key: cord-0889449-fhmyge72
authors: Verdiner, Ricardo E.
title: Is Angiotensin II Unopposed a Good Thing?
date: 2020-06-09
journal: Anesth Analg
DOI: 10.1213/ane.0000000000005046
sha: f6164677a8cc48eba73694bd3cf9b7974fa141db
doc_id: 889449
cord_uid: fhmyge72

nan

To the Editor I am writing this letter in regard to the article by Chow et al. 1 In the article, the authors propose the mechanism of action of angiotensin II as a vasoactive agent in Coronavirus Disease 2019 (COVID-19)associated vasodilatory shock. If ACE-2 expression was not impaired in COVID-19 infections, administering exogenous angiotensin II would be less worrisome. Unfortunately, several studies have shown that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), on binding to the ACE-2 transmembrane receptor, reduces its expression. 2 This reduction in intracellular ACE-2 leaves angiotensin II's downstream actions unopposed. They include vasoconstriction, cytokine release, and complement system activation to name but a few. [3] [4] [5] One could surmise that it is because of the reduction of the intracellular activity of ACE-2 that SARS-CoV-2 in part exhibits its effects on the pulmonary, renal, cardiac, and coagulation system. In fact, mouse models with ACE-2 deletion show evidence of renal and cardiac impairment. 6 Further laboratory studies with ACE-2 deletion or SARS-CoV-2-infected cells would help determine if unopposed exogenous angiotensin II is safe and has an overall benefit besides increasing vascular tone in the setting of COVID-19. 

Angiotensin II for the treatment of COVID-19-related vasodilatory shock

SARS-coronavirus modulation of myocardial ACE2 expression and inflammation in patients with SARS

Severe COVID-19 infection associated with endothelial activation

Complement associated microvascular injury and thrombosis in the pathogenesis of severe COVID-19 infection: a report of five cases

ACE inhibition, ACE2 and angiotensin-(1-7) axis in kidney and cardiac inflammation and fibrosis

ACE2 deficiency increases NADPH-mediated oxidative stress in the kidney

Is Angiotensin II Unopposed a Good Thing?