Plasma ACE2 and risk of death or cardiometabolic diseases: a case-cohort analysis

• Published in: The Lancet (British edition) 2020-10, Vol.396 (10256), p.968-976
• Main Authors: Narula, Sukrit, Yusuf, Salim, Chong, Michael, Ramasundarahettige, Chinthanie, Rangarajan, Sumathy, Bangdiwala, Shrikant I, van Eikels, Martin, Leineweber, Kirsten, Wu, Annie, Pigeyre, Marie, Paré, Guillaume
• Format: Article
• Language: English
• Subjects: ACE2; Adult; Aged; Angiotensin; Angiotensin-Converting Enzyme 2; Atherosclerosis; Blood pressure; Body Mass Index; Cardiovascular disease; Cardiovascular diseases; Cardiovascular Diseases - blood; Cardiovascular Diseases - mortality; Case-Control Studies; Cerebral infarction; Cohort analysis; Congestive heart failure; Coronaviruses; COVID-19; Death; Diabetes; Diabetes mellitus; Enzymes; Epidemiology; Fatalities; Female; Genomes; Heart attacks; Heart failure; Humans; Immunoassay; Lipids; Low income groups; Male; Metabolism; Middle Aged; Mortality; Myocardial infarction; Peptidyl-dipeptidase A; Peptidyl-Dipeptidase A - blood; Plasma; Population; Proteins; Rankings; Renin; Risk analysis; Risk Factors; Severe acute respiratory syndrome coronavirus 2; Sex; Stroke; Survival Rate
• ISSN: 0140-6736; 1474-547X
• DOI: 10.1016/S0140-6736(20)31964-4

Angiotensin-converting enzyme 2 (ACE2) is an endogenous counter-regulator of the renin–angiotensin hormonal cascade. We assessed whether plasma ACE2 concentrations were associated with greater risk of death or cardiovascular disease events. We used data from the Prospective Urban Rural Epidemiology (PURE) prospective study to conduct a case-cohort analysis within a subset of PURE participants (from 14 countries across five continents: Africa, Asia, Europe, North America, and South America). We measured plasma concentrations of ACE2 and assessed potential determinants of plasma ACE2 levels as well as the association of ACE2 with cardiovascular events. We included 10 753 PURE participants in our study. Increased concentration of plasma ACE2 was associated with increased risk of total deaths (hazard ratio [HR] 1·35 per 1 SD increase [95% CI 1·29–1·43]) with similar increases in cardiovascular and non-cardiovascular deaths. Plasma ACE2 concentration was also associated with higher risk of incident heart failure (HR 1·27 per 1 SD increase [1·10–1·46]), myocardial infarction (HR 1·23 per 1 SD increase [1·13–1·33]), stroke (HR 1·21 per 1 SD increase [1·10–1·32]) and diabetes (HR 1·44 per 1 SD increase [1·36–1·52]). These findings were independent of age, sex, ancestry, and traditional cardiac risk factors. With the exception of incident heart failure events, the independent relationship of ACE2 with the clinical endpoints, including death, remained robust after adjustment for BNP. The highest-ranked determinants of ACE2 concentrations were sex, geographic ancestry, and body-mass index (BMI). When compared with clinical risk factors (smoking, diabetes, blood pressure, lipids, and BMI), ACE2 was the highest ranked predictor of death, and superseded several risk factors as a predictor of heart failure, stroke, and myocardial infarction. Increased plasma ACE2 concentration was associated with increased risk of major cardiovascular events in a global study. Canadian Institute of Health Research, Heart & Stroke Foundation of Canada, and Bayer.