Background: Angiotensin-converting enzyme (ACE) 2 is the receptor by which SARS CoV-2 enters cells, and inhibitors of the renin-angiotensin-aldosterone system such as ACE inhibitors (ACEI) and angiotensin receptor blockers (ARBs) may influence ACE2 expression, and thus affect risk for severity of illness in patients with COVID-19.

Methods: Single-center study in Wuhan, China. All patients admitted from January 15 to March 15, 2020, were included in a retrospective analysis.

Results: Patients with hypertension (30.7% of the population) were older, had more co-morbidities, and had higher rates of ARDS and in-hospital mortality (21.3% versus 6.5% for patients without hypertension). Among the 362 patients with hypertension, 31.8% were on ACEIs or ARBs, and these patients had higher prevalence of coronary artery disease than patients with hypertension not on ACE/ARBs, but otherwise the two groups were fairly similar. Among hypertensive patients, there was no difference in the proportion of patients with severe illness or non-survivors taking ACEIs or ARBs. This held true among subgroups of patients with coronary artery disease, cerebrovascular disease, diabetes, neurologic disease, and chronic kidney disease.

Limitations: Single-center study, relatively small numbers. The statistical analysis plan is rudimentary, and could have been better performed by development of a prediction model to identify if ACEI/ARBs are independent predictors of severity of COVID-19 while controlling for confounders, rather than simply comparing the rates of severely ill or non-surviving patients taking ACEI/ARBs.

Conclusions: Within the limitations of this hastily performed observational study, it appears that ACEI/ARB use does not pose additional risk for development of severe COVID-19 illness. Older patients with hypertension, along with other comorbidities, are at significantly higher risk for severe disease and in-hospital mortality.

Reference:

• 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. Published online April 23, 2020. doi:10.1001/jamacardio.2020.1624

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This article by Stephen Halliday, MD, MSCI, assistant professor, Allergy, Pulmonary and Critical Care Medicine.