COVID-19 Evidence Alerts
from McMaster PLUSTM

Current best evidence for clinical care (more info)

Treatment, Etiology Mackey K, King VJ, Gurley S, et al. Risks and Impact of Angiotensin-Converting Enzyme Inhibitors or Angiotensin-Receptor Blockers on SARS-CoV-2 Infection in Adults: A Living Systematic Review. Ann Intern Med. 2020 Aug 4;173(3):195-203. doi: 10.7326/M20-1515. Epub 2020 May 15.

BACKGROUND: The role of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin-receptor blockers (ARBs) in coronavirus disease 2019 (COVID-19) susceptibility, severity, and treatment is unclear.

PURPOSE: To evaluate, on an ongoing basis, whether use of ACEIs or ARBs either increases risk for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection or is associated with worse COVID-19 disease outcomes, and to assess the efficacy of these medications for COVID-19 treatment.

DATA SOURCES: MEDLINE (Ovid) and Cochrane Database of Systematic Reviews from 2003 to 4 May 2020, with planned ongoing surveillance for 1 year; the World Health Organization database of COVID-19 publications and through 17 April 2020; and to 24 April 2020, with planned ongoing surveillance.

STUDY SELECTION: Observational studies and trials in adults that examined associations and effects of ACEIs or ARBs on risk for SARS-CoV-2 infection and COVID-19 disease severity and mortality.

DATA EXTRACTION: Single-reviewer abstraction confirmed by another reviewer, independent evaluation by 2 reviewers of study quality, and collective assessment of certainty of evidence.

DATA SYNTHESIS: Two retrospective cohort studies found that ACEI and ARB use was not associated with a higher likelihood of receiving a positive SARS-CoV-2 test result, and 1 case-control study found no association with COVID-19 illness in a large community (moderate-certainty evidence). Fourteen observational studies, involving a total of 23 565 adults with COVID-19, showed consistent evidence that neither medication was associated with more severe COVID-19 illness (high-certainty evidence). Four registered randomized trials plan to evaluate ACEIs and ARBs for treatment of COVID-19.

LIMITATION: Half the studies were small and did not adjust for important confounding variables.

CONCLUSION: High-certainty evidence suggests that ACEI or ARB use is not associated with more severe COVID-19 disease, and moderate-certainty evidence suggests no association between use of these medications and positive SARS-CoV-2 test results among symptomatic patients. Whether these medications increase the risk for mild or asymptomatic disease or are beneficial in COVID-19 treatment remains uncertain.

PRIMARY FUNDING SOURCE: None. (PROSPERO: registration number pending).

Discipline / Specialty Area Score
General Internal Medicine-Primary Care(US)
Family Medicine (FM)/General Practice (GP)
Hospital Doctor/Hospitalists
Internal Medicine
Infectious Disease
Intensivist/Critical Care
Emergency Medicine
Comments from MORE raters

Emergency Medicine rater

As an ER doc in the era of Covid, we are beginning to know a little more. This article is a decent meta-analysis that helps eliminate some uncertainty.

Infectious Disease rater

This study addresses one of the many concerns in the Covid-19 pandemic. The evidence highlighted clarifies the safety of ACEi/ARB in the studied population. Although speculations about Covid-19 infection and related presentations are rife, these studies are important for ensuring safety in this subset of patients.

Infectious Disease rater

Although there is a need for stroger evidence, the results of this study will guide the use of ACEIs and ARBs during the ongoing COVID 19 pandemic.

Intensivist/Critical Care rater

Useful review addressing an early COVID myth in a methodologically sound manner that produced clinically applicable results.