Association of Renin-angiotensin-aldosterone System Inhibitors With Coronavirus Disease 2019 (COVID-19)- Related Outcomes in Korea: A Nationwide Population-based Cohort Study

Clin Infect Dis. 2020 Nov 19;71(16):2121-2128. doi: 10.1093/cid/ciaa624.


Background: Renin-angiotensin-aldosterone system (RAAS) inhibitors may facilitate host cell entry of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or attenuate organ injury via RAAS blockade. We aimed to assess the associations between prior use of RAAS inhibitors and clinical outcomes among Korean patients with coronavirus disease 2019 (COVID-19).

Methods: We performed a nationwide population-based cohort study using the Korean Health Insurance Review and Assessment database. Claim records were screened for 69 793 individuals who were tested for COVID-19 until 8 April 2020. Adjusted odds ratios (ORs) were used to compare the clinical outcomes between RAAS inhibitor users and nonusers.

Results: Among 5179 confirmed COVID-19 cases, 762 patients were RAAS inhibitor users and 4417 patients were nonusers. Relative to nonusers, RAAS inhibitor users were more likely to be older, male, and have comorbidities. Among 1954 hospitalized patients with COVID-19, 377 patients were RAAS inhibitor users, and 1577 patients were nonusers. In-hospital mortality was observed for 33 RAAS inhibitor users (9%) and 51 nonusers (3%) (P < .001). However, after adjustment for age, sex, Charlson comorbidity index, immunosuppression, and hospital type, the use of RAAS inhibitors was not associated with a higher risk of mortality (adjusted OR, 0.88; 95% confidence interval, 0.53-1.44; P = .60). No significant differences were observed between RAAS inhibitor users and nonusers in terms of vasopressor use, modes of ventilation, extracorporeal membrane oxygenation, renal replacement therapy, and acute cardiac events.

Conclusions: Our findings suggest that prior use of RAAS inhibitors was not independently associated with mortality among COVID-19 patients in Korea.

Keywords: ACEI/ARB; COVID-19; SARS-CoV-2; comorbidity; renin-angiotensin system.

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • Angiotensin Receptor Antagonists / therapeutic use
  • Angiotensin-Converting Enzyme Inhibitors / therapeutic use
  • COVID-19 / mortality*
  • Cohort Studies
  • Female
  • Humans
  • Male
  • Middle Aged
  • Multivariate Analysis
  • Odds Ratio
  • Renin-Angiotensin System / drug effects*
  • Republic of Korea / epidemiology
  • SARS-CoV-2 / pathogenicity
  • Young Adult


  • Angiotensin Receptor Antagonists
  • Angiotensin-Converting Enzyme Inhibitors