COVID-19 Evidence Alerts
from McMaster PLUSTM

Current best evidence for clinical care (more info)

Etiology Pranata R, Permana H, Huang I, et al. The use of renin angiotensin system inhibitor on mortality in patients with coronavirus disease 2019 (COVID-19): A systematic review and meta-analysis. Diabetes Metab Syndr. 2020 Sep - Oct;14(5):983-990. doi: 10.1016/j.dsx.2020.06.047. Epub 2020 Jun 27.

BACKGROUND: and Aims; To investigate the association between use of angiotensin-converting enzyme inhibitor (ACEI)/angiotensin-receptor blocker (ARB) and outcomes of hypertensive COVID-19 patients, a systematic review and meta-analysis were performed.

METHODS: We systematically searched PubMed, EuropePMC, ProQuest, and Cochrane Central Databases using the terms "(COVID-19 OR SARS-CoV-2) AND (angiotensin converting enzyme OR angiotensin receptor blocker)". The primary and second outcomes were mortality (non-survivor) and severe COVID-19, respectively.

RESULTS: Totally, 7410 patients were included from 15 studies. Pooled analysis showed that the use of ACEI/ARB was not associated with mortality (OR 0.73 [0.38, 1.40], p = 0.34; I2: 81%) and severity (OR 1.03 [0.73, 1.45], p = 0.87; I2: 65%). Pooled adjusted OR showed no risk/benefit associated with ACEI/ARB use in terms of mortality (OR 0.83 [0.54, 1.27], p = 0.38; I2: 0%). Subgroup analysis showed that the use of ARB was associated with reduced mortality (OR 0.51 [0.29, 0.90], p = 0.02; I2: 22%) but not ACEI subgroup (OR 0.68 [0.39, 1.17], p = 0.16; I2: 0%). Meta-regression showed that the association between ACEI/ARB use and mortality in patients with COVID-19 do not varies by gender (p = 0.104). GRADE showed a very low certainty of evidence for effect of ACEI/ARB on mortality and severity. The certainty of evidence was very low for both ACEI and ARB subgroups.

CONCLUSION: Administration of a renin angiotensin system (RAS) inhibitor, was not associated with increased mortality or severity of COVID-19 in patients with hypertension. Specifically, ARB and not ACEI use, was associated with lower mortality.

Discipline / Specialty Area Score
Intensivist/Critical Care
Hospital Doctor/Hospitalists
Internal Medicine
Infectious Disease
Comments from MORE raters

Infectious Disease rater

This meta-analysis did not show any effect of ACEI/ARBs on mortality or severity of COVID-19. However the certainty of evidence was low, with significant heterogeneity among the studies. Exclusion of one study which showed increased mortality with ACEI/ARBs, resulted in significantly reduced mortality with ACEI/ARBs.

Infectious Disease rater

This is a meta-analysis as of early June 2020 showing no adverse effect of ACEI/ARB treatment on Covid-19 infection outcomes.

Internal Medicine rater

The structured methods are similar to other published evidence.

Respirology/Pulmonology rater

This systematic review addresses an important topic that is of interest to many clinicians - whether ACEi/ARB have an effect on susceptibility to, or outcome with, COVID-19. The results are not conclusive and should not change clinical practice. "GRADE showed a very low certainty of evidence for effect of ACEI/ARB on mortality and severity. The certainty of evidence was very low for both ACEI and ARB subgroups."

Respirology/Pulmonology rater

This meta-analyses of relatively few studies found neither increased risk nor benefit with use of ACEI/ARB's in the setting of Covid-19 infection. It provides a degree of reassurance to practitioners that these medications are not harmful.

Respirology/Pulmonology rater

This was a very useful and timely systematic review that was well conducted providing useful clinical information for the management of hypertensive COVID-19 patients. ARB's or ACEI's provide little to no benefit in the management of hypertensive COVID-19 patients.