Renin-Angiotensin System Inhibitors Use and Risk of COVID-19

Sarfaroj Khan 


April 13, 2021


  • The use of angiotensin-converting enzyme (ACE) inhibitors in hypertensive patients was not associated with an increased risk of suspected or confirmed COVID-19, whereas the use of angiotensin II receptor blockers (ARBs) was associated with a non-significantly increased risk of COVID-19 vs calcium channel blockers (CCBs).

  • However, neither of the renin-angiotensin system (RAS) inhibitor classes was associated with a significantly increased risk of all-cause mortality during the first peak of the pandemic.

Why this matters

  • The Council on Hypertension of the European Society of Cardiology emphasised the lack of evidence supporting the harmful effects of ACE inhibitors and ARBs in the context of the COVID-19 pandemic.

Study design

  • A propensity score-matched cohort study used data from The Health Improvement Network (THIN) database in the UK.

  • There were 18,895 patients in each arm of the ACE inhibitor and CCB paired cohorts and 10,623 in each arm of the ARB and CCB paired cohorts.

  • Primary outcome was incidence of confirmed/suspected COVID-19 in each drug exposure group; secondary outcome was all-cause mortality.

  • Funding: None.

Key results

  • The incidence rates of COVID-19 were 9.3 and 9.5 per 1000 person-years in ACE inhibitor users (0.44%) and CCB users (0.45%), respectively (adjusted HR [aHR], 0.92; 95% CI, 0.68-1.26).

  • There was a non-significantly increased risk of all-cause mortality between ACE inhibitor and CCB users (aHR, 1.25; 95% CI, 0.90-1.73)

  • The incidence rates of COVID-19 were 15.8 and 11.6 per 1000 person-years in ARB users (0.74%) and CCB users (0.55%), respectively (aHR, 1.38; 95% CI, 0.98-1.95).

  • No statistically significant difference was observed in all-cause mortality between ARB and CCB users (aHR, 0.85; 95% CI, 0.56-1.30).


  • Suspected or confirmed COVID-19 may not have been well recorded in primary care records.


Haroon S, Subramanian A, Cooper J, Anand A, Gokhale K, Byne N, Dhalla S, Acosta-Mena D, Taverner T, Okoth K, Wang J, Chandan JS, Sainsbury C, Zemedikun DT, Thomas GN, Parekh D, Marshall T, Sapey E, Adderley NJ, Nirantharakumar K. Renin-angiotensin system inhibitors and susceptibility to COVID-19 in patients with hypertension: a propensity score-matched cohort study in primary care. BMC Infect Dis. 2021;21(1):262. doi: 10.1186/s12879-021-05951-w. PMID: 33722197.  View full text 

This clinical summary originally appeared on Univadis, part of the Medscape Professional Network.


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