Association of angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers with risk of mortality, severity or SARS-CoV-2 test positivity in COVID-19 patients: meta-analysis

Abstract

The effects of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) in the treatment of COVID-19 are highly debated. This study was aimed to assess aggregated risk by investigating the association of ACEIs/ARBs users against non-users of ACEIs/ARBs with the risk of mortality or severe clinical manifestations or magnitude of SARS-CoV-2 test positivity in COVID-19 patients. Systematic literature search was carried out in different databases for eligible studies. The pooled relative risks (RRs) were measured using RevMan software where P<0.05 was set as statistical significance. In total, 10 studies were included in this analysis. After pooled estimation, it was demonstrated that SARS-CoV-2 positive patients taking ACEIs/ARBs were not associated with an increased risk of mortality compared to those not taking ACEIs/ARBs (RR 0.89; 95% CI 0.64–1.23; P=0.48). Furthermore, the risk of composite severe clinical manifestations was not significantly different between the positive patients with or without ACEIs/ARBs users (RR 1.29; 95% CI 0.81–2.04; P=0.28). There was no risk difference for SARS-CoV-2 test positivity in patients with or without ACEIs/ARBs users (RR 1.00; 95% CI 0.95–1.05; P=0.91). These findings may augment current professional society guidelines for not discontinuing ACEIs/ARBs in treating COVID-19 patients where it is clinically indicated.

Coronavirus Disease-2019 and Heart Failure: A Scientific Statement From the Heart Failure Society of America

“…Despite aforementioned concerns regarding a potentially increased propensity for more severe disease by way of enhanced viral entry via upregulated ACE2 receptors in patients on RAAS pathway inhibitors, 47 accumulating retrospective and prospective data as well as a joint statement by the American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Failure Society of America (HFSA) affirm that RAAS pathway inhibitors should generally not be discontinued in patients with HF who are at risk for or hospitalized with COVID-19. [56][57][58][59] In fact, discontinuation of these medications in patients not only with HF but also hypertension and coronary artery disease has not been shown to improve outcomes and likely deprives patients of evidence-based therapy. 57 Statins have been studied as treatment in COVID-19.…”

Potential predictors of outcomes among hospitalized COVID-19 patients treated with convalescent plasma: a single-center study

“…The use of ACEI/ARB inhibitors in COVID-19 illness has been the focus of multiple research studies since the start of the pandemic due to a theoretical concern that it may increase the expression of the ACE2 receptor, which is needed by the SARS CoV-2 virus for cell entry [ 23 , 24 ]. However, this has not been validated in subsequent studies [ 25 , 26 ]. In our study, the use of ACEI/ARB was associated with lower survival after CP therapy.…”

Pharmacotherapeutic agents for the management of COVID-19 patients with preexisting cardiovascular disease

“…Recent studies have demonstrated that ACEI/ARB treatment in COVID-19 patients is associated with a reduced mortality risk, with a meta-analysis demonstrating a reduction in all-cause mortality [ 44 , 45 ]. Zhang et al [ 46 ] showed no significant difference in the outcome and length of hospital stay in hypertensive COVID-19 patients who continued to take RAS inhibitors compared to the control group [ 46 ]. Another study indicated that the peak viral load for patients taking ACEI/ARBs was significantly lower than the control group (p = 0.03), even though the baseline viral load remained the same for both groups [ 38 ].…”