BACKGROUND: Angiotensin converting enzyme inhibitors (ACEIs) and angiotensin 
receptor blockers (ARBs) are known to increase the expression of angiotensin 
converting enzyme 2 receptor, which has been shown to be the receptor for the 
acute severe respiratory syndrome coronavirus 2 (SARS-CoV-2).
AREAS OF UNCERTAINTY: Based on these observations, speculations raised the 
concerns that ACEIs/ARBs users would be more susceptible to SARS-CoV-2 infection 
and would be at higher risk for severe COVID-19 disease and death. Therefore, we 
systematically reviewed the literature and performed a meta-analysis of the 
association between prior use of ACEIs and ARBs and mortality due to COVID-19 
disease.
DATA SOURCES: A comprehensive search of several databases from November 2019 to 
June 18, 2020 was conducted. The databases included Ovid MEDLINE(R) and Epub 
Ahead of Print, In-Process and Other Non-Indexed Citations and Daily, Ovid 
Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane 
Database of Systematic Reviews, Web of Science, and Scopus. Medrxiv.org was also 
searched for unpublished data.
THERAPEUTIC ADVANCES: Nine studies with a total of 18,833 patients infected with 
SARS-CoV-2 met our eligibility criteria. Prior use of ACEIs and/or ARBs was 
associated with reduced mortality among SARS-CoV-2-infected patients, with a 
pooled adjusted relative risk (aRR) from 6 studies of 0.63, 95% confidence 
interval (CI) (0.42-0.94) (I 2 = 65%). Three studies reported separately on 
ACEIs or ARBs and their association with survival among SARS-CoV-2-infected 
patients, with a pooled adjusted relative risk of 0.78, 95% CI (0.58-1.04) (I 2 
= 0%) and 0.97, 95% CI (0.73-1.30) (I 2 = 0%) respectively. The results of 
sensitivity analyses were consistent with the main analysis.
CONCLUSION: Our meta-analysis suggests that use of ACEIs/ARBs is associated with 
a decreased risk of death among SARS-CoV-2-infected patients. This finding 
provides a reassurance to the public not to stop prescribed ACEIs/ARBs because 
of fear of severe COVID-19.