BACKGROUND: Speculations whether treatment with angiotensin-converting enzyme 
inhibitors (ACE-I) or angiotensin II receptor blockers (ARB) predisposes to 
severe coronavirus disease 2019 (COVID-19) or worsens its outcomes. This study 
assessed the association of ACE-I/ARB therapy with the development of severe 
COVID-19.
METHODS: This multi-center, prospective study enrolled patients hospitalized for 
COVID-19 and receiving one or more antihypertensive agents to manage either 
hypertension or cardiovascular disease. ACE-I/ARB therapy associations with 
severe COVID-19 on the day of hospitalization, intensive care unit (ICU) 
admission, mechanical ventilation and in-hospital death on follow-up were tested 
using a multivariate logistic regression model adjusted for age, obesity, and 
chronic illnesses. The composite outcome of mechanical ventilation and death was 
examined using the adjusted Cox multivariate regression model.
RESULTS: Of 338 enrolled patients, 245 (72.4%) were using ACE-I/ARB on the day 
of hospital admission, and 197 continued ACE-I/ARB therapy during 
hospitalization. Ninety-eight (29%) patients had a severe COVID-19, which was 
not significantly associated with the use of ACE-I/ARB (OR 1.17, 95% CI 
0.66-2.09; P = .57). Prehospitalization ACE-I/ARB therapy was not associated 
with ICU admission, mechanical ventilation, or in-hospital death. Continuing 
ACE-I/ARB therapy during hospitalization was associated with decreased mortality 
(OR 0.22, 95% CI 0.073-0.67; P = .008). ACE-I/ARB use was not associated with 
developing the composite outcome of mechanical ventilation and in-hospital death 
(HR 0.95, 95% CI 0.51-1.78; P = .87) versus not using ACE-I/ARB.
CONCLUSION: Patients with hypertension or cardiovascular diseases receiving 
ACE-I/ARB therapy are not at increased risk for severe COVID-19 on admission to 
the hospital. ICU admission, mechanical ventilation, and mortality are not 
associated with ACE-I/ARB therapy. Maintaining ACE-I/ARB therapy during 
hospitalization for COVID-19 lowers the likelihood of death.
CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT4357535.