Current 1 - Support for ACEi and ARB Use in the COVID-19 Era

Summary

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-analyses⁵ 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).^1,6 However, 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.

Sources

¹Bavishi C, Maddox TM, Messerli FH. Coronavirus disease 2019 (COVID-19) infection and renin angiotensin system blockers. JAMA Cardiol. 2020;5(7):745-747. doi:10.1001/jamacardio.2020.1282.

²Cure E, Cumhur Cure M. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers may be harmful in patients with diabetes during COVID-19 pandemic. Diabetes Metab Syndr. 2020 Jul-Aug;14(4):349-350. doi.org/10.1016/j.dsx.2020.04.019.

³Zhang 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.

⁴Fosbøl 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. 2020;324(2):168-177. doi:10.1001/jama.2020.11301.

⁵Guo X, Zhu Y, Hong Y. Decreased mortality of COVID-19 with renin-angiotensin-aldosterone system inhibitors therapy in patients with hypertension: a meta-analysis. Hypertension. 2020;76(2):e13-e14. doi:10.1161/HYPERTENSIONAHA.120.15572.

⁶White Solaru K & Wright JT Jr. COVID-19 and Use of Drugs Targeting the Renin-Angiotensin-System. 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.