Renin-angiotensin system inhibitors and susceptibility to COVID-19 in patients with hypertension: a propensity score-matched cohort study in primary care

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Colleges, School and Institutes


Introduction: Renin-angiotensin system (RAS) inhibitors have been postulated to influence susceptibility to Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2). This study investigated whether there is an association between their prescription and the incidence of COVID-19 and all-cause mortality. Methods: We conducted a propensity-score matched cohort study comparing the incidence of COVID-19 among patients with hypertension prescribed angiotensin-converting enzyme I (ACE) inhibitors or angiotensin II type-1 receptor blockers (ARBs) to those treated with calcium channel blockers (CCBs) in a large UK-based primary care database (The Health Improvement Network). We estimated crude incidence rates for confirmed/suspected COVID-19 in each drug exposure group. We used Cox proportional hazards models to produce adjusted hazard ratios for COVID-19. We assessed all-cause mortality as a secondary outcome. Results: The incidence rate of COVID-19 among users of ACE inhibitors and CCBs was 9.3 per 1000 person-years (83 of 18,895 users [0.44%]) and 9.5 per 1000 person-years (85 of 18,895 [0.45%]), respectively. The adjusted hazard ratio was 0.92 (95% CI 0.68 to 1.26). The incidence rate among users of ARBs was 15.8 per 1000 person-years (79 out of 10,623 users [0.74%]). The adjusted hazard ratio was 1.38 (95% CI 0.98 to 1.95). There were no significant associations between use of RAS inhibitors and all-cause mortality. Conclusion: Use of ACE inhibitors was not associated with the risk of COVID-19 whereas use of ARBs was associated with a statistically non-significant increase compared to the use of CCBs. However, no significant associations were observed between prescription of either ACE inhibitors or ARBs and all-cause mortality.

Bibliographic note

Funding Information: The authors have no competing interests to declare. ES reports receiving funding from HDR-UK (PIONEER Hub), Wellcome, MRC, British Lung Foundation and NIHR. DP reports receiving funding from NIHR and MRC. Publisher Copyright: © 2021, The Author(s).


Original languageEnglish
Article number262
JournalBMC Infectious Diseases
Issue number1
Publication statusPublished - 15 Mar 2021


  • Adolescent, Adult, Aged, Aged, 80 and over, Angiotensin Receptor Antagonists/adverse effects, Angiotensin-Converting Enzyme Inhibitors/adverse effects, Antihypertensive Agents/adverse effects, COVID-19/complications, Calcium Channel Blockers/adverse effects, Cohort Studies, Female, Humans, Hypertension/complications, Incidence, Male, Middle Aged, Mortality, Propensity Score, Proportional Hazards Models, Renin-Angiotensin System, United Kingdom, Young Adult