COVID-19 Evidence Alerts
from McMaster PLUSTM

Current best evidence for clinical care (more info)

Etiology Braude P, Carter B, Short R, et al. The influence of ACE inhibitors and ARBs on hospital length of stay and survival in people with COVID-19. Int J Cardiol Heart Vasc. 2020 Dec;31:100660. doi: 10.1016/j.ijcha.2020.100660. Epub 2020 Oct 15.

Objective: During the COVID-19 pandemic the continuation or cessation of angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARBs) has been contentious. Mechanisms have been proposed for both beneficial and detrimental effects. Recent studies have focused on mortality with no literature having examined length of hospital stay. The aim of this study was to determine the influence of ACEi and ARBs on COVID-19 mortality and length of hospital stay.

Methods: COPE (COVID-19 in Older People) is a multicenter observational study including adults of all ages admitted with either laboratory or clinically confirmed COVID-19. Routinely generated hospital data were collected. Primary outcome: mortality; secondary outcomes: Day-7 mortality and length of hospital stay. A mixed-effects multivariable Cox's proportional baseline hazards model and logistic equivalent were used.

Results: 1371 patients were included from eleven centres between 27th February to 25th April 2020. Median age was 74 years [IQR 61-83]. 28.6% of patients were taking an ACEi or ARB. There was no effect of ACEi or ARB on inpatient mortality (aHR = 0.85, 95%CI 0.65-1.11). For those prescribed an ACEi or ARB, hospital stay was significantly reduced (aHR = 1.25, 95%CI 1.02-1.54, p = 0.03) and in those with hypertension the effect was stronger (aHR = 1.39, 95%CI 1.09-1.77, p = 0.007).

Conclusions: Patients and clinicians can be reassured that prescription of an ACEi or ARB at the time of COVID-19 diagnosis is not harmful. The benefit of prescription of an ACEi or ARB in reducing hospital stay is a new finding.

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

Infectious Disease rater

The paper shows reduced length-of-stay in hospital in COVID- infected patients who received ACE inhibitors or ARBs. Mortality was not affected. I`m not sure whether the paper adds much to the existing literature. Most would continue these drugs in COVID-infected patients.

Intensivist/Critical Care rater

Observational design with potential for confounding but, most importantly, this is not new information and generally accepted at this point that using ACEi/ARB is not harmful in COVID.

Internal Medicine rater

At my institution, this early worry about ACE/ARBs has been dispelled by subsequent data, so it`s really not an issue here anymore.

Internal Medicine rater

More info to support not discontinuing these drugs.

Internal Medicine rater

As we grapple with understanding and managing this pandemic, we focus our attention on "easily" modifiable factors. Given their widespread use for hypertension management, ACE/ARB became a clear area of focus, but the underlying pathophysiology remains debated. This study confirms what others have already shown: there is no clear association between using this class of medication and outcomes from COVID-19. What they did show is that it potentially led to shorter hospitalization, but why that is the case remains to be seen.

Respirology/Pulmonology rater

This is a well-designed observational study that adds to our knowledge that ACEi and ARBs do not appear to affect mortality from COVID-19 infection in general. The reduced length of hospital stay may be a local effect. A key concern is that the authors did not collect information on whether patients taking ACEi or ARBs on admission were continued on these drugs during hospitalization. Nevertheless, this study improves our knowledge of the safety and use of ACEi/ARB during COVID-19 infection in hospitalized patients.

Respirology/Pulmonology rater

Since the SARS-CoV-2 Pandemic started in the Western world in February, we are only now getting to the point at which we can start to look at retrospective data and attempt to makes sense of risk factors and potential therapeutic benefits. ACE-I and ARB do not appear to harm patients, but likewise offer no benefit to those infected. Most providers in the ICU already continue the ACE-I or ARB unless there is renal injury/hypotension.

Respirology/Pulmonology rater

Although there is already data to show no increased mortality risk with ACEI/ARB use and Covid-19 infection, this study also suggests benefit. Length-of-stay in hospital is shorter for those using these agents. Further evidence supporting continued use of ACEI/ARB in Covid-19 patients.