Renin–angiotensin system inhibition and risk of infection and mortality in COVID‐19: a systematic review and meta‐analysis

• Published in: Internal medicine journal 2020-12, Vol.50 (12), p.1468-1474
• Main Authors: Koshy, Anoop N., Murphy, Alexandra C., Farouque, Omar, Ramchand, Jay, Burrell, Louise M., Yudi, Matias B.
• Format: Article
• Language: English
• Subjects: ace inhibitor; ACE2; Aminopeptidase; Angiotensin; Angiotensin Receptor Antagonists - administration & dosage; Angiotensin Receptor Antagonists - adverse effects; Angiotensin-converting enzyme 2; Angiotensin-Converting Enzyme 2 - antagonists & inhibitors; Angiotensin-Converting Enzyme 2 - metabolism; Angiotensin-Converting Enzyme Inhibitors - administration & dosage; Angiotensin-Converting Enzyme Inhibitors - adverse effects; Case-Control Studies; Clinical trials; Coronaviruses; COVID-19; COVID-19 - diagnosis; COVID-19 - metabolism; COVID-19 - mortality; Enzymes; Humans; Meta-analysis; metaanalysis; Mortality; Mortality - trends; Original; Renin; renin angiotensin inhibitor; Renin-Angiotensin System - drug effects; Renin-Angiotensin System - physiology; Retrospective Studies; Risk Factors; Severe acute respiratory syndrome coronavirus 2; Systematic review
• ISSN: 1444-0903; 1445-5994
• DOI: 10.1111/imj.15002

Background Severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), the causative agent of COVID‐19, enters human cells by binding of its viral protein to the aminopeptidase angiotensin‐converting enzyme 2 (ACE2). This has led to speculation whether treatment with renin–angiotensin system (RAS) inhibitors was associated with an increased likelihood of a positive test for COVID‐19 and risk of mortality. Aims We performed a systematic review and meta‐analysis to investigate whether RAS inhibitors increased the likelihood of a positive test or death/severe illness in patients with COVID‐19. Methods A systematic search of MEDLINE, PubMed and EMBASE was conducted for studies stratified by the use of angiotensin‐converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB). Pooled analysis was performed using a random‐effects model. Results Seven trials of 73 122 patients were included. Overall, 16 624 (22.7%) patients had a positive COVID‐19 test and 7892 (10.8%) were on a RAS inhibitor. RAS inhibitors were not associated with higher likelihood of a positive COVID‐19 test result (odds ratio (OR) 0.97 (95% CI 0.97–1.05, P = 0.48) with low heterogeneity. This was comparable when stratifying by use of each medication class. The use of RAS inhibitors was also not associated with mortality or severe illness (OR 0.89, 95% CI 0.73–1.07, P = 0.21) with moderate heterogeneity. Conclusion Use of ACEI or ARB was not associated with a heightened susceptibility for a positive diagnosis of COVID‐19. Furthermore, they were not associated with increased illness severity or mortality due to COVID‐19. Randomised controlled trials are needed to address definitively the potential benefits or harms of RAS inhibitors in patients with COVID‐19.