ACEI/ARB Use in COVID-19 Patients With Hypertension

Quick Takes

  • Among patients with COVID-19, in-hospital use of ACEI/ARB was associated with lower risk of all-cause mortality.
  • Since this was a retrospective study, these data need to be validated in a geographically diverse, prospective cohort or randomized controlled studies.
  • At this time, ACEI/ARB should be continued among patients with co-existing hypertension and COVID-19 as recommended by a statement jointly published by the AHA, HFSA, and ACC.

Study Questions:

What is the association between in-hospital use of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) and all-cause mortality in COVID-19 patients with hypertension?

Methods:

The investigators conducted a retrospective, multicenter study of 1,128 adult patients with hypertension diagnosed with COVID-19, including 188 taking ACEI/ARB (ACEI/ARB group; median age, 64 [interquartile range (IQR), 55-68] years; 53.2% men) and 940 without using ACEI/ARB (non-ACEI/ARB group; median age, 64 [IQR, 57-69]; 53.5% men), who were admitted to nine hospitals in Hubei Province, China from December 31, 2019 to February 20, 2020. Propensity score-matched cohorts were created based on variables that were expected to be potential confounders associated with exposure to ACEI/ARB, including age, gender, fever, cough, dyspnea, comorbidities (diabetes, coronary heart disease, and chronic renal disease), computed tomography-diagnosed bilateral lung lesions, and incidence of increased C-reactive protein and creatinine. The risk of composite endpoints and corresponding hazard ratio (HR) were calculated using the Cox proportional hazard model comparing the ACEI/ARB group versus non-ACEI/ARB group.

Results:

Unadjusted mortality rate was lower in the ACEI/ARB group versus the non-ACEI/ARB group (3.7% vs. 9.8%; p = 0.01). In the mixed-effect Cox model treating site as a random effect, after adjusting for age, gender, comorbidities, and in-hospital medications, the detected risk for all-cause mortality was lower in the ACEI/ARB group versus the non-ACEI/ARB group (adjusted hazard ratio [aHR], 0.42; 95% confidence interval [CI], 0.19-0.92; p = 0.03). In a propensity score-matched analysis followed by adjusting imbalanced variables in mixed-effect Cox model, the results consistently demonstrated lower risk of COVID-19 mortality in patients who received ACEI/ARB versus those who did not receive ACEI/ARB (aHR, 0.37; 95% CI, 0.15-0.89; p = 0.03). Further subgroup propensity score-matched analysis indicated that, compared to use of other antihypertensive drugs, ACEI/ARB was also associated with decreased mortality (aHR, 0.30; 95% CI, 0.12-0.70; p = 0.01) in COVID-19 patients with hypertension.

Conclusions:

The authors concluded that among hospitalized COVID-19 patients with hypertension, inpatient use of ACEI/ARB was associated with lower risk of all-cause mortality compared with ACEI/ARB nonusers.

Perspective:

This retrospective, multicenter study reports that among patients with COVID-19, in-hospital use of ACEI/ARB was associated with lower risk of all-cause mortality compared with either nonuse of ACEI/ARB or use of a different class of antihypertensive agent among patients with hypertension. Overall, these data provide clinical evidence in support of recently published guidance statements by several international societies (i.e., a statement jointly published by the American Heart Association [AHA], Heart Failure Society of America [HFSA], and American College of Cardiology [ACC]) to continue ACEI/ARB in patients with COVID-19. Since this was a retrospective study, these data need to be validated in a geographically diverse, prospective cohort or randomized controlled studies. However, totality of data suggests that it is unlikely that inpatient use of ACEI/ARB is associated with an increased risk of mortality.

Clinical Topics: Heart Failure and Cardiomyopathies, Prevention, Heart Failure and Cardiac Biomarkers, Hypertension

Keywords: Angiotensin Receptor Antagonists, Angiotensin-Converting Enzyme Inhibitors, Antihypertensive Agents, Cough, COVID-19, Coronary Disease, Coronavirus, C-Reactive Protein, Creatinine, Diabetes Mellitus, Dyspnea, Hypertension, Inpatients, Lung Diseases, Primary Prevention, Renal Insufficiency, Risk, severe acute respiratory syndrome coronavirus 2, Vascular Diseases


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