Association of outpatient ACE inhibitors and angiotensin receptor blockers and outcomes of acute respiratory illness: a retrospective cohort study

• Published in: BMJ open 2021-03, Vol.11 (3), p.e044010-e044010
• Main Authors: Jeffery, Molly Moore, Cummins, Nathan W, Dempsey, Timothy M, Limper, Andrew H., Shah, Nilay D, Bellolio, Fernanda
• Format: Article
• Language: English
• Subjects: Bacterial infections; Blood pressure; Cardiovascular disease; Chronic illnesses; Codes; Cohort analysis; Comorbidity; Coronaviruses; COVID-19; Diabetes; Health care policy; Health Services Research; Hospitals; Hypertension; Influenza; Lungs; Medicare; Mortality; Pathophysiology; Patients; Pharmacy; Respiratory diseases; respiratory infections; Severe acute respiratory syndrome coronavirus 2; therapeutics
• ISSN: 2044-6055; 2044-6055
• DOI: 10.1136/bmjopen-2020-044010

ObjectivesEvaluate associations between ACE inhibitors (ACEis) and angiotensin receptor blockers (ARBs) and clinical outcomes in acute viral respiratory illness (AVRI).DesignRetrospective cohort analysis of claims data.SettingThe USA; 2018–2019 influenza season.ParticipantsMain cohort: people with hypertension (HTN) taking an ACEi, ARB or other HTN medications, and experiencing AVRI. Falsification cohort: parallel cohort receiving elective knee or hip replacement.Main outcome measuresMain cohort: hospital admission, intensive care unit, acute respiratory distress (ARD), ARD syndrome and all-cause mortality. Falsification cohort: complications after surgery and all-cause mortality.ResultsThe main cohort included 236 843 episodes of AVRI contributed by 202 629 unique individuals. Most episodes were in women (58.9%), 81.4% in people with Medicare Advantage and 40.3% in people aged 75+ years. Odds of mortality were lower in the ACEi (0.78 (0.74 to 0.83)) and ARB (0.64 (0.61 to 0.68)) cohorts compared with other HTN medications. On all other outcomes, people taking ARBs (but not ACEis) had a >10% reduction in odds of inpatient stays compared with other HTN medications.In the falsification analysis (N=103 353), both ACEis (0.89 (0.80 to 0.98)) and ARBs (0.82 (0.74 to 0.91)) were associated with decreased odds of complications compared with other HTN medications; ARBs (0.64 (0.47 to 0.87)) but not ACEis (0.79 (0.60 to 1.05)) were associated with lower odds of death compared with other HTN medications.ConclusionsOutpatient use of ARBs was associated with better outcomes with AVRI compared with other medications for HTN. ACEis were associated with reduced risk of death, but with minimal or no reduction in risk of other complications. A falsification analysis conducted to provide context on the possible causal implications of these findings did not provide a clear answer. Further analysis using observational data will benefit from additional approaches to assess causal relationships between these drugs and outcomes in AVRI.