Angiotensin Converting Enzyme Inhibitor and Angiotensin II Receptor Blocker Use Among Outpatients Diagnosed With COVID-19

Abstract

Coronavirus disease 2019 (COVID-19) is a viral pandemic precipitated by the severe acute respiratory syndrome coronavirus 2. Since previous reports suggested that viral entry into cells may involve angiotensin converting enzyme 2, there has been growing concern that angiotensin converting enzyme inhibitor (ACEI) and angiotensin II receptor blocker (ARB) use may exacerbate the disease severity. In this retrospective, single-center US study of adult patients diagnosed with COVID-19, we evaluated the association of ACEI/ARB use with hospital admission. Secondary outcomes included: ICU admission, mechanical ventilation, length of hospital stay, use of inotropes, and all-cause mortality. Propensity score matching was performed to account for potential confounders. Among 590 unmatched patients diagnosed with COVID-19, 78 patients were receiving ACEI/ARB (median age 63 years and 59.7% male) and 512 patients were non-users (median age 42 years and 47.1% male). In the propensity matched population, multivariate logistic regression analysis adjusting for age, gender and comorbidities demonstrated that ACEI/ARB use was not associated with hospital admission (OR 1.2, 95%CI 0.5 to 2.7, p = 0.652). CAD and CKD/end stage renal disease [ESRD] remained independently associated with admission to hospital. All-cause mortality, ICU stay, need for ventilation, and inotrope use was not significantly different between the 2 study groups. In conclusion, among patients who were diagnosed with COVID-19, ACEI/ARB use was not associated with increased risk of hospital admission.

Figure 1

Association of ACEI/ARB use with number of comorbidities. Panel A shows the unmatched population. For patients not on ACEI/ARB, the number of comorbidities was higher in admitted patients (median 2, IQR 1 to 3) compared to those not admitted (median 1, IQR 0 to 2, p <0.001). For patients on ACEI/ARB, the number of comorbidities was higher in admitted patients (median 4, IQR 3 to 5) compared to those who were not admitted (median 3, IQR 2 to 4, p <0.001). Panel B shows the matched population. For patients not on ACEI/ARB, number of comorbidities was higher in admitted patients (median 3, IQR 2.25 to 5) compared to those not admitted (median 2 IQR 2 to 4, p <0.022). For patients on ACEI/ARB, number of comorbidities was higher in admitted patients (median 4, IQR 3 to 5) compared to those not admitted (median 3, IQR 2 to 4, p <0.001). In both the matched and unmatched cohort, ACEI/ARB use was associated with increased number of comorbidities compared to nonuse in both hospitalized and nonhospitalized patients. IQR = interquartile range.

Figure 2

Age and Number of Comorbidities in Relation to Hospital Admission. Panel A shows ROC for age (AUC 0.72, 95%CI: 0.67 to 0.78, p <0.001) and number of comorbidities (AUC 0.75, 95%CI: 0.70 to 0.80, p <0.001) in all unmatched patients (n = 590). Panel B shows ROC for age (AUC 0.69, 95%CI: 0.63 to 0.76, p <0.001) and number of comorbidities (AUC 0.72, 95%CI: 0.66 to 0.78, p <0.001) in all unmatched patients not on an ACEI/ARB (n = 590). Panel C shows the ROC for age (AUC 0.66, 95%CI: 0.54 to 0.79, p = 0.013) and number of comorbidities (AUC 0.76, 95%CI: 0.66 to 0.87, p = 0.13) in all unmatched patients on a ACEI/ARB (n = 78). Panel D shows the ROC for age (AUC 0.66, 95%CI: 0.57 to 0.75, p = 0.001) and number of comorbidities (AUC 0.71, 95%CI: 0.63 to 0.80, p < 0.001) in all matched patients (n = 149). Panel E shows the ROC for age (AUC 0.66, 95%CI: 0.53 to 0.79, p = 0.024) and number of comorbidities (AUC 0.66, 95%CI: 0.53 to 0.79, p = 0.027 in all matched patients not on an ACEI/ARB (n = 71). Panel F shows the ROC for age (AUC 0.66, 95%CI: 0.54 to 0.79, p = 0.013) and number of comorbidities (AUC 0.76, 95%CI: 0.66 to 0.87, p <0.001) in all matched patients on an ACEI/ARB (n = 78). AUC = area under the curve; CI = confidence interval; ROC = receiver operating curve.