Angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and COVID-19-related outcomes: A patient-level analysis of the PCORnet blood pressure control lab

Steven M. Smith*, Raj A. Desai, Marta G. Walsh, Ester Kim Nilles, Katie Shaw, Myra Smith, Alanna M. Chamberlain, Catherine G. Derington, Adam P. Bress, Cynthia H. Chuang, Daniel E. Ford, Bradley W. Taylor, Sravani Chandaka, Lav Parshottambhai Patel, James McClay, Elisa Priest, Jyotsna Fuloria, Kruti Doshi, Faraz S. Ahmad, Anthony J. VieraMadelaine Faulkner, Emily C. O'Brien, Mark J. Pletcher, Rhonda M. Cooper-DeHoff

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

4 Scopus citations


SARS-CoV-2 accesses host cells via angiotensin-converting enzyme-2, which is also affected by commonly used angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), raising concerns that ACEI or ARB exposure may portend differential COVID-19 outcomes. In parallel cohort studies of outpatient and inpatient COVID-19-diagnosed adults with hypertension, we assessed associations between antihypertensive exposure (ACEI/ARB vs. non-ACEI/ARB antihypertensives, as well as between ACEI- vs. ARB) at the time of COVID-19 diagnosis, using electronic health record data from PCORnet health systems. The primary outcomes were all-cause hospitalization or death (outpatient cohort) or all-cause death (inpatient), analyzed via Cox regression weighted by inverse probability of treatment weights. From February 2020 through December 9, 2020, 11,246 patients (3477 person-years) and 2200 patients (777 person-years) were included from 17 health systems in outpatient and inpatient cohorts, respectively. There were 1015 all-cause hospitalization or deaths in the outpatient cohort (incidence, 29.2 events per 100 person-years), with no significant difference by ACEI/ARB use (adjusted HR 1.01; 95% CI 0.88, 1.15). In the inpatient cohort, there were 218 all-cause deaths (incidence, 28.1 per 100 person-years) and ACEI/ARB exposure was associated with reduced death (adjusted HR, 0.76; 95% CI, 0.57, 0.99). ACEI, versus ARB exposure, was associated with higher risk of hospitalization in the outpatient cohort, but no difference in all-cause death in either cohort. There was no evidence of effect modification across pre-specified baseline characteristics. Our results suggest ACEI and ARB exposure have no detrimental effect on hospitalizations and may reduce death among hypertensive patients diagnosed with COVID-19.

Original languageEnglish (US)
Article number100112
JournalAmerican Heart Journal Plus: Cardiology Research and Practice
StatePublished - Jan 2022


  • ACE inhibitors
  • ARBs
  • Covid-19
  • Hypertension
  • PCORnet

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine


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