Outcomes of renin–angiotensin–aldosterone system blockers in patients with COVID-19: a systematic review and meta-analysis

Abstract

The coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has recently reached the pandemic level. COVID-19 is associated with higher case fatality in patients with comorbidities, including those with arterial hypertension or other cardiovascular diseases. Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) are extensively used for different clinical indications. It has been hypothesized that the use of ACEIs/ARBs may negatively impact on the clinical outcomes of COVID-19 patients by affecting the expression of angiotensin-converting enzyme 2 aminopeptidase (ACE-2), the human receptor for SARS-CoV-2. Accruing evidence is available that does not show a higher risk with ACEIs/ARBs in patients with COVID-19. However, available studies have limited statistical power to detect signals of increased mortality. In this context, a meta-analysis provides more precise estimates of the direction and strength of association between the use of ACEIs/ARBs and prognosis. Few meta-analyses have been published that do not show an increase in death with ACEIs/ARBs. However, new studies are now available that suggest the opportunity for an update.