Plasma angiotensin-converting enzyme 2: novel biomarker in h
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Angiotensin-converting enzyme 2 (ACE2) has emerged as the negative regulator of the renin–angiotensin system (RAS) and was more recently identified as the SARS-CoV-2 receptor responsible for the current COVID-19 pandemic. The high burden of illness and high case fatality rate in patients with COVID-19 is driven in part by the high affinity of SARS-CoV-2 for ACE2, leading to viral entry and multisystem illness with pulmonary, gut, renal, central nervous stystem, and cardiovascular manifestations.

The novel dual role of ACE2 in the RAS and as the SARS-CoV-2 receptor provides a fundamental connection between viral infection, immunity, and cardiovascular disease. Direct clinical evidence came with SARS and the current COVID-19 pandemic, where there is down-regulation of tissue ACE2 through endocytosis and proteolytic processing which leads to a corresponding increase in plasma angiotensin II (Ang II) levels as seen in COVID-19 patients (linearly correlated with SARS-CoV-2 viral load), thus providing a direct link between the tissue and systemic RAS.

The SARS-CoV genome was detected in postmortem autopsy heart samples of patients who succumbed to SARS infection, suggesting prompt viral infiltration of myocardial tissue during infection. These hearts had markedly decreased myocardial ACE2 expression levels with a concomitant increase in myocardial inflammation and fibrosis.

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