ACE2, COVID-19, and Cardiovascular Damage
Several reports have noted COVID-19 is associated with cardiac involvement. In cohort studies of hospitalized patients with confirmed COVID-19, several patients presented with elevated troponin I, C-reactive protein, and N-terminal pro–B-type natriuretic peptide suggestive of myocardial injury (2,59,60). Anecdotal studies have reported patients presenting with cardiac magnetic resonance imagining−verified acute myopericarditis with systolic dysfunction masquerading as diffuse ST-segment elevation myocardial infarction with elevated cardiac markers in the absence of obstructive coronary disease (59). In a cohort study of 139 patients with COVID-19 hospitalized in Wuhan, China, 7.2% had acute myocardial injury, 8.7% had shock, and 16.7% had an arrhythmia (61). Of the observed patients, those with cardiac injury were found to have a high risk of death both from time of symptom onset and time of admission (60). As more epidemiological studies emerge from China, Italy, and other affected areas, more data will be available to elucidate the clinical presentation of patients and the cardiovascular damage associated with this novel coronavirus.
With regard to COVID-19, there are currently several clinical studies investigating the effects of RAS inhibition and ACE2 regulation. An ongoing study will assess the impact of ACE inhibitor and ARB treatment on the severity and prognosis of patients with COVID-19 (Hypertension in Patients Hospitalized With COVID-19 [HT-COVID19], NCT04318301; ACE Inhibitors, Angiotensin II Type-I Receptor Blockers and Severity of COVID-19 [CODIV-ACE], NCT04318418). Along these lines, there are 2 recently launched trials testing the effects of losartan among patients hospitalized with COVID-19 (Losartan for Patients With COVID-19 Requiring Hospitalization; NCT04312009) and those who are ambulatory (Losartan for Patients With COVID-19 Not Requiring Hospitalization; NCT04311177). Further studies have been launched to evaluate the effect of continuation versus replacement (Coronavirus [COVID-19] ACEi/ARB Investigation [CORONACION]; NCT04330300) or withdrawal (ACE Inhibitors or ARBs Discontinuation in Context of SARS-CoV-2 Pandemic [ACORES-2]; NCT04329195) of RAS inhibitors on the clinical outcomes in patients with cardiovascular disease and COVID-19. There is also an ongoing pilot study assessing the effects of rhACE2 treatment in patients with COVID-19 (Recombinant Human Angiotensin-converting Enzyme 2 [rhACE2] as a Treatment for Patients With COVID-19; NCT04287686). Currently, there is no data to support any conclusive effects of the use of RAS inhibitors in patients with COVID-19.