IJCS | Volume 33, Nº4, July and August 2020

414 likely to need intensive treatment. A retrospective cohort study found that patients with severe obesity defined by a body mass index (BMI) >40kg/m2 who contracted COVID-19 in France were more likely to have mechanical ventilation, regardless of the presence of advanced age, hypertension, or diabetes. 7,8 The position of the European Association for the Study of Obesity on COVID-19 shows concern about the possibility of weight gain in quarantined patients and recommends caloric control in the diet, as well as good glycemic control in those who are also diabetic, as a method of try to reduce the risk and severity of infection. 21 Diabetes plays a central role in the interaction of HFpEF and COVID-19. Diabetes is a primary risk factor for the development of severe pneumonia and sepsis due to viral infections in general. In parallel, glycemic dysregulation associated with insulin resistance is associated with progressive changes in cardiac structure and function that result in myocardial remodeling and left ventricular systolic and diastolic dysfunction. More specifically, diabetes can determine diabetic cardiomyopathy, and may be associated with HF manifestations and higher frequency of clinical complications resulting from this syndrome. 22 The occurrence of the association of diabetes with structural heart disease typical of HFpEF is, therefore, a first explanation for the increased susceptibility of diabetic patients to complications in COVID-19. Another possibility may be associated with innate defects of immunity, affecting the cellular immune response mediated by viral aggression. 23 When affected by COVID-19, diabetic patients experience exacerbated hyperglycemia, especially in older individuals. 24 Acute hyperglycemia has be en a s soc i a t ed wi t h t he a c t i va t i on o f t he angiotensin‑converting enzyme 2 (ACE-2), which is the receptor for the coronavirus spike protein. Coronavirus infection reduces the expression of ACE2, inducing cell damage, hyperinflammation, and respiratory failure. 25 In addition, the virus has the potential to damage pancreatic beta cells, which can determine insulin deficiency and frequent cases of severe diabetic ketoacidosis on hospital admission. 23 The COVID-19 event in diabetic patients, therefore, affected even the recommendations for drug treatment of type II diabetes. A group of drugs strongly indicated for the treatment in the context of high cardiovascular risk, frequent in HFpEF, are the Sodium-Glucose- Cotransporter 2 (SGLT2) inhibitors. Initial reports associated these drugs with an increased risk of developing ketosis in insulinopenic patients (type I Figure 2 – Comorbidities: overlaping risk factos for COVID-19 and HFpEF. Mesquita et al. HFpEF and COVID-19 Int J Cardiovasc Sci. 2020; 33(4):412-418 Viewpoint