression among patients with mild and moderate diseases. In phase 3 trials, antivirals nirmatrelvir–ritonavir [40] and molnupiravir [41] were shown to reduce the composite risk of hospitalization and 28-day mortality among symptomatic, unvaccinated adults with at least one risk factor for progression. While the nirmatrelvir–ritonavir trial included hypertension as a risk factor for progression, the molnupiravir trial did not. Our findings serve to strengthen the role of hypertension as a risk factor for COVID-19 disease progression and promote its consideration as an additional indication for prescribing these promising therapeutics.

In the Philippines, a sizeable proportion of the population has hypertension, ranging from 19.2% among adults 20–59 years of age to 35% for those aged 60 years and above [8]. Based on previous studies and confirmed by our findings, individuals with hypertension are at significantly higher risk of mortality and poor clinical outcomes once infected with COVID-19. Since they are at risk for disease progression requiring mechanical ventilation and intensive care, hypertensive patients with COVID-19 represent a vulnerable population. Further study must be done to determine which subsets of the hypertensive population, if any, are most at risk and if they would benefit from intensified protective measures, such as vaccine prioritization and antiviral distribution.

Our data were limited and did not include hypertension-related characteristics, such as chronicity, severity of hypertension, level of blood pressure control, and anti-hypertensives used. Data on whether hypertension was primary or secondary were also unavailable. These factors may affect the pathophysiology of COVID-19 through worsened atherosclerosis, endothelial dysfunction, and target organ damage such as myocardial injury.


Our analysis of nationwide data confirmed previous findings that hypertension is an independent risk factor for worse clinical outcomes among patients hospitalized for COVID-19, with increased odds of in-hospital mortality, respiratory failure, ICU admission, severe/critical COVID-19 at nadir, and neurologic complications. More specific studies should be done to clarify the impact of hypertension characteristics, such as chronicity, severity, and level of control on these clinical outcomes.

Availability of data and materials

All data related to this research have been included in this paper.


  1. World Health Organization. WHO COVID-19 dashboard. Published 2022. Accessed 19 May 2022.

  2. Department of Health. COVID 19 case tracker. Published 2022. Accessed 19 May 2022

  3. de Vito A, Fiore V, Princic E, et al. Predictors of infection, symptoms development, and mortality in people with SARS-CoV-2 living in retirement nursing homes. PLoS ONE. 2021;16(3):e0248009.

    Article  CAS  Google Scholar 

  4. Vaira LA, Hopkins C, Salzano G, et al. Olfactory and gustatory function impairment in <scp>COVID</scp> -19 patients: Italian objective multicenter-study. Head Neck. 2020;42(7):1560–9.

    Article  Google Scholar 

  5. Geremia N, de Vito A, Gunnella S, et al. A case of vasculitis-like skin eruption associated with COVID-19. Infect Dis Clin Pract. 2020;28(6):e30–1.

    Article  Google Scholar 

  6. Guanjie W, Lianghua W, Zhao Y, et al. Comorbidity and its impact on 1590 patients with COVID-19 in China: a nationwide analysis. Eur Respir J. 2020;55(5):2000547.

    Article  CAS  Google Scholar 

  7. Pranata R, Lim MA, Huang I, Raharjo SB, Lukito AA. Hypertension is associated with increased mortality and severity of disease in COVID-19 pneumonia: a systematic review, meta-analysis and meta-regression. J Renin-Angiotensin-Aldosterone Sys. 2020.

    Article  Google Scholar 

  8. Philippine Nutrition Facts and Figures: 2018 expanded national nutrition survey (ENNS). 2018. Accessed 19 May 2022.

  9. Bauer AZ, Gore R, Sama SR, et al. Hypertension, medications, and risk of severe COVID-19: a Massachusetts community-based observational study. J Clin Hypertens. 2021;23(1):21–7.

    Article  CAS  Google Scholar 

  10. Barrera FJ, Shekhar S, Wurth R, et al. Prevalence of diabetes and hypertension and their associated risks for poor outcomes in Covid-19 patients. J Endocr Soc. 2020.

    Article  Google Scholar 

  11. Sun Y, Guan X, Jia L, et al. Independent and combined effects of hypertension and diabetes on clinical outcomes in patients with COVID-19: a retrospective cohort study of Huoshen mountain hospital and Guanggu Fangcang Shelter Hospital. J Clin Hypertens. 2021;23(2):218–31.

    Article  CAS  Google Scholar 

  12. Gupta S, Hayek SS, Wang W, et al. Factors associated with death in critically Ill patients with coronavirus disease 2019 in the US. JAMA Intern Med. 2020;180(11):1436.

    Article  CAS  Google Scholar 

  13. Grasselli G, Greco M, Zanella A, et al. Risk factors associated with mortality among patients with COVID-19 in intensive care units in Lombardy, Italy. JAMA Intern Med. 2020;180(10):1345.

    Article  CAS  Google Scholar 

  14. Dennis JM, Mateen BA, Sonabend R, et al. Type 2 diabetes and COVID-19–related mortality in the critical care setting: a national cohort Study in England, March–July 2020. Diabetes Care. 2021;44(1):50–7.

    Article  CAS  Google Scholar 

  15. Espiritu AI, Sy MCC, Anlacan VMM, et al. COVID-19 outcomes of 10,881 patients: retrospective study of neurological symptoms and associated manifestations (Philippine CORONA Study). J Neural Transm. 2021;128(11):1687–703.

    Article  CAS  Google Scholar 

  16. Espiritu AI, Sy MCC, Anlacan VMM, Jamora RDG. The Philippine COVID-19 Outcomes: a Retrospective study Of Neurological manifestations and Associated symptoms (The Philippine CORONA study): a protocol study. BMJ Open. 2020;10(11):e040944.

    Article  Google Scholar 

  17. Espiritu AI, Reyes NGD, Leochico CFD, et al. Body mass index and its association with COVID-19 clinical outcomes: findings from the Philippine CORONA study. Clin Nutr ESPEN. 2022;49:402–10.

    Article  Google Scholar 

  18. Espiritu AI, Chiu HHC, Sy MCC, et al. The outcomes of patients with diabetes mellitus in the Philippine CORONA study. Sci Rep. 2021;11(1):24436.

    Article  CAS  Google Scholar 

  19. Espiritu AI, Larrazabal RB, Sy MCC, Villanueva EQ, Anlacan VMM, Jamora RDG. Outcomes and risk factors of patients with COVID-19 and cancer (ONCORONA): findings from the Philippine CORONA study. Front Oncol. 2022.

    Article  Google Scholar 

  20. Jamora RDG, Prado MB, Anlacan VMM, Sy MCC, Espiritu AI. Incidence and risk factors for stroke in patients with COVID-19 in the Philippines: an analysis of 10,881 cases. J Stroke Cerebrovascular Dis. 2022;31(11):106776.

    Article  Google Scholar 

  21. Ran J, Song Y, Zhuang Z, et al. Blood pressure control and adverse outcomes of COVID-19 infection in patients with concomitant hypertension in Wuhan China. Hypertension Res. 2020;43(11):1267–76.

    Article  CAS  Google Scholar 

  22. Chen R, Yang J, Gao X, et al. Influence of blood pressure control and application of renin-angiotensin-aldosterone system inhibitors on the outcomes in COVID-19 patients with hypertension. J Clin Hypertension. 2020;22(11):1974–83.

    Article  CAS  Google Scholar 

  23. Nägele MP, Haubner B, Tanner FC, Ruschitzka F, Flammer AJ. Endothelial dysfunction in COVID-19: current findings and therapeutic implications. Atherosclerosis. 2020;314:58–62.

    Article  CAS  Google Scholar 

  24. Peng M, He J, Xue Y, Yang X, Liu S, Gong Z. Role of hypertension on the severity of COVID-19: a review. J Cardiovasc Pharmacol. 2021;78(5):e648–55.

    Article  CAS  Google Scholar 

  25. Li Y, Wei B, Liu X, Shen XZ, Shi P. Microglia, autonomic nervous system, immunity and hypertension: is there a link? Pharmacol Res. 2020;155:104451.

    Article  CAS  Google Scholar 

  26. Norlander AE, Madhur MS, Harrison DG. The immunology of hypertension. J Exp Med. 2018;215(1):21–33.

    Article  CAS  Google Scholar 

  27. Trump S, Lukassen S, Anker MS, et al. Hypertension delays viral clearance and exacerbates airway hyperinflammation in patients with COVID-19. Nat Biotechnol. 2021;39(6):705–16.

    Article  CAS  Google Scholar 

  28. Igase M, Strawn WB, Gallagher PE, Geary RL, Ferrario CM. Angiotensin II AT 1 receptors regulate ACE2 and angiotensin-(1–7) expression in the aorta of spontaneously hypertensive rats. Am J Physiol-Heart Circ Physiol. 2005;289(3):H1013–9.

    Article  CAS  Google Scholar 

  29. Li J, Wang X, Chen J, Zhang H, Deng A. Association of renin-angiotensin system inhibitors with severity or risk of death in patients with hypertension hospitalized for coronavirus disease 2019 (COVID-19) Infection in Wuhan, China. JAMA Cardiol. 2020;5(7):825.

    Article  Google Scholar 

  30. Zhang P, Zhu L, Cai J, et al. Association of inpatient use of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers with mortality among patients with hypertension hospitalized with COVID-19. Circ Res. 2020;126(12):1671–81.

    Article  CAS  Google Scholar 

  31. Yang G, Tan Z, Zhou L, et al. Effects of angiotensin II receptor blockers and ACE (angiotensin-converting enzyme) inhibitors on virus infection, inflammatory status, and clinical outcomes in patients with COVID-19 and hypertension. Hypertension. 2020;76(1):51–8.

    Article  CAS  Google Scholar 

  32. Rezel-Potts E, Douiri A, Chowienczyk PJ, Gulliford MC. Antihypertensive medications and COVID-19 diagnosis and mortality: Population-based case-control analysis in the United Kingdom. Br J Clin Pharmacol. 2021;87(12):4598–607.

    Article  CAS  Google Scholar 

  33. Lopes RD, Macedo AVS, de Barrose Silva PGM, et al. Continuing versus suspending angiotensin-converting enzyme inhibitors and angiotensin receptor blockers: impact on adverse outcomes in hospitalized patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)–The BRACE CORONA trial. Am Heart J. 2020;226:49–59.

    Article  CAS  Google Scholar 

  34. Iaccarino G, Borghi C, Cicero AFG, et al. Renin-angiotensin system inhibition in cardiovascular patients at the time of COVID19: much Ado for nothing? A statement of activity from the directors of the board and the scientific directors of the italian society of hypertension. High Blood Pressure Cardiovascular Prev. 2020;27(2):105–8.

    Article  CAS  Google Scholar 

  35. de Simone G. Position Statement of the ESC Council on Hypertension on ACE-Inhibitors and Angiotensin Receptor Blockers. Published online 2020. Accessed 19 May 2022.

  36. BSH & BCS Joint Statement on ACEi or ARB in Relation to COVID-19. 2020.

  37. Pinto-Sietsma SJ, Flossdorf M, Buchholz VR, et al. Antihypertensive drugs in COVID-19 infection. Eur Heart J Cardiovasc Pharmacother. 2020;6(6):415–6.

    Article  Google Scholar 

  38. Xiong TY, Huang FY, Liu Q, et al. Hypertension is a risk factor for adverse outcomes in patients with coronavirus disease 2019: a cohort study. Ann Med. 2020;52(7):361–6.

    Article  CAS  Google Scholar 

  39. Ren L, Yu S, Xu W, Overton JL, Chiamvimonvat N, Thai PN. Lack of association of antihypertensive drugs with the risk and severity of COVID-19: a meta-analysis. J Cardiol. 2021;77(5):482–91.

    Article  Google Scholar 

  40. Hammond J, Leister-Tebbe H, Gardner A, et al. Oral nirmatrelvir for high-risk, nonhospitalized adults with Covid-19. N Engl J Med. 2022;386(15):1397–408.

    Article  CAS  Google Scholar 

  41. Jayk Bernal A, Gomes da Silva MM, Musungaie DB, et al. Molnupiravir for oral treatment of Covid-19 in nonhospitalized patients. New England J Med. 2022;386(6):509–20.

    Article  Google Scholar 

Download references


We would like to thank the Philippine CORONA Study Group Investigators and sites: Asian Hospital and Medical Center, Muntinlupa City(Corina Maria Socorro A. Macalintal, MD; Joanne B. Robles, MD), Baguio General Hospital and Medical Center, Baguio City (Paulo L. Cataniag, MD; Manolo Kristoffer C. Flores, MD, MBA), Cagayan Valley Medical Center, Tuguegarao City (Noreen Jhoanna T. Trinidad, MD), Capitol Medical Center, Quezon City (Dan Neftalie A. Juangco, MD; Giuliani Renz G. Paas, MD), Cardinal Santos Medical Center, San Juan City (Audrey Marie U. Chua, MD, Valmarie S. Estrada, MD, Philip Rico P. Mejia, MD, Therese Franz B. Reyes, MD), Chong Hua Hospital, Cebu City (Maria Teresa A. Cañete, MD; Ferdinand Renfred A. Zapata, MD), De La Salle University Medical and Health Sciences Institute, Dasmariñas City, (Franko Eugenio B. Castillo, MD; Romulo U. Esagunde, MD; Jean B. Gantioque, MD), Dr. Jose N. Rodriguez Memorial and Sanitarium Hospital, Caloocan City (Maritoni C. Abbariao, MD; Geramie M. Acebuque, MD), Dr. Pablo O. Torre Memorial Hospital, Bacolod City (Evram V. Corral, MD), East Avenue Medical Center, Quezon City (Marian Irene C. Escasura, MD; Marissa T. Ong, MD), Jose B. Lingad Memorial Regional Hospital, City of San Fernando (Arnold Angelo M. Pineda, MD; Khasmeen D. Aradani, MD), Jose R. Reyes Memorial Medical Center, Manila (Joseree-Ann S. Catindig, MD; Mark Timothy T. Cinco, MD; Mark Erving H. Ramos, MD), Lung Center of the Philippines, Quezon City (Romulus Emmanuel H. Cruz, MD; Marita B. Dantes, MD; Norberto A. Francisco, MD; Rosalia A. Teleg, MD), Makati Medical Center, Makati City (Krisverlyn B. Bellosillo, MD; Jean Paolo M. Delfino, MD; Cid C. Diesta, MD; Rosalina B. Espiritu-Picar, MD; Julie Anne V. Gamboa, MD; Cara Camille M. Matute, MD; Franzelle P. Padilla, MD; John Joshua Q. Punsalan, MD), Manila Doctors Hospital, Manila (Ma. Epifania V. Collantes, MD; Charmaine B. Que, MD; Hanifa A. Sampao, MD; Maxine Camela S. Sta. Maria, MD), Medical Center Manila, Manila (Marita M. Fuentes, MD; Jennifer Justice F. Manzano, MD; Rizza J. Umali, MD), New Era General Hospital, Quezon City (Marc Conrad C. Molina, MD), Northern Mindanao Medical Center, Cagayan de Oro City (Hazel Claire Minerva-Ang, MD; Arturo F. Surdilla, MD; Loreto P. Talabucon Jr., MD; Natasha F. Wabe, MD), Quirino Memorial Medical Center, Quezon City (Maria Victoria G. Manuel, MD; Al Inde John A. Pajantoy, MD; Josephine Cecilia V. Roque, MD; Paul Emmanuel L. Yambao, MD), Ospital ng Makati, Makati City (Christian Paul B. Banday, MD; Chritopher C. Cipriano, MD; Nehar A. Pangandaman, MD; Avery Gail C. Wasil, MD), Perpetual Succour Hospital, Cebu City (Elrey P. Inocian, MD; Jarungchai Anton S. Vatanagul, MD), Philippine General Hospital, Manila (Almira Doreen Abigail O. Apor, MD; Carissa Paz C. Dioquino, MD), Philippine Heart Center, Quezon City (Prinz Andrew M. Dela Cruz, MD; Maricar P. Yumul, MD), Research Institute for Tropical Medicine, Muntinlupa City (Ma. Alma E. Carandang-Concepcion, MD), San Juan De Dios Educational Foundation Inc. Hospital, Pasay City (Ma. Caridad V. Desquitado, MD; Carl Kevin L. Julao, MD), San Lazaro Hospital, Manila(Dante P. Bornales, MD), Southern Isabela Medical Center, Santiago City (Generaldo D. Maylem, MD; Mark Joseph F. Cuntapay, MD), Southern Philippines Medical Center, Davao City (Annabelle Y. Lao-Reyes, MD; Aileen Mae B. Lee, MD; Nadia O. Manlegro, MD; Dave Mar L. Pelere, MD), St. Luke’s Medical Center—Global City, Taguig City(Lina C. Laxamana, MD; Diana-Lynn S. Que, MD; Jeryl Ritzi T. Yu, MD), St. Luke’s Medical Center, Quezon City (Ma. Socorro C. Martinez, MD; Alexandria E. Matic, MD; John Angelo Luigi S. Perez, MD), The Medical City, Pasig City (Glenn Anthony A. Constantino, MD; Aldanica R. Olano, MD; Liz Edenberg P. Quiles, MD; Artemio A. Roxas, Jr., MD; Jo Ann R. Soliven, MD; Michael Dorothy Frances Montojo-Tamayo, MD), University of Santo Tomas Hospital, Manila (Ma. Lourdes C. Joson, MD; Jojo R. Evangelista, MD), University of the East Ramon Magsaysay Memorial Medical Center Inc., Quezon City (Ma. Clarissa B. Nuñez, MD; Marietta C. Olaivar, MD; Dominique Q. Perez, MD), Veterans Memorial Medical Center, Quezon City (Mark Deneb O. Armeña, MD; Robert A. Barja, MD), Vicente Sotto Memorial Medical Center, Cebu City (Joshua Emmanuel E. Abejero, MD; Maritzie R. Eribal, MD), Western Visayas Medical Center, Iloilo City (Ryndell G. Alava, MD), Zamboanga City Medical Center, Zamboanga City (Muktader A. Kalbi, MD; Nasheera W. Radja, MD; Mohammad Elshad S. Sali, MD).


The study was supported by the Philippine Neurological Association (Grant number: not applicable) and the Expanded Hospital Research Office, University of the Philippines Manila (Grant Number: not applicable).

Author information

Authors and Affiliations



All the authors participated in the conceptualization of work, acquisition and analysis of data, drafting and revising, and final approval of the version to be published. All the authors read and approved the final manuscript.

Corresponding authors

Correspondence to Adrian I. Espiritu or Roland Dominic G. Jamora.

Ethics declarations

Ethics approval and consent to participate

Approval was granted by the Single Joint Research Ethics Board of the Philippine Department of Health of the Philippines (SJREB-2020–24) and the institutional review board of the different study sites.

Competing interests

All the authors have stated explicitly that there are no conflicts of interest in connection with this article.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Espiritu, A.I., Sucaldito, M.S.F.P., Ona, D.I.D. et al. Clinical outcomes in COVID-19 among patients with hypertension in the Philippine CORONA Study. Eur J Med Res 28, 62 (2023).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI:


  • COVID-19
  • SARS-CoV-2
  • Hypertension
  • Clinical outcomes
  • Mortality
  • Respiratory failure
  • ICU Admission
  • Retrospective cohort