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Systematic review and meta-analysis of the clinical outcomes of ACEI/ARB in East-Asian patients with COVID-19. PLoS One 2023; 18:e0280280. [PMID: 36634085 PMCID: PMC9836310 DOI: 10.1371/journal.pone.0280280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 12/25/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND SARS-CoV-2 invades human cells and leads to COVID-19 by direct associating with angiotensin converting enzyme 2 (ACE2) receptors, the level of which may be increased by treatment with angiotensin-converting enzyme inhibitors (ACEIs) and/or angiotensin receptor blockers (ARBs). This meta-analysis aimed to explore the impact of ACEI/ARB treatment on the clinical outcomes of patients with COVID-19 infections among population in the East-Asia region. METHODS We collected clinical data published from January 2000 to May 2022 in the English databases including PubMed, Embase, and the Cochrane Library. Two reviewers independently screened and identified studies that met the prespecified criteria. Review Manager 5.3 software was used to perform the meta-analysis. RESULTS A total of 28 articles were included in this analysis. The results showed that patients who were prescribed with ACEI/ARB had a shorter duration of hospital stay [MD = -2.37, 95%CI (-3.59, -1.14), P = 0.000 2] and a lower mortality rate [OR = 0.61, 95% CI (0.52, 0.70), P<0.000 01] than patients who were not on ACEI/ARB. Furthermore, there was no statistically significant difference in disease severity [OR = 0.99, 95% CI (0.83, 1.17), P = 0.90] between individuals receiving ACEI/ARB or not. CONCLUSIONS This meta-analysis suggested that the use of ACEI/ARB was not associated with adverse clinical outcomes in East-Asian Covid-19 patients and a reduced mortality and shorter duration of hospital stay among East-Asian population (especially for female subjects) was found. Thus, ACEI/ARB should be continued in patients infected by Covid-19.
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Ruan Z, Li D, Hu Y, Qiu Z, Chen X. The Association of Renin-Angiotensin System Blockades and Mortality in Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease and Acute Respiratory Failure: A Retrospective Cohort Study. Int J Chron Obstruct Pulmon Dis 2022; 17:2001-2011. [PMID: 36072611 PMCID: PMC9444000 DOI: 10.2147/copd.s370817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 08/28/2022] [Indexed: 11/23/2022] Open
Abstract
Background Acute respiratory failure (ARF) is a common cause of admission to the intensive care unit (ICU) for patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). There is still a lack of effective interventions and treatments. ACE inhibitors (ACEI)/ angiotensin II receptor blockers (ARB) were effective in COPD patients. We aimed to study the effect of ACEI/ARB use on AECOPD combined with ARF and evaluate the effect of in-hospital continuation of medication. Methods We included patients with AECOPD and ARF from the Medical Information Bank for Intensive Care (MIMIC-III) database. MIMIC III is a large cohort database from Boston, USA. Patients were divided into two groups according to the use of ACEI/ARB before admission. Propensity score matching (PSM) was used to reduce potential bias between the two groups. Cox regression and Kaplan-Meier curves compared 30-day mortality in ACEI/ARB users and non-users. We also defined and analyzed the use of in-hospital ACEI/ARB. Multiple models were used to ensure the robustness of the findings. Subgroup analysis was used to analyze the variability between groups. Results A total of 544 patients were included in the original study. After PSM, 256 patients were included in the matched cohort. Multivariate Cox regression showed 30-day mortality was significantly lower in ACEI/ARB users compared with controls (HR = 0.50, 95% CI: 0.29–0.86, p= 0.013). In PSM and inverse probability-weighted models, the results are stable Continued in-hospital use of ACEI/ARB remains effective (HR 0.40, 95% CI 0.22–0.74, p = 0.003). Kaplan-Meier showed a significant difference in survival between the two groups. Conclusion This study found that pre-hospital ACEI/ARB use was associated with reduced mortality in patients with AECOPD and ARF.
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Affiliation(s)
- Zhishen Ruan
- The First Clinical College, Shandong Chinese Medical University, Ji Nan, People’s Republic of China
| | - Dan Li
- The First Clinical College, Shandong Chinese Medical University, Ji Nan, People’s Republic of China
| | - Yuanlong Hu
- The First Clinical College, Shandong Chinese Medical University, Ji Nan, People’s Republic of China
| | - Zhanjun Qiu
- The First Clinical College, Shandong Chinese Medical University, Ji Nan, People’s Republic of China
- Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Ji Nan, People’s Republic of China
- Correspondence: Zhanjun Qiu; Xianhai Chen, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Ji Nan, People’s Republic of China, Tel/Fax +86 0531 18660199889, Email ;
| | - Xianhai Chen
- The First Clinical College, Shandong Chinese Medical University, Ji Nan, People’s Republic of China
- Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Ji Nan, People’s Republic of China
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Minato T, Yamaguchi T, Hoshizaki M, Nirasawa S, An J, Takahashi S, Penninger JM, Imai Y, Kuba K. ACE2-like enzyme B38-CAP suppresses abdominal sepsis and severe acute lung injury. PLoS One 2022; 17:e0270920. [PMID: 35867642 PMCID: PMC9307200 DOI: 10.1371/journal.pone.0270920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 06/17/2022] [Indexed: 11/19/2022] Open
Abstract
Angiotensin-converting enzyme 2 (ACE2) is the carboxypeptidase to degrade angiotensin II (Ang II) to angiotensin 1–7 (Ang 1–7) and improves the pathologies of cardiovascular disease and acute respiratory distress syndrome (ARDS)/acute lung injury. B38-CAP is a bacteria-derived ACE2-like carboxypeptidase as potent as human ACE2 and ameliorates hypertension, heart failure and SARS-CoV-2-induced lung injury in mice. Recombinant B38-CAP is prepared with E. coli protein expression system more efficiently than recombinant soluble human ACE2. Here we show therapeutic effects of B38-CAP on abdominal sepsis- or acid aspiration-induced acute lung injury. ACE2 expression was downregulated in the lungs of mice with cecal ligation puncture (CLP)-induced sepsis or acid-induced lung injury thereby leading to upregulation of Ang II levels. Intraperitoneal injection of B38-CAP significantly decreased Ang II levels while upregulated angiotensin 1–7 levels. B38-CAP improved survival rate of the mice under sepsis. B38-CAP suppressed the pathologies of lung inflammation, improved lung dysfunction and downregulated elevated cytokine mRNA levels in the mice with acute lung injury. Thus, systemic treatment with an ACE2-like enzyme might be a potential therapeutic strategy for the patients with severe sepsis or ARDS.
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Affiliation(s)
- Takafumi Minato
- Department of Biochemistry and Metabolic Science, Akita University Graduate School of Medicine, Akita, Japan
| | - Tomokazu Yamaguchi
- Department of Biochemistry and Metabolic Science, Akita University Graduate School of Medicine, Akita, Japan
| | - Midori Hoshizaki
- Department of Biochemistry and Metabolic Science, Akita University Graduate School of Medicine, Akita, Japan
- Laboratory of Regulation of Intractable Infectious Diseases, National Institute of Biomedical Innovation, Health and Nutrition (NIBIOHN), Ibaraki, Osaka, Japan
| | - Satoru Nirasawa
- Biological Resources and Post-Harvest Division, Japan International Research Center for Agricultural Sciences, Tsukuba, Ibaraki, Japan
| | - Jianbo An
- Department of Biochemistry and Metabolic Science, Akita University Graduate School of Medicine, Akita, Japan
| | | | - Josef M. Penninger
- Department of Medical Genetics, Life Science Institute, University of British Columbia, Vancouver, BC, Canada
| | - Yumiko Imai
- Laboratory of Regulation of Intractable Infectious Diseases, National Institute of Biomedical Innovation, Health and Nutrition (NIBIOHN), Ibaraki, Osaka, Japan
| | - Keiji Kuba
- Department of Biochemistry and Metabolic Science, Akita University Graduate School of Medicine, Akita, Japan
- * E-mail:
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Fang Y, Zhang X. A propensity score-matching analysis of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker exposure on in-hospital mortality in patients with acute respiratory failure. Pharmacotherapy 2022; 42:387-396. [PMID: 35344607 PMCID: PMC9322533 DOI: 10.1002/phar.2677] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 03/06/2022] [Accepted: 03/07/2022] [Indexed: 02/05/2023]
Abstract
STUDY OBJECTIVE To explore the impact of pre-hospital ACEI and ARB exposure on the prognosis of ARF patients. DESIGN A single-center retrospective cohort study. SETTING Medical Information Mart for Intensive Care-III (MIMIC-III) database. PATIENTS The patients meeting ICD-9 code of acute respiratory failure were enrolled. INTERVENTION The primary exposure was the pre-hospital exposure of ACEI and ARB. MEASUREMENT AND MAIN RESULTS The primary outcome was in-hospital mortality. Multiple logistic regression analysis was conducted to determine the independent effect of ACEI/ARB exposure on mortality. Propensity score matching (PSM) method was adopted to reduce bias of the confounders. Subgroup analysis and sensitivity analysis were used to test the stability of the conclusion. 5335 adult ARF patients were enrolled. Mortality was significantly decreased in patients with ACEI/ARB exposure before and after PSM, and the adjusted odds ratio (OR) of ACEI/ARB exposure was 0.56 (95% CI 0.43-0.72). In the subgroup analysis, ACEI/ARB lost its protective effect in young subgroup, but no significant interaction was found between ACEI/ARB exposure and age (p = 0.082). The point estimation and lower 95% limit of E-value was 2.97 and 2.12. In sensitivity analysis, ACEI/ARB exposure showed similar effect in ARDS cohort, but no significantly difference was found in the MIMIC-IV database, which may be explained by small sample size of the ACEI/ARB group. CONCLUSIONS Among patients with acute respiratory failure, pre-hospital ACEI/ARB exposure was associated with better outcomes and acted as an independent factor. The relationship between ACEI/ARB and prognosis of ARF is worth investigating further.
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Affiliation(s)
- Yi‐Peng Fang
- Laboratory of Molecular CardiologyThe First Affiliated Hospital of Shantou University Medical CollegeShantouChina
- Laboratory of Medical Molecular ImagingThe First Affiliated Hospital of Shantou University Medical CollegeShantouChina
- Shantou University Medical CollegeShantouChina
| | - Xin Zhang
- Laboratory of Molecular CardiologyThe First Affiliated Hospital of Shantou University Medical CollegeShantouChina
- Laboratory of Medical Molecular ImagingThe First Affiliated Hospital of Shantou University Medical CollegeShantouChina
- Shantou University Medical CollegeShantouChina
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Krenn K, Tretter V, Kraft F, Ullrich R. The Renin-Angiotensin System as a Component of Biotrauma in Acute Respiratory Distress Syndrome. Front Physiol 2022; 12:806062. [PMID: 35498160 PMCID: PMC9043684 DOI: 10.3389/fphys.2021.806062] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 12/29/2021] [Indexed: 12/13/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a major concern in critical care medicine with a high mortality of over 30%. Injury to the lungs is caused not only by underlying pathological conditions such as pneumonia, sepsis, or trauma, but also by ventilator-induced lung injury (VILI) resulting from high positive pressure levels and a high inspiratory oxygen fraction. Apart from mechanical factors that stress the lungs with a specific physical power and cause volutrauma and barotrauma, it is increasingly recognized that lung injury is further aggravated by biological mediators. The COVID-19 pandemic has led to increased interest in the role of the renin-angiotensin system (RAS) in the context of ARDS, as the RAS enzyme angiotensin-converting enzyme 2 serves as the primary cell entry receptor for severe acute respiratory syndrome (SARS) coronavirus (CoV)-2. Even before this pandemic, studies have documented the involvement of the RAS in VILI and its dysregulation in clinical ARDS. In recent years, analytical tools for RAS investigation have made major advances based on the optimized precision and detail of mass spectrometry. Given that many clinical trials with pharmacological interventions in ARDS were negative, RAS-modifying drugs may represent an interesting starting point for novel therapeutic approaches. Results from animal models have highlighted the potential of RAS-modifying drugs to prevent VILI or treat ARDS. While these drugs have beneficial pulmonary effects, the best targets and application forms for intervention still have to be determined to avoid negative effects on the circulation in clinical settings.
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Tidal Volume-Dependent Activation of the Renin-Angiotensin System in Experimental Ventilator-Induced Lung Injury. Crit Care Med 2022; 50:e696-e706. [PMID: 35191411 DOI: 10.1097/ccm.0000000000005495] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Ventilator-induced lung injury (VILI) is a major contributor to morbidity and mortality in critically ill patients. Mechanical damage to the lungs is potentially aggravated by the activation of the renin-angiotensin system (RAS). This article describes RAS activation profiles in VILI and discusses the effects of angiotensin (Ang) 1-7 supplementation or angiotensin-converting enzyme (ACE) inhibition with captopril as protective strategies. DESIGN Animal study. SETTING University research laboratory. SUBJECTS C57BL/6 mice. INTERVENTIONS Anesthetized mice (n = 12-18 per group) were mechanically ventilated with low tidal volume (LVT, 6 mL/kg), high tidal volume (HVT, 15 mL/kg), or very high tidal volume (VHVT, 30 mL/kg) for 4 hours, or killed after 3 minutes (sham). Additional VHVT groups received infusions of 60 μg/kg/hr Ang 1-7 or a single dose of 100 mg/kg captopril. MEASUREMENTS AND MAIN RESULTS VILI was characterized by increased bronchoalveolar lavage fluid levels of interleukin (IL)-6, keratinocyte-derived cytokine, and macrophage inflammatory protein-2 (MIP2). The Ang metabolites in plasma measured with liquid chromatography tandem mass spectrometry showed a strong activation of the classical (Ang I, Ang II) and alternative RAS (Ang 1-7, Ang 1-5), with highest concentrations found in the HVT group. Although the lung-tissue ACE messenger RNA expression was unchanged, its protein expression showed a dose-dependent increase under mechanical ventilation. The ACE2 messenger RNA expression decreased in all ventilated groups, whereas ACE2 protein levels remained unchanged. Both captopril and Ang 1-7 led to markedly increased Ang 1-7 plasma levels, decreased Ang II levels, and ACE activity (Ang II/Ang I ratio), and effectively prevented VILI. CONCLUSIONS VILI is accompanied by a strong activation of the RAS. Based on circulating Ang metabolite levels and tissue expression of RAS enzymes, classical ACE-dependent and alternative RAS cascades were activated in the HVT group, whereas classical RAS activation prevailed with VHVT ventilation. Ang 1-7 or captopril protected from VILI primarily by modifying the systemic RAS profile.
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Shylesh C M S, V S A, S K K, P UD. Renin-angiotensin system modulators in COVID-19 patients with hypertension: friend or foe? Clin Exp Hypertens 2021; 44:1-10. [PMID: 34414841 DOI: 10.1080/10641963.2021.1963070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background: ACE2, a component of the non-classic renin-angiotensin system (RAS), acts as a functional receptor for severe acute respiratory syndrome coronavirus 2 (SARS-CoV 2) spike protein, which enables the entry of the virus into the host cells. Non-classical ACE2 is one of two types of ACE2 that has a protective effect on vascular and respiratory cells. RAS modulators like angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are among the first-line treatment for hypertensive patients. An upregulation in ACE2 levels with RAS modulators was observed in few preclinical studies, which raised concerns regarding possible increased infectivity among patients treated with RAS modulators.Method: For shortlisting the outcome effects, open-ended, English-restricted databases, published literature, and various clinical studies performed utilizing RAS modulators in COVID 19 patients were considered. Conclusion: Current evidence reveals no increased risk of COVID-19 infection among hypertensive patients on ACEIs/ARBs compared to other antihypertensive medications. Several studies have demonstrated no detrimental effects of RAS modulators on clinical severity, hospital/intensive care unit stay, ventilation and mortality. Hence, we can conclude that neither ARBs nor ACEIs treatment will cause any side effects or undesirable interactions in COVID-19 infected hypertensive patients.
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Affiliation(s)
- Shakhi Shylesh C M
- Department of Pharmacology, Amrita School of Pharmacy, Amrita Vishwa Vidyapeetham, AIMS Health Science Campus, Kochi, Kerala 682041
| | - Arya V S
- Department of Pharmacology, Amrita School of Pharmacy, Amrita Vishwa Vidyapeetham, AIMS Health Science Campus, Kochi, Kerala 682041
| | - Kanthlal S K
- Department of Pharmacology, Amrita School of Pharmacy, Amrita Vishwa Vidyapeetham, AIMS Health Science Campus, Kochi, Kerala 682041
| | - Uma Devi P
- Department of Pharmacology, Amrita School of Pharmacy, Amrita Vishwa Vidyapeetham, AIMS Health Science Campus, Kochi, Kerala 682041
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Vura NVRK, Sandooja R, Firoz A. To do or not to do: Angiotensin converting enzyme inhibitors/angiotensin receptor blocker in COVID-19 elderly patients. EXCLI JOURNAL 2021; 20:1145-1151. [PMID: 34345233 PMCID: PMC8326497 DOI: 10.17179/excli2021-3821] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 07/02/2021] [Indexed: 12/15/2022]
Affiliation(s)
| | - Rashi Sandooja
- Department of Internal Medicine, Cleveland Clinic Akron General, Akron, Ohio
| | - Amena Firoz
- Pondicherry Institute of Medical Sciences, India
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Abedtash A, Taherkhani M, Shokrishakib S, Nikpour S, Taherkhani A. Association between Angiotensin-Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers and Mortality in Patients with Hypertension Hospitalized with COVID-19. J Tehran Heart Cent 2021; 16:95-101. [PMID: 35633826 PMCID: PMC9108475 DOI: 10.18502/jthc.v16i3.8185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 06/20/2021] [Indexed: 11/26/2022] Open
Abstract
Background: Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) are common hypertension medications. We aimed to investigate the association between treatment with ACEIs/ARBs and disease severity and mortality in patients with hypertension hospitalized for coronavirus disease 2019 (COVID-19). Methods: Information from the medical records of 180 hospitalized patients diagnosed with COVID-19 infection admitted in 2020 to Loghman Hakim Hospital, Tehran, Iran, was collected. Clinical histories, drug therapies, radiological findings, hospital courses, and outcomes were analyzed in all the patients. The demographic and clinical characteristics of the patients were also analyzed, and the percentage of patients with hypertension taking ACEIs/ARBs was compared between survivors and nonsurvivors. Results: The study population consisted of 180 patients at mean±SD age of 67.76±18.72 years. Hypertension was reported in 72 patients (40.0%). Patients with hypertension were older than those without it (mean±SD age =72.35±12.09 y). Among those with hypertension, death occurred in 33 patients (45.8%), of whom 60.6% were men. Fifty-three patients (73.6%) with hypertension were on ACEIs/ARBs. The ACEIs/ARBs group had a significantly lower mortality rate than the non-ACEIs/ARBs group (37.7% vs 68.4%; OR: 0.192; 95% CI: 0.05-0.68; P=0.011). Conclusion: This single-center study found no harmful effects associated with ACEIs/ARBs treatment. Patients on ACEIs/ARBs had a lower rate of mortality and disease severity than the non-ACEIs/ARBs group. Our study supports the current guideline to continue ACEIs/ARBs in patients with hypertension.
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Affiliation(s)
| | - Maryam Taherkhani
- Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | | | - Shahriar Nikpour
- Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Adineh Taherkhani
- Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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Taheri M, Rad LM, Hussen BM, Nicknafs F, Sayad A, Ghafouri-Fard S. Evaluation of expression of VDR-associated lncRNAs in COVID-19 patients. BMC Infect Dis 2021; 21:588. [PMID: 34147082 PMCID: PMC8214050 DOI: 10.1186/s12879-021-06248-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 05/27/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) has been shown to cause serious health problems among them is the Acute Respiratory Distress syndrome (ARDS). Vitamin D receptor (VDR) signaling possibly partakes in the pathophysiology of this devastating complication. METHODS In the current project, we have appraised expression levels of VDR, CYP27B1 and a number of associated lncRNAs in the circulation of COVID-19 patients versus healthy subjects using real-time PCR method. RESULTS Expression of SNHG6 was considerably lower in COVID-19 patients compared with control subjects (Ratio of mean expression (RME) = 0.22, P value = 7.04E-05) and in both female and male COVID-19 patients compared with sex-matched unaffected individuals (RME = 0.32, P value = 0.04 and RME = 0.16, P value = 0.000679683, respectively). However, its expression was similar among ICU-hospitalized and non-ICU patients. Similarly, expression of SNHG16 was lower in in COVID-19 patients compared with controls (RME = 0.20, P value = 5.94E-05) and in both female and male patients compared with sex-matched controls (RME = 0.32, P value = 0.04 and RME = 0.14, P value = 0.000496435, respectively) with no significant difference among ICU-hospitalized and non-ICU hospitalized patients. Expression of VDR was lower in COVID-19 patients compared with controls (RME = 0.42, P value = 0.04) and in male patients compared with male controls (RME = 0.27, P value = 0.02). Yet, expression of VDR was statistically similar between female subgroups and between ICU-hospitalized and non-ICU hospitalized patients. Expression levels CYP27B, Linc00511 and Linc00346 were similar among COVID-19 patients and healthy subjects or between their subgroups. Significant correlations have been detected between expression levels of VDR, CYP27B and SNHG6, SNHG16, Linc00511 and Linc00346 lncRNAs both among COVID-19 patients and among healthy controls with the most significant ones being SNHG6 and SNHG16 (r = 0.74, P value = 3.26e-17 and r = 0.81, P = 1.54e-22, respectively). CONCLUSION Combination of transcript levels of VDR, CYP27B and SNHG6, SNHG16, Linc00511 and Linc00346 could differentiate patients from controls with AUC = 0.76, sensitivity = 0.62 and specificity = 0.81. The current data potentiate SNHG6, SNHG16 and VDR as possible contributors in COVID-19 infection but not in the severity of ARDS.
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Affiliation(s)
- Mohammad Taheri
- Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Lina Moallemi Rad
- Department of Molecular and Cell Biology, Faculty of Basic Sciences, University of Mazandaran, Babolsar, Iran
| | - Bashdar Mahmud Hussen
- Department of Pharmacognosy, College of Pharmacy, Hawler Medical University, Erbil, Iraq
| | - Fwad Nicknafs
- Department of Medical Genetics, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Arezou Sayad
- Department of Medical Genetics, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Soudeh Ghafouri-Fard
- Department of Medical Genetics, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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11
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Lee HW, Yoon CH, Jang EJ, Lee CH. Renin-angiotensin system blocker and outcomes of COVID-19: a systematic review and meta-analysis. Thorax 2021; 76:479-486. [PMID: 33504565 PMCID: PMC7843212 DOI: 10.1136/thoraxjnl-2020-215322] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 11/01/2020] [Accepted: 12/04/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND The association of ACE inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) with disease severity of patients with COVID-19 is still unclear. We conducted a systematic review and meta-analysis to investigate if ACEI/ARB use is associated with the risk of mortality and severe disease in patients with COVID-19. METHODS We searched all available clinical studies that included patients with confirmed COVID-19 who could be classified into an ACEI/ARB group and a non-ACEI/ARB group up until 4 May 2020. A meta-analysis was performed, and primary outcomes were all-cause mortality and severe disease. RESULTS ACEI/ARB use did not increase the risk of all-cause mortality both in meta-analysis for 11 studies with 12 601 patients reporting ORs (OR=0.52 (95% CI=0.37 to 0.72), moderate certainty of evidence) and in 2 studies with 8577 patients presenting HRs. For 12 848 patients in 13 studies, ACEI/ARB use was not related to an increased risk of severe disease in COVID-19 (OR=0.68 (95% CI=0.44 to 1.07); I2=95%, low certainty of evidence). CONCLUSIONS ACEI/ARB therapy was not associated with increased risk of all-cause mortality or severe manifestations in patients with COVID-19. ACEI/ARB therapy can be continued without concern of drug-related worsening in patients with COVID-19.
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Affiliation(s)
- Hyun Woo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Seoul Metropolitan Government Boramae Medical Center, Dongjak-gu, Seoul, The Republic of Korea
| | - Chang-Hwan Yoon
- Division of Cardiology, Department of Internal Medicine, Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, The Republic of Korea
| | - Eun Jin Jang
- Department of Information Statistics, Andong National University, Andong, Gyeongsangbuk-do, The Republic of Korea
| | - Chang-Hoon Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Jongno-gu, Seoul, The Republic of Korea
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12
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Oz M, Lorke DE, Kabbani N. A comprehensive guide to the pharmacologic regulation of angiotensin converting enzyme 2 (ACE2), the SARS-CoV-2 entry receptor. Pharmacol Ther 2021; 221:107750. [PMID: 33275999 PMCID: PMC7854082 DOI: 10.1016/j.pharmthera.2020.107750] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/18/2020] [Accepted: 11/19/2020] [Indexed: 02/06/2023]
Abstract
The recent emergence of coronavirus disease-2019 (COVID-19) as a global pandemic has prompted scientists to address an urgent need for defining mechanisms of disease pathology and treatment. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent for COVID-19, employs angiotensin converting enzyme 2 (ACE2) as its primary target for cell surface attachment and likely entry into the host cell. Thus, understanding factors that may regulate the expression and function of ACE2 in the healthy and diseased body is critical for clinical intervention. Over 66% of all adults in the United States are currently using a prescription drug and while earlier findings have focused on possible upregulation of ACE2 expression through the use of renin angiotensin system (RAS) inhibitors, mounting evidence suggests that various other widely administered drugs used in the treatment of hypertension, heart failure, diabetes mellitus, hyperlipidemias, coagulation disorders, and pulmonary disease may also present a varied risk for COVID-19. Specifically, we summarize mechanisms on how heparin, statins, steroids and phytochemicals, besides their established therapeutic effects, may also interfere with SARS-CoV-2 viral entry into cells. We also describe evidence on the effect of several vitamins, phytochemicals, and naturally occurring compounds on ACE2 expression and activity in various tissues and disease models. This comprehensive review aims to provide a timely compendium on the potential impact of commonly prescribed drugs and pharmacologically active compounds on COVID-19 pathology and risk through regulation of ACE2 and RAS signaling.
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Key Words
- adam17, a disintegrin and metalloprotease 17
- ace, angiotensin i converting enzyme
- ace-inh., angiotensin i converting enzyme inhibitor
- ampk, amp-activated protein kinase
- ang-ii, angiotensin ii
- arb, angiotensin ii type 1-receptor blocker
- ards, acute respiratory distress syndrome
- at1-r, angiotensin ii type 1-receptor
- βarb, β-adrenergic receptor blockers
- bk, bradykinin
- ccb, calcium channel blockers
- ch25h, cholesterol-25-hydroxylase
- copd, chronic obstructive lung disease
- cox, cyclooxygenase
- covid-19, coronavirus disease-2019
- dabk, [des-arg9]-bradykinin
- erk, extracellular signal-regulated kinase
- 25hc, 25-hydroxycholesterol
- hs, heparan sulfate
- hspg, heparan sulfate proteoglycan
- ibd, inflammatory bowel disease
- map, mitogen-activated protein
- mers, middle east respiratory syndrome
- mrb, mineralocorticoid receptor blocker
- nos, nitric oxide synthase
- nsaid, non-steroid anti-inflammatory drug
- ras, renin-angiotensin system
- sars-cov, severe acute respiratory syndrome coronavirus
- sh, spontaneously hypertensive
- s protein, spike protein
- sirt1, sirtuin 1
- t2dm, type 2 diabetes mellitus
- tcm, traditional chinese medicine
- tmprss2, transmembrane protease, serine 2
- tnf, tumor necrosis factor
- ufh, unfractionated heparin
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Affiliation(s)
- Murat Oz
- Department of Pharmacology and Therapeutics, Faculty of Pharmacy, Kuwait University, Safat 13110, Kuwait.
| | - Dietrich Ernst Lorke
- Department of Anatomy and Cellular Biology, College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, United Arab Emirates; Center for Biotechnology, Khalifa University of Science and Technology, Abu Dhabi, United Arab Emirates
| | - Nadine Kabbani
- School of Systems Biology, George Mason University, Fairfax, VA 22030, USA
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13
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Martin JH, Head R. A pharmacological framework for integrating treating the host, drug repurposing and the damage response framework in COVID-19. Br J Clin Pharmacol 2021; 87:875-885. [PMID: 32959913 PMCID: PMC7646655 DOI: 10.1111/bcp.14551] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 08/27/2020] [Accepted: 09/02/2020] [Indexed: 12/19/2022] Open
Abstract
With any new disease a framework for the development of preventative or treatment therapeutics is key; the absence of such in COVID-19 has enabled ineffective and potentially unsafe treatments to be taken up by governments and clinicians desperate to have options for patients. As we still have few therapies and nil vaccines yet available, the void of a clear framework for research and practice is increasingly clear. We describe a framework that has been used to prioritise therapeutic research in previous pandemics which could be used to progress clinical pharmacology and therapeutics research in COVID-19. This is particularly relevant as discussion has already moved on from antiviral therapeutics to delineating the treatment of the host from treatment and elimination of the infective agent. Focussing on the host brings together three concepts: host treatment, the damage response framework and therapeutic repurposing. The integration of these three areas plays to the traditional strength of pharmaceuticals in providing a period of stabilization to permit time for the development of novel antiviral drugs and vaccines. In integrating approaches to repurposing, host treatment and damage response we identified three key properties that a potentially effective repurposed drug must possess by way of a framework. There must be homology, i.e., the same or similar relation with the pathogenesis of the disease, ideally targeted to the conserved pathophysiological outcomes of the viral attack; there must be a defined locus within the spectrum to prevention to severe disease and the framework must draw upon the historical dose and safety experience of the repurposed drug. To illustrate, we have mapped therapeutics that impact upon a key dysregulated pathway in COVID-19 - the renin angiotensin system - using this approach. Collectively this type of analysis reveals the importance of existing data (repurposed information and administrative observational data) and the importance of the details of the known pathophysiological response to viruses in approaches to treating the host.
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Affiliation(s)
- Jennifer H. Martin
- Centre for Human Drug Repurposing and Medicines ResearchUniversity of NewcastleNSW2305Australia
| | - Richard Head
- University of South AustraliaSouth AustraliaAustralia
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14
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COVID-19 pandemic: a glimpse into newly diagnosed hypertensive patients. Cardiovasc Endocrinol Metab 2021; 10:1-2. [PMID: 33629040 PMCID: PMC7540198 DOI: 10.1097/xce.0000000000000234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 08/09/2020] [Indexed: 11/26/2022]
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15
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Gul R, Kim UH, Alfadda AA. Renin-angiotensin system at the interface of COVID-19 infection. Eur J Pharmacol 2021; 890:173656. [PMID: 33086029 PMCID: PMC7568848 DOI: 10.1016/j.ejphar.2020.173656] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 10/07/2020] [Accepted: 10/16/2020] [Indexed: 11/30/2022]
Abstract
Angiotensin-converting enzyme 2 (ACE2) has been recognized as a potential entry receptor for SARS-CoV-2 infection. Binding of SARS-CoV-2 to ACE2 allows engagement with pulmonary epithelial cells and pulmonary infection with the virus. ACE2 is an essential component of renin-angiotensin system (RAS), and involved in promoting protective effects to counter-regulate angiotensin (Ang) II-induced pathogenesis. The use of angiotensin receptor blockers (ARBs) and ACE inhibitors (ACEIs) was implicitly negated during the early phase of COVID-19 pandemic, considering the role of these antihypertensive agents in enhancing ACE2 expression thereby promoting the susceptibility to SARS-CoV-2. However, no clinical data has supported this assumption, but indeed evidence demonstrates that ACEIs and ARBs, besides their cardioprotective effects in COVID-19 patients with cardiovascular diseases, might also be beneficial in acute lung injuries by preserving the ACE2 function and switching the balance from deleterious ACE/Ang II/AT1 receptor axis towards a protective ACE2/Ang (1-7)/Mas receptor axis.
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Affiliation(s)
- Rukhsana Gul
- Obesity Research Center, College of Medicine, King Saud University, P.O. Box 2925, Riyadh, 11461, Saudi Arabia.
| | - Uh-Hyun Kim
- Department of Biochemistry & National Creative Research Laboratory for Ca(2+) Signaling, Chonbuk National University Medical School, Jeonju, 54907, Republic of Korea
| | - Assim A Alfadda
- Obesity Research Center, College of Medicine, King Saud University, P.O. Box 2925, Riyadh, 11461, Saudi Arabia; Department of Medicine, College of Medicine, King Saud University, PO Box 2925, Riyadh, 11461, Saudi Arabia; Strategic Center for Diabetes Research, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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16
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Nejat R, Sadr AS. Are losartan and imatinib effective against SARS-CoV2 pathogenesis? A pathophysiologic-based in silico study. In Silico Pharmacol 2020; 9:1. [PMID: 33294307 PMCID: PMC7716628 DOI: 10.1007/s40203-020-00058-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 11/04/2020] [Indexed: 12/13/2022] Open
Abstract
Proposing a theory about the pathophysiology of cytokine storm in COVID19, we were to find the potential drugs to treat this disease and to find any effect of these drugs on the virus infectivity through an in silico study. COVID-19-induced ARDS is linked to a cytokine storm phenomenon not explainable solely by the virus infectivity. Knowing that ACE2, the hydrolyzing enzyme of AngII and SARS-CoV2 receptor, downregulates when the virus enters the host cells, we hypothesize that hyperacute AngII upregulation is the eliciting factor of this ARDS. We were to validate this theory through reviewing previous studies to figure out the role of overzealous activation of AT1R in ARDS. According to this theory losartan may attenuate ARDS in this disease. Imatinib, has previously been elucidated to be promising in modulating lung inflammatory reactions and virus infectivity in SARS and MERS. We did an in silico study to uncover any probable other unconsidered inhibitory effects of losartan and imatinib against SARS-CoV2 pathogenesis. Reviewing the literature, we could find that over-activation of AT1R could explain precisely the mechanism of cytokine storm in COVID19. Our in silico study revealed that losartan and imatinib could probably: (1) decline SARS-CoV2 affinity to ACE2. (2) inhibit the main protease and furin, (3) disturb papain-like protease and p38MAPK functions. Our reviewing on renin-angiotensin system showed that overzealous activation of AT1R by hyper-acute excess of AngII due to acute downregulation of ACE2 by SARS-CoV2 explains precisely the mechanism of cytokine storm in COVID-19. Besides, based on our in silico study we concluded that losartan and imatinib are promising in COVID19.
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Affiliation(s)
- Reza Nejat
- Department of Anesthesiology and Critical Care Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ahmad Shahir Sadr
- Bioinformatics Research Center, Cheragh Medical Institute and Hospital, Kabul, Afghanistan
- Department of Computer Science, Faculty of Mathematical Sciences, Shahid Beheshti University, Tehran, Iran
- Department of Phytochemistry, Medicinal Plants and Drugs Research Institute, Shahid Beheshti University, Tehran, Iran
- School of Biological Sciences, Institute for Research in Fundamental Sciences (IPM), Tehran, Iran
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17
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Hasan SS, Kow CS, Hadi MA, Zaidi STR, Merchant HA. Mortality and Disease Severity Among COVID-19 Patients Receiving Renin-Angiotensin System Inhibitors: A Systematic Review and Meta-analysis. Am J Cardiovasc Drugs 2020; 20:571-590. [PMID: 32918209 PMCID: PMC7486167 DOI: 10.1007/s40256-020-00439-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The use of renin-angiotensin system (RAS) inhibitors, including angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), was alleged to cause a more severe course of novel coronavirus disease 2019 (COVID-19). METHODS We systematically reviewed the published studies to assess the association of RAS inhibitors with mortality as well as disease severity in COVID-19 patients. A systematic literature search was performed to retrieve relevant original studies investigating mortality and severity (severe/critical disease) in COVID-19 patients with and without exposure to RAS inhibitors. RESULTS A total of 59 original studies were included for qualitative synthesis. Twenty-four studies that reported adjusted effect sizes (24 studies reported mortality outcomes and 16 studies reported disease severity outcomes), conducted in RAS inhibitor-exposed and unexposed groups, were pooled in random-effects models to estimate overall risk. Quality assessment of studies revealed that most of the studies included were of fair quality. The use of an ACEI/ARB in COVID-19 patients was significantly associated with lower odds (odds ratio [OR] = 0.73, 95% confidence interval [CI] 0.56-0.95; n = 18,749) or hazard (hazard ratio [HR] = 0.75, 95% CI 0.60-0.95; n = 26,598) of mortality compared with non-use of ACEI/ARB. However, the use of an ACEI/ARB was non-significantly associated with lower odds (OR = 0.91, 95% CI 0.75-1.10; n = 7446) or hazard (HR = 0.73, 95% CI 0.33-1.66; n = 6325) of developing severe/critical disease compared with non-use of an ACEI/ARB. DISCUSSION Since there was no increased risk of harm, the use of RAS inhibitors for hypertension and other established clinical indications can be maintained in COVID-19 patients.
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Affiliation(s)
- Syed Shahzad Hasan
- Department of Pharmacy, University of Huddersfield, Huddersfield, HD1 3DH, UK.
| | - Chia Siang Kow
- School of Postgraduate Studies, International Medical University, Kuala Lumpur, 57000, Malaysia
| | - Muhammad Abdul Hadi
- Institute of Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Syed Tabish Razi Zaidi
- School of Healthcare, University of Leeds, Leeds, LS2 9JT, UK
- Leeds Teaching Hospitals NHS Trust, Leeds, LS2 9JT, UK
| | - Hamid A Merchant
- Department of Pharmacy, University of Huddersfield, Huddersfield, HD1 3DH, UK
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18
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Renin-Angiotensin System Inhibitors in COVID-19: Current Concepts. Int J Hypertens 2020; 2020:1025913. [PMID: 33145103 PMCID: PMC7596458 DOI: 10.1155/2020/1025913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 09/17/2020] [Indexed: 11/29/2022] Open
Abstract
The functional receptor to SARS-CoV-2, the virus responsible for the coronavirus disease 2019 (COVID-19) pandemic, is angiotensin-converting enzyme-2 (ACE-2), the same enzyme that physiologically counters the renin-angiotensin system (RAS) activation. Some researchers have questioned RAS inhibitors' safety in COVID-19 patients since these drugs have demonstrated an increase in ACE-2 expression in preclinical studies; therefore, they may facilitate viral invasion. On the contrary, others have hypothesized a protective role of RAS inhibitors against COVID-19-associated lung injury. Overall, the data are grossly inadequate to reach any conclusion since no human trials have yet evaluated the effects of RAS inhibitors in COVID-19. We review the current data and pathophysiological mechanisms behind this intriguing interplay between the RAS inhibitors and the COVID-19.
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19
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Hrenak J, Simko F. Renin-Angiotensin System: An Important Player in the Pathogenesis of Acute Respiratory Distress Syndrome. Int J Mol Sci 2020; 21:ijms21218038. [PMID: 33126657 PMCID: PMC7663767 DOI: 10.3390/ijms21218038] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 10/24/2020] [Accepted: 10/26/2020] [Indexed: 02/08/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is characterized by massive inflammation, increased vascular permeability and pulmonary edema. Mortality due to ARDS remains very high and even in the case of survival, acute lung injury can lead to pulmonary fibrosis. The renin-angiotensin system (RAS) plays a significant role in these processes. The activities of RAS molecules are subject to dynamic changes in response to an injury. Initially, increased levels of angiotensin (Ang) II and des-Arg9-bradykinin (DABK), are necessary for an effective defense. Later, augmented angiotensin converting enzyme (ACE) 2 activity supposedly helps to attenuate inflammation. Appropriate ACE2 activity might be decisive in preventing immune-induced damage and ensuring tissue repair. ACE2 has been identified as a common target for different pathogens. Some Coronaviruses, including SARS-CoV-2, also use ACE2 to infiltrate the cells. A number of questions remain unresolved. The importance of ACE2 shedding, associated with the release of soluble ACE2 and ADAM17-mediated activation of tumor necrosis factor-α (TNF-α)-signaling is unclear. The roles of other non-classical RAS-associated molecules, e.g., alamandine, Ang A or Ang 1-9, also deserve attention. In addition, the impact of established RAS-inhibiting drugs on the pulmonary RAS is to be elucidated. The unfavorable prognosis of ARDS and the lack of effective treatment urge the search for novel therapeutic strategies. In the context of the ongoing SARS-CoV-2 pandemic and considering the involvement of humoral disbalance in the pathogenesis of ARDS, targeting the renin-angiotensin system and reducing the pathogen's cell entry could be a promising therapeutic strategy in the struggle against COVID-19.
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Affiliation(s)
- Jaroslav Hrenak
- Department of Cardiovascular Surgery, Inselspital – University Hospital of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland;
- Institute of Pathophysiology, Faculty of Medicine, Comenius University, Sasinkova 4, 811 08 Bratislava, Slovak
| | - Fedor Simko
- Institute of Pathophysiology, Faculty of Medicine, Comenius University, Sasinkova 4, 811 08 Bratislava, Slovak
- 3rd Department of Internal Medicine, Faculty of Medicine, Comenius University, Limbova 5, 833 05 Bratislava, Slovak
- Institute of Experimental Endocrinology, Biomedical Research Center, Slovak Academy of Sciences, Dúbravská cesta 9, 845 05 Bratislava, Slovak
- Correspondence:
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20
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Gao YL, Du Y, Zhang C, Cheng C, Yang HY, Jin YF, Duan GC, Chen SY. Role of Renin-Angiotensin System in Acute Lung Injury Caused by Viral Infection. Infect Drug Resist 2020; 13:3715-3725. [PMID: 33116692 PMCID: PMC7585866 DOI: 10.2147/idr.s265718] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 09/12/2020] [Indexed: 12/14/2022] Open
Abstract
The renin-angiotensin system (RAS) is the most important regulatory system of electrolyte homeostasis and blood pressure and acts through angiotensin-converting enzyme (ACE)/angiotensin II (Ang II)/Ang II type 1 (AT1) receptor axis and angiotensin-converting enzyme 2 (ACE2)/angiotensin (1-7)/MAS receptor axis. RAS dysfunction is related to the occurrence and development of acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) and causes a serious prognosis and even death. ALI/ARDS can be induced by various ways, one of which is viral infections, such as SARS-CoV, SARS-CoV-2, H5N1, H7N9, and EV71. This article reviews the specific mechanism on how RAS dysfunction affects ALI/ARDs caused by viral infections. SARS-CoV and SARS-CoV-2 enter the host cells by binding with ACE2. H5N1 and H7N9 avian influenza viruses reduce the ACE2 level in the body, and EV71 increases Ang II concentration. Treatment with angiotensin-converting enzyme inhibitor and angiotensin AT1 receptor blocker can alleviate ALI/ARDS symptoms. This review provides suggestions for the treatment of lung injury caused by viral infections.
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Affiliation(s)
- Yan-Lei Gao
- Department of Epidemiology, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Yue Du
- Department of Epidemiology, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Chao Zhang
- Department of Epidemiology, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Cheng Cheng
- Department of Epidemiology, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Hai-Yan Yang
- Department of Epidemiology, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Yue-Fei Jin
- Department of Epidemiology, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Guang-Cai Duan
- Department of Epidemiology, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Shuai-Yin Chen
- Department of Epidemiology, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
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21
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Bavishi C, Maddox TM, Messerli FH. Coronavirus Disease 2019 (COVID-19) Infection and Renin Angiotensin System Blockers. JAMA Cardiol 2020; 5:745-747. [PMID: 32242890 DOI: 10.1001/jamacardio.2020.1282] [Citation(s) in RCA: 163] [Impact Index Per Article: 40.8] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Chirag Bavishi
- Division of Cardiology, Warren Alpert Medical School of Brown University, Lifespan Cardiovascular Institute, Providence, Rhode Island
| | - Thomas M Maddox
- Division of Cardiology, Washington University School of Medicine in St Louis, St Louis, Missouri.,Healthcare Innovation Lab, BJC HealthCare, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Franz H Messerli
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland.,Jagiellonian University, Kraków, Poland.,Division of Cardiology, Mount Sinai Health Medical Center, Icahn School of Medicine, New York, New York
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22
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Edmonston DL, South AM, Sparks MA, Cohen JB. Coronavirus Disease 2019 and Hypertension: The Role of Angiotensin-Converting Enzyme 2 and the Renin-Angiotensin System. Adv Chronic Kidney Dis 2020; 27:404-411. [PMID: 33308506 PMCID: PMC7334971 DOI: 10.1053/j.ackd.2020.07.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/30/2020] [Accepted: 07/02/2020] [Indexed: 02/07/2023]
Abstract
Hypertension emerged from early reports as a potential risk factor for worse outcomes for persons with coronavirus disease 2019 (COVID-19). Among the putative links between hypertension and COVID-19 is a key counter-regulatory component of the renin-angiotensin system (RAS): angiotensin-converting enzyme 2 (ACE2). ACE2 facilitates entry of severe acute respiratory syndrome coronavirus 2, the virus responsible for COVID-19, into host cells. Because RAS inhibitors have been suggested to increase ACE2 expression, health-care providers and patients have grappled with the decision of whether to discontinue these medications during the COVID-19 pandemic. However, experimental models of analogous viral pneumonias suggest RAS inhibitors may exert protective effects against acute lung injury. We review how RAS and ACE2 biology may affect outcomes in COVID-19 through pulmonary and other systemic effects. In addition, we briefly detail the data for and against continuation of RAS inhibitors in persons with COVID-19 and summarize the current consensus recommendations from select specialty organizations.
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23
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Quesada-Gomez JM, Entrenas-Castillo M, Bouillon R. Vitamin D receptor stimulation to reduce acute respiratory distress syndrome (ARDS) in patients with coronavirus SARS-CoV-2 infections: Revised Ms SBMB 2020_166. J Steroid Biochem Mol Biol 2020; 202:105719. [PMID: 32535032 PMCID: PMC7289092 DOI: 10.1016/j.jsbmb.2020.105719] [Citation(s) in RCA: 96] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 05/25/2020] [Accepted: 06/07/2020] [Indexed: 02/06/2023]
Abstract
Coronavirus infection is a serious health problem awaiting an effective vaccine and/or antiviral treatment. The major complication of coronavirus disease 2019 (COVID-19), the Acute Respiratory Distress syndrome (ARDS), is due to a variety of mechanisms including cytokine storm, dysregulation of the renin-angiotensin system, neutrophil activation and increased (micro)coagulation. Based on many preclinical studies and observational data in humans, ARDS may be aggravated by vitamin D deficiency and tapered down by activation of the vitamin D receptor. Several randomized clinical trials using either oral vitamin D or oral Calcifediol (25OHD) are ongoing. Based on a pilot study, oral calcifediol may be the most promising approach. These studies are expected to provide guidelines within a few months.
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Affiliation(s)
- Jose Manuel Quesada-Gomez
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC). Hospital Universitario Reina Sofía, Universidad de Córdoba, Fundación Progreso y Salud, Avda. Menéndez Pidal s/n, 14004, Córdoba, Spain; CIBER de Fragilidad y Envejecimiento Saludable (CIBERFES), Spain
| | - Marta Entrenas-Castillo
- UGC de Neumología. Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC). Hospital Universitario Reina Sofía, Universidad de Córdoba, Avda Menéndez Pidal s/n, 14004, Córdoba, Spain
| | - Roger Bouillon
- Department of Chronic Diseases, Metabolism and Ageing, Laboratory of Clinical and Experimental Endocrinology, KU Leuven, Herestraat, ON 1/902, 3000, Leuven, Belgium.
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24
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de la Cruz A, Ashraf S, Vittorio TJ, Bella JN. COVID-19 and renin-angiotensin system modulators: what do we know so far? Expert Rev Cardiovasc Ther 2020; 18:743-748. [PMID: 32842817 DOI: 10.1080/14779072.2020.1814143] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION The novel coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory system-coronavirus-2 (SARS-CoV-2), is an important medical problem worldwide. Increased risk of mortality has been reported in patients with cardiovascular disease, such as hypertension (HTN). SARS-CoV-2 invades the pulmonary alveolar epithelial cells by binding to the surface receptor, angiotensin-converting enzyme 2 (ACE2). Renin-angiotensin system (RAS) modulators can increase levels of ACE2. Thus, concerns have been raised regarding an increased risk of severe COVID-19 infection in patients receiving RAS antagonists. AREAS COVERED We reviewed current literature about the potential association between the utilization of RAS inhibitors, namely angiotensin-converting enzyme inhibitors (ACE-inhibitors) and angiotensin-receptor blockers (ARBs) and likelihood of developing severe COVID-19 infection and whether or not continuation of these medications is appropriate in patients with active disease. EXPERT OPINION The joint statement from the American College of Cardiology (ACC), American Heart Association (AHA), European Society of Cardiology (ESC) and Heart Failure Society of America (HFSA), strongly recommends that physicians should not initiate or withdraw their usual RAS-related treatments (ACE-inhibitor/ARB) to COVID-19 infected patients with cardiovascular disease. The decision should be made based upon each patient's clinical presentation and hemodynamic status.
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Affiliation(s)
- Angel de la Cruz
- Department of Internal Medicine, BronxCare Health System Bronx, NY, USA
| | - Shoaib Ashraf
- Department of Internal Medicine, BronxCare Health System Bronx, NY, USA
| | - Timothy J Vittorio
- Department of Cardiology, BronxCare Health System , Bronx, NY, USA.,Department of Cardiology, Icahn School of Medicine at Mount Sinai , New York, NY, USA
| | - Jonathan N Bella
- Department of Cardiology, BronxCare Health System , Bronx, NY, USA.,Department of Cardiology, Icahn School of Medicine at Mount Sinai , New York, NY, USA
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25
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Chaudhri I, Koraishy FM, Bolotova O, Yoo J, Marcos LA, Taub E, Sahib H, Bloom M, Ahmad S, Skopicki H, Mallipattu SK. Outcomes Associated with the Use of Renin-Angiotensin-Aldosterone System Blockade in Hospitalized Patients with SARS-CoV-2 Infection. ACTA ACUST UNITED AC 2020; 1:801-809. [PMID: 33345195 DOI: 10.34067/kid.0003792020] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background Data regarding the benefits or harm associated with the continuation of Angiotensin Converting Enzyme Inhibitors (ACEIs) and Angiotensin II Receptor Blockers (ARBs), especially the impact on inflammation, in hypertensive, hospitalized patients with COVID-19 in the United States is unclear. Methods This is a single-center cohort study of sequentially hospitalized patients with COVID-19 at Stony Brook University Medical Center from March 7, 2020 to April 1, 2020, inclusive of these dates. Data collection included history of known comorbidities, medications, vital signs and laboratory values (admission and during the hospitalization). Outcomes include inflammatory burden (composite scores for multiple markers of inflammation), acute kidney injury (AKI), admission to the intensive care unit (ICU), need for invasive mechanical ventilation, and mortality. Results Of the 300 patients in the study cohort, 80 patients (26.7%) had history of ACEI or ARB use prior to admission, with 61.3% (49/80) of these patients continuing the medications during hospitalization. Multivariable analysis revealed that the history of ACEI or ARB use prior to hospitalization was not associated with worse outcomes. In addition, the continuation of these agents during hospitalization was not associated with an increase in adverse outcomes and predicted fewer ICU admissions (OR=0.25, 0.08-0.81) with a decrease in the severity of inflammatory burden (peak CRP (6.9±3.1mg/dl, p=0.03) and peak inflammation score (2.3±1.1unit reduction, p=0.04)). Conclusion Use of ACEI or ARBs prior to hospitalization was not associated with adverse outcomes in COVID-19 and the therapeutic benefits of continuing ACEI or ARB in hospitalized patients with COVID-19 was not offset by adverse outcomes.
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Affiliation(s)
- Imran Chaudhri
- Department of Medicine, Stony Brook University, Stony Brook, NY
| | | | - Olena Bolotova
- Department of Medicine, Stony Brook University, Stony Brook, NY
| | - Jeanwoo Yoo
- Department of Medicine, Stony Brook University, Stony Brook, NY
| | - Luis A Marcos
- Department of Medicine, Stony Brook University, Stony Brook, NY
| | - Erin Taub
- Department of Medicine, Stony Brook University, Stony Brook, NY
| | - Haseena Sahib
- Department of Medicine, Stony Brook University, Stony Brook, NY
| | - Michelle Bloom
- Department of Medicine, Stony Brook University, Stony Brook, NY
| | - Sahar Ahmad
- Department of Medicine, Stony Brook University, Stony Brook, NY
| | - Hal Skopicki
- Department of Medicine, Stony Brook University, Stony Brook, NY
| | - Sandeep K Mallipattu
- Department of Medicine, Stony Brook University, Stony Brook, NY.,Renal Section, Northport VA Medical Center, Northport, NY
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26
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Stancioiu F, Papadakis GZ, Kteniadakis S, Izotov BN, Coleman MD, Spandidos DA, Tsatsakis A. A dissection of SARS‑CoV2 with clinical implications (Review). Int J Mol Med 2020; 46:489-508. [PMID: 32626922 PMCID: PMC7307812 DOI: 10.3892/ijmm.2020.4636] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 06/09/2020] [Indexed: 02/06/2023] Open
Abstract
We are being confronted with the most consequential pandemic since the Spanish flu of 1918‑1920 to the extent that never before have 4 billion people quarantined simultaneously; to address this global challenge we bring to the forefront the options for medical treatment and summarize SARS‑CoV2 structure and functions, immune responses and known treatments. Based on literature and our own experience we propose new interventions, including the use of amiodarone, simvastatin, pioglitazone and curcumin. In mild infections (sore throat, cough) we advocate prompt local treatment for the naso‑pharynx (inhalations; aerosols; nebulizers); for moderate to severe infections we propose a tried‑and‑true treatment: the combination of arginine and ascorbate, administered orally or intravenously. The material is organized in three sections: i) Clinical aspects of COVID‑19; acute respiratory distress syndrome (ARDS); known treatments; ii) Structure and functions of SARS‑CoV2 and proposed antiviral drugs; iii) The combination of arginine‑ascorbate.
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Affiliation(s)
| | | | | | - Boris Nikovaevich Izotov
- Department of Analytical and Forensic Medical Toxicology, Sechenov University, 119991 Moscow, Russia
| | - Michael D. Coleman
- School of Life and Health Sciences, Aston University, B4 7ET Birmingham, UK
| | | | - Aristidis Tsatsakis
- Department of Analytical and Forensic Medical Toxicology, Sechenov University, 119991 Moscow, Russia
- Department of Forensic Sciences and Toxicology, Faculty of Medicine, University of Crete, 71003 Heraklion, Greece
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27
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Sieńko J, Kotowski M, Bogacz A, Lechowicz K, Drożdżal S, Rosik J, Sietnicki M, Sieńko M, Kotfis K. COVID-19: The Influence of ACE Genotype and ACE-I and ARBs on the Course of SARS-CoV-2 Infection in Elderly Patients. Clin Interv Aging 2020; 15:1231-1240. [PMID: 32764907 PMCID: PMC7382582 DOI: 10.2147/cia.s261516] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 06/19/2020] [Indexed: 12/23/2022] Open
Abstract
Since the beginning of 2020, the whole world has been struggling with the pandemic of Coronavirus Disease 2019 (COVID-19) caused by a novel coronavirus SARS-CoV-2. The SARS-CoV-2 infection depends on ACE2, TMPRSS2, and CD147, which are expressed on host cells. Several studies suggest that some single nucleotide polymorphisms (SNPs) of ACE2 might be a risk factor of COVID-19 infection. Genotypes affect ACE2 structure, its serum concentration, and levels of circulating angiotensin (1-7). Moreover, there is evidence that ACE genotype affects the outcomes of acute respiratory distress syndrome (ARDS) treatment, the most severe consequence of SARS-CoV-2 infection. COVID-19 morbidity, infection course, and mortality might depend on ACE D allele frequency. The aim of this narrative review was to analyze and identify the mechanisms of ACE-I and ARBs with particular emphasis on angiotensin receptors and their polymorphism in the light of COVID-19 pandemic as these medications are commonly prescribed to elderly patients. There is no direct evidence yet for ACE-I or ARBs in the treatment of COVID-19. However, for those already taking these medications, both the European Society of Cardiology and the American College of Cardiology recommend continuing the treatment, because at present, there is no clear clinical or scientific evidence to justify the discontinuation of ACE-I or ARBs. Individualized treatment decisions should be based on the clinical condition and co-morbidities of each patient.
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Affiliation(s)
- Jerzy Sieńko
- Department of General Surgery and Transplantology, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | - Maciej Kotowski
- Department of General Surgery and Transplantology, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | - Anna Bogacz
- Department of Pharmacology and Phytochemistry, Institute of Natural Fibers and Medicinal Plants, Poznan, Poland
| | - Kacper Lechowicz
- Department of Anaesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | - Sylwester Drożdżal
- Department of Pharmacokinetics and Monitored Therapy, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | - Jakub Rosik
- Department of Physiology, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | - Marek Sietnicki
- Department of Civil Engineering and Architecture, West Pomeranian University of Technology in Szczecin, Szczecin, Poland
| | - Magdalena Sieńko
- Department of Pediatrics, Endocrinology, Diabetology, Metabolic Diseases and Cardiology, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | - Katarzyna Kotfis
- Department of Anaesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University in Szczecin, Szczecin, Poland
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28
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Ingraham NE, Barakat AG, Reilkoff R, Bezdicek T, Schacker T, Chipman JG, Tignanelli CJ, Puskarich MA. Understanding the renin-angiotensin-aldosterone-SARS-CoV axis: a comprehensive review. Eur Respir J 2020; 56:13993003.00912-2020. [PMID: 32341103 PMCID: PMC7236830 DOI: 10.1183/13993003.00912-2020] [Citation(s) in RCA: 108] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 04/18/2020] [Indexed: 02/06/2023]
Abstract
Importance Coronavirus disease 2019 (COVID-19), the disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been declared a global pandemic with significant morbidity and mortality since first appearing in Wuhan, China, in late 2019. As many countries are grappling with the onset of their epidemics, pharmacotherapeutics remain lacking. The window of opportunity to mitigate downstream morbidity and mortality is narrow but remains open. The renin–angiotensin–aldosterone system (RAAS) is crucial to the homeostasis of both the cardiovascular and respiratory systems. Importantly, SARS-CoV-2 utilises and interrupts this pathway directly, which could be described as the renin–angiotensin–aldosterone–SARS-CoV (RAAS–SCoV) axis. There exists significant controversy and confusion surrounding how anti-hypertensive agents might function along this pathway. This review explores the current state of knowledge regarding the RAAS–SCoV axis (informed by prior studies of SARS-CoV), how this relates to our currently evolving pandemic, and how these insights might guide our next steps in an evidence-based manner. Observations This review discusses the role of the RAAS–SCoV axis in acute lung injury and the effects, risks and benefits of pharmacological modification of this axis. There may be an opportunity to leverage the different aspects of RAAS inhibitors to mitigate indirect viral-induced lung injury. Concerns have been raised that such modulation might exacerbate the disease. While relevant preclinical, experimental models to date favour a protective effect of RAAS–SCoV axis inhibition on both lung injury and survival, clinical data related to the role of RAAS modulation in the setting of SARS-CoV-2 remain limited. Conclusion Proposed interventions for SARS-CoV-2 predominantly focus on viral microbiology and aim to inhibit viral cellular injury. While these therapies are promising, immediate use may not be feasible, and the time window of their efficacy remains a major unanswered question. An alternative approach is the modulation of the specific downstream pathophysiological effects caused by the virus that lead to morbidity and mortality. We propose a preponderance of evidence that supports clinical equipoise regarding the efficacy of RAAS-based interventions, and the imminent need for a multisite randomised controlled clinical trial to evaluate the inhibition of the RAAS–SCoV axis on acute lung injury in COVID-19. The interplay of SARS-CoV-2 with the renin–angiotensin–aldosterone system probably accounts for much of its unique pathology. Appreciating the degree and mechanism of this interaction highlights potential therapeutic options, including blockade (ARBs).https://bit.ly/3aue4tS
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Affiliation(s)
- Nicholas E Ingraham
- Dept of Medicine, University of Minnesota, Division of Pulmonary and Critical Care, Minneapolis, MN, USA
| | - Abdo G Barakat
- Dept of Anesthesiology, University of Minnesota, Minneapolis, MN, USA
| | - Ronald Reilkoff
- Dept of Medicine, University of Minnesota, Division of Pulmonary and Critical Care, Minneapolis, MN, USA
| | - Tamara Bezdicek
- Dept of Pharmacy, Fairview Pharmacy Services, Minneapolis, MN, USA
| | - Timothy Schacker
- Dept of Medicine, University of Minnesota, Division of Medicine and Infectious Disease, Minneapolis, MN, USA
| | - Jeffrey G Chipman
- Dept of Surgery, University of Minnesota, Division of Acute Care Surgery, Minneapolis, MN, USA
| | - Christopher J Tignanelli
- Dept of Surgery, University of Minnesota, Division of Acute Care Surgery, Minneapolis, MN, USA.,Institute for Health Informatics, University of Minnesota, Minneapolis, MN, USA
| | - Michael A Puskarich
- Dept of Emergency Medicine, University of Minnesota, Minneapolis, MN, USA.,Dept of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
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29
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Sarzani R, Giulietti F, Di Pentima C, Giordano P, Spannella F. Disequilibrium between the classic renin-angiotensin system and its opposing arm in SARS-CoV-2-related lung injury. Am J Physiol Lung Cell Mol Physiol 2020; 319:L325-L336. [PMID: 32639866 PMCID: PMC7414236 DOI: 10.1152/ajplung.00189.2020] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
A dysregulation of the renin-angiotensin system (RAS) has been involved in the genesis of lung injury and acute respiratory distress syndrome from different causes, including several viral infections. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection of pneumocytes, the hallmark of the pandemic coronavirus disease 2019 (COVID-19) involving both alveolar interstitium and capillaries, is linked to angiotensin-converting enzyme 2 (ACE2) binding and its functional downregulation. ACE2 is a key enzyme for the balance between the two main arms of the RAS: the ACE/angiotensin (Ang) II/Ang II type 1 receptor axis (“classic RAS”) and the ACE2/Ang(1–7)/Mas receptor (MasR) axis (“anti-RAS”). The ACE2 downregulation, as a result of SARS-coronaviruses binding, enhances the classic RAS, leading to lung damage and inflammation with leaky pulmonary blood vessels and fibrosis, when the attenuation mediated by the anti-RAS arm is reduced. ACE inhibitors (ACE-I) and Ang II type 1 receptor blockers (ARB), effective in cardiovascular diseases, were found to prevent and counteract acute lung injury in several experimental models by restoring the balance between these two opposing arms. The evidence of RAS arm disequilibrium in COVID-19 and the hypothesis of a beneficial role of RAS modulation supported by preclinical and clinical studies are the focus of the present review. Preclinical and clinical studies on drugs balancing RAS arms might be the right way to counter COVID-19.
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Affiliation(s)
- Riccardo Sarzani
- Internal Medicine and Geriatrics, "Hypertension Excellence Centre" of the European Society of Hypertension, Istituto di Ricovero e Cura a Carattere Scientifico Istituto Nazionale Ricovero e Cura per Anziani, Ancona, Italy.,Department of Clinical and Molecular Sciences, University "Politecnica delle Marche," Ancona, Italy
| | - Federico Giulietti
- Internal Medicine and Geriatrics, "Hypertension Excellence Centre" of the European Society of Hypertension, Istituto di Ricovero e Cura a Carattere Scientifico Istituto Nazionale Ricovero e Cura per Anziani, Ancona, Italy.,Department of Clinical and Molecular Sciences, University "Politecnica delle Marche," Ancona, Italy
| | - Chiara Di Pentima
- Internal Medicine and Geriatrics, "Hypertension Excellence Centre" of the European Society of Hypertension, Istituto di Ricovero e Cura a Carattere Scientifico Istituto Nazionale Ricovero e Cura per Anziani, Ancona, Italy.,Department of Clinical and Molecular Sciences, University "Politecnica delle Marche," Ancona, Italy
| | - Piero Giordano
- Internal Medicine and Geriatrics, "Hypertension Excellence Centre" of the European Society of Hypertension, Istituto di Ricovero e Cura a Carattere Scientifico Istituto Nazionale Ricovero e Cura per Anziani, Ancona, Italy
| | - Francesco Spannella
- Internal Medicine and Geriatrics, "Hypertension Excellence Centre" of the European Society of Hypertension, Istituto di Ricovero e Cura a Carattere Scientifico Istituto Nazionale Ricovero e Cura per Anziani, Ancona, Italy.,Department of Clinical and Molecular Sciences, University "Politecnica delle Marche," Ancona, Italy
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30
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Ruilope LM, Garcia Donaire JA, de la Sierra A. [Renin-angiotensin system blockers and COVID-19 infection]. HIPERTENSION Y RIESGO VASCULAR 2020; 37:99-100. [PMID: 32448641 PMCID: PMC7161518 DOI: 10.1016/j.hipert.2020.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 04/14/2020] [Indexed: 11/12/2022]
Affiliation(s)
- L M Ruilope
- Cardiorenal Translational Laboratory, Institute of Research i+12, Hospital Universitario 12 de Octubre, Madrid, España; Unidad de Hipertensión, Hospital Universitario 12 de Octubre, Madrid, España; Universidad Europea Madrid, Madrid, España; CIBER-CV, Hospital Universitario 12 de Octubre, Madrid, España.
| | - J A Garcia Donaire
- Unidad de Hipertensión Arterial, Hospital Clínico San Carlos, Madrid, España; Unidad de Hipertensión. Servicio de Medicina Interna, Hospital Mutua Terrassa, Terrassa, Barcelona, España
| | - A de la Sierra
- Departament de Medicina, Universitat de Barcelona, Barcelona, España; Unidad de Hipertensión, Servicio de Medicina Interna, Hospital Mutua Terrassa, Terrassa, España
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31
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Imazio M, Klingel K, Kindermann I, Brucato A, De Rosa FG, Adler Y, De Ferrari GM. COVID-19 pandemic and troponin: indirect myocardial injury, myocardial inflammation or myocarditis? Heart 2020; 106:1127-1131. [PMID: 32499236 DOI: 10.1136/heartjnl-2020-317186] [Citation(s) in RCA: 130] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 05/14/2020] [Accepted: 05/17/2020] [Indexed: 12/15/2022] Open
Abstract
The initial mechanism for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection is the binding of the virus to the membrane-bound form of ACE2, which is mainly expressed in the lung. Since the heart and the vessels also express ACE2, they both could become targets of the virus. However, at present the extent and importance of this potential involvement are unknown. Cardiac troponin levels are significantly higher in patients with more severe infections, patients admitted to intensive care units or in those who have died. In the setting of COVID-19, myocardial injury, defined by an increased troponin level, occurs especially due to non-ischaemic myocardial processes, including severe respiratory infection with hypoxia, sepsis, systemic inflammation, pulmonary thrombosis and embolism, cardiac adrenergic hyperstimulation during cytokine storm syndrome, and myocarditis. At present, there are limited reports on definite diagnosis of myocarditis caused by SARS-CoV-2 in humans and limited demonstration of the virus in the myocardium. In conclusion, although the heart and the vessels are potential targets in COVID-19, there is currently limited evidence on the direct infection of the myocardium by SARS-CoV-2. Additional pathological studies and autopsy series will be very helpful to clarify the potentiality of COVID-19 to directly infect the myocardium and cause myocarditis.
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Affiliation(s)
- Massimo Imazio
- University Cardiology, AOU Città della Salute e della Scienza di Torino, Torino, Italy .,Department of Public Health and Pediatrics, University of Torino, Torino, Italy
| | - Karin Klingel
- Cardiopathology, University Hospital Tuebingen, Tuebingen, Germany
| | - Ingrid Kindermann
- Department of Internal Medicine III (Cardiology, Angiology and Intensive Care), Saarland University Medical Center, Saarland University, Homburg/Saar, Germany
| | - Antonio Brucato
- Department of biomedical and clinical sciences, Fatebenefratelli Hospital and University of Milano, Milano, Italy
| | | | - Yehuda Adler
- College of Law and Business, Ramat Gan, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gaetano Maria De Ferrari
- University Cardiology, AOU Città della Salute e della Scienza di Torino and Department of Medical Sciences, University of Torino, Torino, Italy
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32
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Meira E Cruz M, Miyazawa M, Gozal D. Putative contributions of circadian clock and sleep in the context of SARS-CoV-2 infection. Eur Respir J 2020; 55:2001023. [PMID: 32350105 PMCID: PMC7191115 DOI: 10.1183/13993003.01023-2020] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 04/20/2020] [Indexed: 12/20/2022]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the aetiological agent of the pandemic coronavirus disease 2019 (COVID-19), is a newly found member of the Coronaviridae family, and is closely related to, albeit with important differences from, SARS-CoV [1]. It enters human cells through the binding of surface spike (S) glycoprotein with angiotensin-converting enzyme 2 (ACE2) [2–4]. The distal S1 subunit of the S protein is responsible for receptor binding, while the transmembrane S2 subunit mediates fusion between the viral envelope and the target cell membrane following proteolytic cleavage by specific cellular enzymes such as transmembrane serine protease 2 for S protein priming [5]. As it is likely that expression levels of ACE2 affect the efficiency of virus attachment and entry, as well as disease severity [6], and the interactions between viral S protein and ACE2 may directly cause lung injury [7], ACE2 may be a potential target of therapeutic and preventative interventions [8]. Circadian deregulation and poor or insufficient sleep may facilitate COVID-19 infection and severity https://bit.ly/2VUlIIJ
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Affiliation(s)
- Miguel Meira E Cruz
- Sleep Unit, Cardiovascular Center of University of Lisbon, Lisbon School of Medicine, Lisbon, Portugal
- Equal contributors
| | - Masaaki Miyazawa
- Dept of Immunology, Faculty of Medicine and Anti-Aging Center, Kindai University, Osaka, Japan
- Equal contributors
| | - David Gozal
- Dept of Child Health and the Child Health Research Institute, The University of Missouri School of Medicine, Columbia, MO, USA
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33
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South AM, Diz DI, Chappell MC. COVID-19, ACE2, and the cardiovascular consequences. Am J Physiol Heart Circ Physiol 2020; 318:H1084-H1090. [PMID: 32228252 PMCID: PMC7191628 DOI: 10.1152/ajpheart.00217.2020] [Citation(s) in RCA: 489] [Impact Index Per Article: 122.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 03/30/2020] [Accepted: 03/30/2020] [Indexed: 01/08/2023]
Abstract
The novel SARS coronavirus SARS-CoV-2 pandemic may be particularly deleterious to patients with underlying cardiovascular disease (CVD). The mechanism for SARS-CoV-2 infection is the requisite binding of the virus to the membrane-bound form of angiotensin-converting enzyme 2 (ACE2) and internalization of the complex by the host cell. Recognition that ACE2 is the coreceptor for the coronavirus has prompted new therapeutic approaches to block the enzyme or reduce its expression to prevent the cellular entry and SARS-CoV-2 infection in tissues that express ACE2 including lung, heart, kidney, brain, and gut. ACE2, however, is a key enzymatic component of the renin-angiotensin-aldosterone system (RAAS); ACE2 degrades ANG II, a peptide with multiple actions that promote CVD, and generates Ang-(1-7), which antagonizes the effects of ANG II. Moreover, experimental evidence suggests that RAAS blockade by ACE inhibitors, ANG II type 1 receptor antagonists, and mineralocorticoid antagonists, as well as statins, enhance ACE2 which, in part, contributes to the benefit of these regimens. In lieu of the fact that many older patients with hypertension or other CVDs are routinely treated with RAAS blockers and statins, new clinical concerns have developed regarding whether these patients are at greater risk for SARS-CoV-2 infection, whether RAAS and statin therapy should be discontinued, and the potential consequences of RAAS blockade to COVID-19-related pathologies such as acute and chronic respiratory disease. The current perspective critically examines the evidence for ACE2 regulation by RAAS blockade and statins, the cardiovascular benefits of ACE2, and whether ACE2 blockade is a viable approach to attenuate COVID-19.
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Affiliation(s)
- Andrew M South
- Cardiovascular Sciences Center, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Debra I Diz
- Cardiovascular Sciences Center, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Mark C Chappell
- Cardiovascular Sciences Center, Wake Forest School of Medicine, Winston-Salem, North Carolina
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34
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Katsiki N, Banach M, Mikhailidis DP. Lipid-lowering therapy and renin-angiotensin-aldosterone system inhibitors in the era of the COVID-19 pandemic. Arch Med Sci 2020; 16:485-489. [PMID: 32399093 PMCID: PMC7212217 DOI: 10.5114/aoms.2020.94503] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 04/05/2020] [Indexed: 12/15/2022] Open
Affiliation(s)
- Niki Katsiki
- First Department of Internal Medicine, Diabetes Centre, Division of Endocrinology and Metabolism, AHEPA University Hospital, Thessaloniki, Greece
| | - Maciej Banach
- Cardiovascular Research Centre, University of Zielona Gora, Zielona Gora, Poland
- Polish Mother’s Memorial Hospital Research Institute (PMMHRI), Lodz, Poland
| | - Dimitri P. Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital campus, University College London Medical School, University College London (UCL), London, UK
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