Angiotensin-converting enzyme 2: a double-edged sword in COVID-19 patients with an increased risk of heart failure
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Angiotensin-converting enzyme 2: a double-edged sword in COVID-19 patients with an increased risk of heart failure Iman Razeghian-Jahromi 1 & Mohammad Javad Zibaeenezhad 1 & Zhibing Lu 2 & Elyaspour Zahra 1 & Razmkhah Mahboobeh 3 & Vicenzo Lionetti 4,5
# Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract The coronavirus disease (COVID-19) pandemic is a global health priority. Given that cardiovascular diseases (CVD) are the leading cause of morbidity around the world and that several trials have reported severe cardiovascular damage in patients infected with SARS-CoV-2, a substantial number of COVID-19 patients with underlying cardiovascular diseases need to continue their medications in order to improve myocardial contractility and to prevent the onset of major adverse cardiovascular events (MACEs), including heart failure. Some of the current life-saving medications may actually simultaneously expose patients to a higher risk of severe COVID-19. Angiotensinconverting enzyme 2 (ACE2), a key counter regulator of the renin-angiotensin system (RAS), is the main entry gate of SARS-CoV-2 into human host cells and an established drug target to prevent heart failure. In fact, ACE inhibitors, angiotensin II receptor blockers, and mineralocorticoid antagonists may augment ACE2 levels to protect organs from angiotensin II overload. Elevated ACE2 expression on the host cell surface might facilitate viral entrance, at the same time sudden nonadherence to these medications triggers MACEs. Hence, safety issues in the use of RAS inhibitors in COVID-19 patients with cardiac dysfunction remain an unsolved dilemma and need paramount attention. Although ACE2 generally plays an adaptive role in both healthy subjects and patients with systolic and/or diastolic dysfunction, we conducted a literature appraisal on its maladaptive role. Understanding the exact role of ACE2 in COVID-19 patients at risk of heart failure is needed to safely manage RAS inhibitors in frail and non-frail critically ill patients. Keywords ACE2 . Angiotensin II . RAS inhibitors . COVID-19 . Heart failure . SARS-CoV-2
Introduction * Iman Razeghian-Jahromi [email protected] * Vicenzo Lionetti [email protected] 1
Cardiovascular Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
2
Department of Cardiology, Zhongnan Hospital of Wuhan University, Wuhan, China
3
Shiraz Institute for Cancer Research, Shiraz University of Medical Sciences, Shiraz, Iran
4
Unit of Translational Critical Care Medicine, Institute of Life Sciences, Scuola Superiore Sant’Anna, Pisa, Italy
5
UOS Anesthesiology and Intensive Care Medicine, Fondazione Toscana G. Monasterio, Pisa, Italy
The outbreak of COVID-19: an unexpected Pandora’s box A few months after the emergence of the coronavirus disease (COVID-19) in China and during the outbreak peak in Italy [1], on 11 March 2020, the World Health Organization (WHO) claimed that the new viral disease was considered a pandemic. However, the global rate of severe acute respirato
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