AIMS: This retrospective case-control study was aimed at identifying potential 
independent predictors of severe/lethal COVID-19, including the treatment with 
Angiotensin-Converting Enzyme inhibitors (ACEi) and/or Angiotensin II Receptor 
Blockers (ARBs).
METHODS AND RESULTS: All adults with SARS-CoV-2 infection in two Italian 
provinces were followed for a median of 24 days. ARBs and/or ACEi treatments, 
and hypertension, diabetes, cancer, COPD, renal and major cardiovascular 
diseases (CVD) were extracted from clinical charts and electronic health 
records, up to two years before infection. The sample consisted of 1603 subjects 
(mean age 58.0y; 47.3% males): 454 (28.3%) had severe symptoms, 192 (12.0%) very 
severe or lethal disease (154 deaths; mean age 79.3 years; 70.8% hypertensive, 
42.2% with CVD). The youngest deceased person aged 44 years. Among hypertensive 
subjects (n = 543), the proportion of those treated with ARBs or ACEi were 
88.4%, 78.7% and 80.6% among patients with mild, severe and very severe/lethal 
disease, respectively. At multivariate analysis, no association was observed 
between therapy and disease severity (Adjusted OR for very severe/lethal 
COVID-19: 0.87; 95% CI: 0.50-1.49). Significant predictors of severe disease 
were older age (with AORs largely increasing after 70 years of age), male gender 
(AOR: 1.76; 1.40-2.23), diabetes (AOR: 1.52; 1.05-2.18), CVD (AOR: 1.88; 
1.32-2.70) and COPD (AOR: 1.88; 1.11-3.20). Only gender, age and diabetes also 
predicted very severe/lethal disease.
CONCLUSION: No association was found between COVID-19 severity and treatment 
with ARBs and/or ACEi, supporting the recommendation to continue medication for 
all patients unless otherwise advised by their physicians.