Angiotensin-converting enzyme 2, coronavirus disease 2019, and abdominal aortic aneurysms

Abstract

Objective: Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is the etiologic agent of the current, world-wide coronavirus disease 2019 (COVID-19) pandemic. Angiotensin-converting enzyme 2 (ACE2) is the SARS-CoV-2 host entry receptor for cellular inoculation and target organ injury. We reviewed ACE2 expression and the role of ACE2-angiotensin 1-7-Mas receptor axis activity in abdominal aortic aneurysm (AAA) pathogenesis to identify potential COVID-19 influences on AAA disease pathogenesis.

Methods: A comprehensive literature search was performed on PubMed, National Library of Medicine. Key words included COVID-19, SARS-CoV-2, AAA, ACE2, ACE or angiotensin II type 1 (AT1) receptor inhibitor, angiotensin 1-7, Mas receptor, age, gender, respiratory diseases, diabetes, and autoimmune diseases. Key publications on the epidemiology and pathogenesis of COVID-19 and AAAs were identified and reviewed.

Results: All vascular structural cells, including endothelial and smooth muscle cells, fibroblasts, and pericytes express ACE2. Cigarette smoking, diabetes, chronic obstructive pulmonary disease, lupus, certain types of malignancies, and viral infection promote ACE2 expression and activity, with the magnitude of response varying by sex and age. Genetic deficiency of AT1 receptor, or pharmacologic ACE or AT1 inhibition also increases ACE2 and its catalytic product angiotensin 1-7. Genetic ablation or pharmacologic inhibition of ACE2 or Mas receptor augments, whereas ACE2 activation or angiotensin 1-7 treatment attenuates, progression of experimental AAAs. The potential influences of SARS-CoV-2 on AAA pathogenesis include augmented ACE-angiotensin II-AT1 receptor activity resulting from decreased reciprocal ACE2-angiotensin 1-7-Mas activation; increased production of proaneurysmal mediators stimulated by viral spike proteins in ACE2-negative myeloid cells or by ACE2-expressing vascular structural cells; augmented local or systemic cross-talk between viral targeted nonvascular, nonleukocytic ACE2-expressing cells via ligand recognition of their cognate leukocyte receptors; and hypoxemia and increased systemic inflammatory tone experienced during severe COVID-19 illness.

Conclusions: COVID-19 may theoretically influence AAA disease through multiple SARS-CoV-2-induced mechanisms. Further investigation and clinical follow-up will be necessary to determine whether and to what extent the COVID-19 pandemic will influence the prevalence, progression, and lethality of AAA disease in the coming decade.

Keywords: Abdominal aortic aneurysm (AAA); Angiotensin-converting enzyme 2; Coronavirus disease 2019 (COVID-19); Severe acute respiratory syndrome (SARS).

Fig 1

Angiotensin-converting enzyme 2 (ACE-2)-dependent potential influences of COVID-19 on abdominal aortic aneurysm (AAA) disease. AT1, Angiotensin II type receptor; EC, endothelial cells; HIF, hypoxia inducible factor; Mas, receptor for Ang 1-7; MMPs, matrix metalloproteinases; RNS, reactive nitrogen species; ROS, reactive oxygen species; SMCs, smooth muscle cells

Fig 2

angiotensin-converting enzyme 2 (ACE-2)-independent potential influence of COVID-19 on clinical adbominal aortic aneurysm (AAA) disease. HIF, Hypoxia inducible factor; LPS, lipopolysaccharide; M1, classically activated; Th, helper T cells; TLR, Toll-like receptor.