Consensus among expert groups is to continue ACEi and ARB use when there is a specific indication for their use, even in patients diagnosed with COVID-19.
SARS-CoV-2 uses the angiotensin converting enzyme 2 (ACE2) receptor for entry into host target cells, the expression of which is increased by two common classes of antihypertensives, angiotensin-converting enzyme inhibitors (ACEi) and angiotensin II receptor blockers (ARB).1
Some have speculated that these medications may increase coronavirus disease 2019 (COVID-19) susceptibility or disease outcome.2
Retrospective studies 3,4 and meta-analyses 5 have thus far demonstrated that among hypertensive patients hospitalized with COVID-19, mortality rate is not higher among those patients treated with ACEi/ARB. Thus, the safety of continuing ACEis and ARBs has been reinforced by several recent retrospective observational studies in COVID-19 patients.
Professional societies (American College of Cardiology, European Society of Cardiology, Hypertension Canada) have released statements regarding ACEi/ARB use during the pandemic; consensus among the groups is to continue their use, even in patients diagnosed with COVID-19 when there is a specific indication for their use (e.g. left ventricular (LV) dysfunction, chronic kidney disease (CKD), secondary stroke prevention).1,6However, the new prescription of these agents over the other recommended first line antihypertensive agents (i.e. thiazide diuretics (THZD) and calcium-channel blockers (CCBs)) must await the results of ongoing randomized controlled trials (RCTs).6
A table6 summarizing recommended initiation or continuation of ACEi/ARB in patients with COVID-19 and those at risk can be found here.
Note: This clinical question is an active area of research worldwide; conclusions and recommendations may change over time.
1 Bavishi C, Maddox TM, Messerli FH. Coronavirus Disease 2019 (COVID-19) Infection and Renin Angiotensin System Blockers. JAMA Cardiol. Published online April 03, 2020. doi:10.1001/jamacardio.2020.1282
2 Cure E and Cure MC. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers may be harmful in patients with diabetes during COVID-19 pandemic. Diabetes & Metabolic Syndrome: Clinical Research and Reviews. 2020;14(4):349-350 https://doi.org/10.1016/j.dsx.2020.04.019
3 Zhang P, Zhu L, Cai J et al. Association of Inpatient Use of Angiotensin-Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers With Mortality Among Patients With Hypertension Hospitalized With COVID-19. Circ Res. 2020;126(12):1671-1681. doi:10.1161/circresaha.120.317134
4 Fosbøl EL ,Butt JH, Østergaard L, et al. Association of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use with COVID-19 diagnosis and mortality. JAMA. Published onlineJune19,2020.doi:10.1001/jama.2020.11301
5 Guo X, Zhu Y, Hong Y. Decreased Mortality of COVID-19 With Renin-Angiotensin-Aldosterone System Inhibitors Therapy in Patients With Hypertension. Hypertension. 2020;76(2). doi:10.1161/hypertensionaha.120.15572
6 White Solaru K, Wright JT Jr. COVID-19 and Use of Drugs Targeting the Renin-Angiotensin-System - American College of Cardiology. American College of Cardiology. https://www.acc.org/latest-in-cardiology/articles/2020/07/15/13/12/covid-19-and-use-of-drugs-targeting-the-renin-angiotensin-system. Published 2020. Accessed July 21, 2020.