Importance: The role of angiotensin-converting enzyme inhibitors (ACEI) and angiotensin II receptor blockers (ARB) in the setting of the coronavirus disease 2019 (COVID-19) pandemic is hotly debated. There have been recommendations to discontinue these medications, which are essential in the treatment of several chronic disease conditions, while, in the absence of clinical evidence, professional societies have advocated their continued use.
Objective: To study the association between use of ACEIs/ARBs with the likelihood of testing positive for COVID-19 and to study outcome data in subsets of patients taking ACEIs/ARBs who tested positive with severity of clinical outcomes of COVID-19 (eg, hospitalization, intensive care unit admission, and requirement for mechanical ventilation).
Design, setting, and participants: Retrospective cohort study with overlap propensity score weighting was conducted at the Cleveland Clinic Health System in Ohio and Florida. All patients tested for COVID-19 between March 8 and April 12, 2020, were included.
Exposures: History of taking ACEIs or ARBs at the time of COVID-19 testing.
Main outcomes and measures: Results of COVID-19 testing in the entire cohort, number of patients requiring hospitalizations, intensive care unit admissions, and mechanical ventilation among those who tested positive.
Results: A total of 18 472 patients tested for COVID-19. The mean (SD) age was 49 (21) years, 7384 (40%) were male, and 12 725 (69%) were white. Of 18 472 patients who underwent COVID-19 testing, 2285 (12.4%) were taking either ACEIs or ARBs. A positive COVID-19 test result was observed in 1735 of 18 472 patients (9.4%). Among patients who tested positive, 421 (24.3%) were admitted to the hospital, 161 (9.3%) were admitted to an intensive care unit, and 111 (6.4%) required mechanical ventilation. Overlap propensity score weighting showed no significant association of ACEI and/or ARB use with COVID-19 test positivity (overlap propensity score-weighted odds ratio, 0.97; 95% CI, 0.81-1.15).
Conclusions and relevance: This study found no association between ACEI or ARB use and COVID-19 test positivity. These clinical data support current professional society guidelines to not discontinue ACEIs or ARBs in the setting of the COVID-19 pandemic. However, further study in larger numbers of hospitalized patients receiving ACEI and ARB therapy is needed to determine the association with clinical measures of COVID-19 severity.
Conflict of interest statement
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 Apr 23:e201624. doi: 10.1001/jamacardio.2020.1624. Online ahead of print. JAMA Cardiol. 2020. PMID: 32324209
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 Apr 17. doi: 10.1161/CIRCRESAHA.120.317134. Online ahead of print. Circ Res. 2020. PMID: 32302265
Risks and Impact of Angiotensin-Converting Enzyme Inhibitors or Angiotensin-Receptor Blockers on SARS-CoV-2 Infection in Adults.Ann Intern Med. 2020 May 15. doi: 10.7326/M20-1515. Online ahead of print. Ann Intern Med. 2020. PMID: 32422062
ACEI/ARB use and risk of infection or severity or mortality of COVID-19: A systematic review and meta-analysis.Pharmacol Res. 2020 May 15;158:104927. doi: 10.1016/j.phrs.2020.104927. Online ahead of print. Pharmacol Res. 2020. PMID: 32422341 Free PMC article. Review.
Interactions of coronaviruses with ACE2, angiotensin II, and RAS inhibitors-lessons from available evidence and insights into COVID-19.Hypertens Res. 2020 Apr 27:1-7. doi: 10.1038/s41440-020-0455-8. Online ahead of print. Hypertens Res. 2020. PMID: 32341442 Free PMC article. Review.
Cited by 1 article
The SARS-CoV-2 receptor, ACE-2, is expressed on many different cell types: implications for ACE-inhibitor- and angiotensin II receptor blocker-based cardiovascular therapies.Intern Emerg Med. 2020 May 19:1-8. doi: 10.1007/s11739-020-02364-6. Online ahead of print. Intern Emerg Med. 2020. PMID: 32430651 Free PMC article.