Purpose Due to the affinity of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) for the human angiotensin converting enzyme 2 (ACE2) receptor, use of angiotensin converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARBs) has been a major concern for clinicians during the 2020 pandemic. Meta-analyses have affirmed that these agents do not worsen clinical outcomes in SARS-CoV-2 infection. To date, only a limited number of studies have directly looked at the safety of inpatient prescription of ACEi/ARBs during acute COVID-19 illness. Methods A retrospective cohort analysis was conducted to investigate the impact of inpatient provision of ACEi/ARBs on morbidity and mortality in patients admitted to hospital with COVID-19. Relationships were explored using linear and logistic regression. Findings Six hundred and twelve adult patients met our inclusion criteria of which 151 (24.7%) patients were established on ACEi/ARBs. Despite correction for known confounders, discontinuation of ACEi/ARBs was highly predictive of worsened outcomes in COVID-19. The proportion of doses omitted in hospital was significantly associated with increased mortality (p<0.001, OR=9.59 [2.55-36.09]), maximum National Early Warning Score (NEWS-2; p<0.001, OR=1.66 [1.27-2.17]), maximum oxygen requirements (p<0.001, OR=3.00 [1.83-4.91]), and maximum C-Reactive Protein concentration (CRP; p=0.030, OR=1.83 [1.06-3.17]). Implications Our data demonstrates a strong association between missed ACEi/ARB doses with increased morbidity and mortality. The available evidence supports continuation of current accepted practice surrounding ACEi/ARB therapy in acute illness – which is to limit drug omission to established acute contraindications, to actively monitor such decisions and to restart therapy as soon as it is safe to do so.
Inpatient omission of ACEi and ARBs is associated with morbidity and mortality in COVID-19