COVID-19 Evidence Alerts
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Current best evidence for clinical care (more info)

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Etiology Zhang G, Wu Y, Xu R, et al. Effects of renin-angiotensin-aldosterone system inhibitors on disease severity and mortality in patients with COVID-19: A meta-analysis. J Med Virol. 2021 Apr;93(4):2287-2300. doi: 10.1002/jmv.26695. Epub 2020 Dec 17.

To investigate the effects of renin-angiotensin-aldosterone system (RAAS) inhibitors on the prognosis in patients with coronavirus disease 2019 (COVID-19). A meta-analysis was performed. We systematically searched PubMed, the Cochrane Library, the Web of Science, EMBASE, medRxiv, and bioRxiv database through October 30, 2020. The primary and secondary outcomes were mortality and severe COVID-19, respectively. We included 25 studies with 22,734 COVID-19 patients, and we compared the outcomes between patients who did and did not receive angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEIs/ARBs). The use of ACEIs/ARBs was not associated with higher risks of severe disease (odds ratio [OR] = 0.89; 95% confidence interval [CI]: 0.63, 1.15; I2 = 38.55%), mechanical ventilation (OR = 0.89; 95% CI: 0.61, 1.16; I2 = 3.19%), dialysis (OR = 1.24; 95% CI: 0.09, 2.39; I2 = 0.00%), or the length of hospital stay (SMD = 0.05; 95% CI: -0.16, 0.26; I2 = 84.43%) in COVID-19 patients. The effect estimates showed an overall protective effect of ACEIs/ARBs against mortality (OR = 0.65; 95% CI: 0.46, 0.85; I2 = 73.37%), severity/mortality (OR = 0.69; 95% CI: 0.43, 0.95; I2 = 22.90%), transfer to the intensive care unit among COVID-19 patients with hypertension (OR = 0.36, 95% CI: 0.19, 0.53, I2 = 0.00%), hospitalization (OR = 0.79; 95% CI: 0.60, 0.98; I2 = 0.00%), and acute respiratory distress syndrome (OR = 0.71; 95% CI: 0.46, 0.95; I2 = 0.00%). The use of RAAS inhibitor was not associated with increased mortality or disease severity in COVID-19 patients. This study supports the current guidelines that discourage the discontinuation of RAAS inhibitors in COVID-19 patients.

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

Cardiology rater

COVID-19 is a big concern in the world. The coronavirus is known as connecting with ACE2 receptor, thus discontinuation of ARB was thought to be necessary in patients with hypertension treated with this medicine. This meta-analysis shows there was no obvious relation with discontinuation of ARB. According to these data, we should keep giving ARB to these patients.

Cardiology rater

These results confirm what I and most of my colleagues know about the effect of renin-angiotensin-aldosterone system (RAAS) inhibitors on the prognosis in patients with COVID-19.

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

This study confirms existing knowledge on this topic.

Internal Medicine rater

This meta analysis of 25 studies showed that the use of ACEIs/ARBs does not worsen outcomes in COVID-19 and may even be protective.