COVID-19 Evidence Alerts
from McMaster PLUSTM

Current best evidence for clinical care (more info)

Etiology Baral R, White M, Vassiliou VS Effect of Renin-Angiotensin-Aldosterone System Inhibitors in Patients with COVID-19: a Systematic Review and Meta-analysis of 28,872 Patients. Curr Atheroscler Rep. 2020 Aug 24;22(10):61. doi: 10.1007/s11883-020-00880-6.

PURPOSE OF REVIEW: The role of renin-angiotensin-aldosterone system (RAAS) inhibitors, notably angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARBs), in the COVID-19 pandemic has not been fully evaluated. With an increasing number of COVID-19 cases worldwide, it is imperative to better understand the impact of RAAS inhibitors in hypertensive COVID patients. PubMed, Embase and the pre-print database Medrxiv were searched, and studies with data on patients on ACEi/ARB with COVID-19 were included. Random effects models were used to estimate the pooled mean difference with 95% confidence interval using Open Meta[Analyst] software.

RECENT FINDINGS: A total of 28,872 patients were included in this meta-analysis. The use of any RAAS inhibition for any conditions showed a trend to lower risk of death/critical events (OR 0.671, CI 0.435 to 1.034, p = 0.071). Within the hypertensive cohort, however, there was a significant lower association with deaths (OR 0.664, CI 0.458 to 0.964, p = 0.031) or the combination of death/critical outcomes (OR 0.670, CI 0.495 to 0.908, p = 0.010). There was no significant association of critical/death outcomes within ACEi vs non-ACEi (OR 1.008, CI 0.822 to 1.235, p = 0.941) and ARB vs non-ARB (OR 0.946, CI 0.735 to 1.218, p = 0.668). This is the largest meta-analysis including critical events and mortality data on patients prescribed ACEi/ARB and found evidence of beneficial effects of chronic ACEi/ARB use especially in hypertensive cohort with COVID-19. As such, we would strongly encourage patients to continue with RAAS inhibitor pharmacotherapy during the COVID-19 pandemic.

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

Family Medicine (FM)/General Practice (GP) rater

This is useful information for clinicians who see patients who may be presenting with Covid-19 infection, or patients on ACEi's or ARBs who are worried about getting infected with Covid-19, while on these medications. This provides some reassurance that patients don't need to stop those meds.

General Internal Medicine-Primary Care(US) rater

This is very reassuring. I have read several articles that give the same information but this is a large group and should put everyone’s doubts to rest. Some of my colleagues have been stopping these medications unless the patient has no reasonable alternative. I think that last January and February, I was very uncertain about what to do what is the information came out I am not really changing my practice. I’m relieved to know that this was correct

Infectious Disease rater

There are no here, but this is potentially useful.

Respirology/Pulmonology rater

Another, larger, meta-analysis finds no association with ACEI/ARB use and increased Covid-19 complications. Despite looking at observational and retrospective studies, the large number of patients provides a degree of reassurance that ACEI/ARB medications are not detrimental in the setting of Covid-19.

Respirology/Pulmonology rater

This very relevant article should be disseminated to providers who treat COVID patients.