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Is ACE Inhibitor Use a Risk Factor for COVID Mortality?

Separating Fact from Fiction

Hypertension is major risk factor for worse outcome with the COVID virus (SARS-CoV-2).  That’s a fact.  There are many people taking ACE inhibitors and ARBs in the USA and the virus enters the lungs and heart through the ACE2 receptor (see image below).  That’s a fact.  

It was initially thought that the use of ACE Inhibitors and ARBs would upregulate the number of ACE2 receptors and allow the virus to be more devastating.  This might be fiction.  The clinical data (to date) doesn’t seem to reflect that theory.

Recent UK multicenter study (Bean et al 2020) found that ACE inhibitor use was actually protective!  Mortality and need for ICU care was 14% compared to 29% for the general population. Issues: very small sample size (N=205) and article is a pre-print (not peer reviewed).

A large multicenter study of over 1000 patients (Zhang et al 2020) found similar results.  ACE Inhibitors were continued upon admission to the hospital for COVID infection and mortality was lower (3.7%) compared to the general population (9.8%).

How could this be?  The new theory (this virus is definitely keeping us on our toes) is that the meds are causing ACE2 receptor blockade, preventing viral entry and reducing the cytokine/inflammatory storm (see image below).

Bottom Line:  Don’t be afraid of ACE Inhibitors or ARBs.  Don’t tell patients to discontinue their blood pressure meds.  Hypertension leading to stroke and MI is a bigger threat than the risk with COVID infection.

Bean DM et al. Treatment with ACE-inhibitors is associated with less severe disease with SARS-Covid-19 infection in a multi-site UK acute hospital trust. MedRxiv 2020 Apr 11; [preprint] (https://doi.org/10.1101/2020.04.07.20056788)

Zhang P et al. Association of inpatient use of angiotensin converting enzyme inhibitors and angiotensin II receptor blockers with mortality among patients with hypertension hospitalized with COVID-19. Circ Res 2020 Apr 17; [e-pub]. (https://doi.org/10.1161/CIRCRESAHA.120.317134)

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