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ACE2, the Counter-Regulatory Renin–Angiotensin System Axis and COVID-19 Severity

Department of Cardiology, Larissa University General Hospital, 41110 Larissa, Greece
Department of Medicine/Cardiovascular Medicine, The Ohio State University, Columbus, OH 43210, USA
Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH 44195, USA
Second Department of Cardiology, National and Kapodistrian University of Athens, Attikon University Hospital, 12462 Athens, Greece
Author to whom correspondence should be addressed.
Academic Editor: Toshihiro Tsuruda
J. Clin. Med. 2021, 10(17), 3885;
Received: 5 July 2021 / Revised: 25 August 2021 / Accepted: 25 August 2021 / Published: 29 August 2021
(This article belongs to the Special Issue JCM-Advances in Cardiology)
Angiotensin (ANG)-converting enzyme (ACE2) is an entry receptor of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that causes coronavirus disease 2019 (COVID-19). ACE2 also contributes to a deviation of the lung renin–angiotensin system (RAS) towards its counter-regulatory axis, thus transforming harmful ANG II to protective ANG (1–7). Based on this purported ACE2 double function, it has been put forward that the benefit from ACE2 upregulation with renin–angiotensin–aldosterone system inhibitors (RAASi) counterbalances COVID-19 risks due to counter-regulatory RAS axis amplification. In this manuscript we discuss the relationship between ACE2 expression and function in the lungs and other organs and COVID-19 severity. Recent data suggested that the involvement of ACE2 in the lung counter-regulatory RAS axis is limited. In this setting, an augmentation of ACE2 expression and/or a dissociation of ACE2 from the ANG (1–7)/Mas pathways that leaves unopposed the ACE2 function, the SARS-CoV-2 entry receptor, predisposes to more severe disease and it appears to often occur in the relevant risk factors. Further, the effect of RAASi on ACE2 expression and on COVID-19 severity and the overall clinical implications are discussed. View Full-Text
Keywords: COVID-19; ACE2; renin–angiotensin system COVID-19; ACE2; renin–angiotensin system
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MDPI and ACS Style

Triposkiadis, F.; Xanthopoulos, A.; Giamouzis, G.; Boudoulas, K.D.; Starling, R.C.; Skoularigis, J.; Boudoulas, H.; Iliodromitis, E. ACE2, the Counter-Regulatory Renin–Angiotensin System Axis and COVID-19 Severity. J. Clin. Med. 2021, 10, 3885.

AMA Style

Triposkiadis F, Xanthopoulos A, Giamouzis G, Boudoulas KD, Starling RC, Skoularigis J, Boudoulas H, Iliodromitis E. ACE2, the Counter-Regulatory Renin–Angiotensin System Axis and COVID-19 Severity. Journal of Clinical Medicine. 2021; 10(17):3885.

Chicago/Turabian Style

Triposkiadis, Filippos, Andrew Xanthopoulos, Grigorios Giamouzis, Konstantinos D. Boudoulas, Randall C. Starling, John Skoularigis, Harisios Boudoulas, and Efstathios Iliodromitis. 2021. "ACE2, the Counter-Regulatory Renin–Angiotensin System Axis and COVID-19 Severity" Journal of Clinical Medicine 10, no. 17: 3885.

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