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COVID-19 Evidence Alerts
from McMaster PLUSTM

Current best evidence for clinical care (more info)

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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 Jun 27;14(5):983-990. doi: 10.1016/j.dsx.2020.06.047.
Abstract

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.

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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.