Advertisement
Mayo Clinic Proceedings Home

Marked Up-Regulation of ACE2 in Hearts of Patients With Obstructive Hypertrophic Cardiomyopathy: Implications for SARS-CoV-2–Mediated COVID-19

      Abstract

      Objective

      To explore the transcriptomic differences between patients with hypertrophic cardiomyopathy (HCM) and controls.

      Patients and Methods

      RNA was extracted from cardiac tissue flash frozen at therapeutic surgical septal myectomy for 106 patients with HCM and 39 healthy donor hearts. Expression profiling of 37,846 genes was performed using the Illumina Human HT-12v3 Expression BeadChip. All patients with HCM were genotyped for pathogenic variants causing HCM. Technical validation was performed using quantitative real-time polymerase chain reaction (qRT-PCR) and Western blot. This study was started on January 1, 1999, and final analysis was completed on April 20, 2020.

      Results

      Overall, 22% of the transcriptome (8443 of 37,846 genes) was expressed differentially between HCM and control tissues. Analysis by genotype revealed that gene expression changes were similar among genotypic subgroups of HCM, with only 4% (1502 of 37,846) to 6% (2336 of 37,846) of the transcriptome exhibiting differential expression between genotypic subgroups. The qRT-PCR confirmed differential expression in 92% (11 of 12 genes) of tested transcripts. Notably, in the context of coronavirus disease 2019 (COVID-19), the transcript for angiotensin I converting enzyme 2 (ACE2), a negative regulator of the angiotensin system, was the single most up-regulated gene in HCM (fold-change, 3.53; q-value =1.30×10−23), which was confirmed by qRT-PCR in triplicate (fold change, 3.78; P=5.22×10−4), and Western blot confirmed greater than 5-fold overexpression of ACE2 protein (fold change, 5.34; P=1.66×10−6).

      Conclusion

      More than 20% of the transcriptome is expressed differentially between HCM and control tissues. Importantly, ACE2 was the most up-regulated gene in HCM, indicating perhaps the heart’s compensatory effort to mount an antihypertrophic, antifibrotic response. However, given that the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) uses ACE2 for viral entry, this 5-fold increase in ACE2 protein may confer increased risk for COVID-19 manifestations and outcomes in patients with increased ACE2 transcript expression and protein levels in the heart.

      Abbreviations and Acronyms:

      ΔCt (transcript of interest minus GAPDH control), ACE2 (angiotensin I converting enzyme 2), ACEi (angiotensin-converting enzyme inhibitor), ARB (angiotensin receptor blocker), AT1R (angiotensin type 1 receptor), BP (blood pressure), cDNA (complementary DNA), CHF (congestive heart failure), COVID-19 (coronavirus disease 2019), ECG (electrocardiogram), GTP (guanosine triphosphate), HCM (hypertrophic cardiomyopathy), hrsACE2 (human recombinant soluble angiotensin I converting enzyme 2), HTN (hypertension), ICU (intensive care unit), IQR (interquartile range), LV (left ventricular), MIG (maximum instantaneous gradient), mRNA (messenger RNA), MYBPC3 (myosin binding protein C), MYH7 (beta myosin heavy chain), NA (not available), NS (not significant), NYHA (New York Heart Association), qRT-PCR (quantitative real-time polymerase chain reaction), RAAS (renin-angiotensin-aldosterone system), SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2), SCD (sudden cardiac death), UTR (untranslated region)
      To read this article in full you will need to make a payment

      Subscribe:

      Subscribe to Mayo Clinic Proceedings
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Maron B.J.
        • Gardin J.M.
        • Flack J.M.
        • Gidding S.S.
        • Kurosaki T.T.
        • Bild D.E.
        Prevalence of hypertrophic cardiomyopathy in a general population of young adults. Echocardiographic analysis of 4111 subjects in the CARDIA Study. Coronary Artery Risk Development in (Young) Adults.
        Circulation. 1995; 92: 785-789
        • Maron B.J.
        • Roberts W.C.
        • McAllister H.A.
        • Rosing D.R.
        • Epstein S.E.
        Sudden death in young athletes.
        Circulation. 1980; 62: 218-229
        • Poetter K.
        • Jiang H.
        • Hassanzadeh S.
        • et al.
        Mutations in either the essential or regulatory light chains of myosin are associated with a rare myopathy in human heart and skeletal muscle.
        Nat Genet. 1996; 13: 63-69
        • Morner S.
        • Richard P.
        • Kazzam E.
        • et al.
        Identification of the genotypes causing hypertrophic cardiomyopathy in northern Sweden.
        J Mol Cell Cardiol. 2003; 35: 841-849
        • Lim D.S.
        • Roberts R.
        • Marian A.J.
        Expression profiling of cardiac genes in human hypertrophic cardiomyopathy: insight into the pathogenesis of phenotypes.
        J Am Coll Cardiol. 2001; 38: 1175-1180
        • Hwang J.J.
        • Allen P.D.
        • Tseng G.C.
        • et al.
        Microarray gene expression profiles in dilated and hypertrophic cardiomyopathic end-stage heart failure.
        Physiol Genomics. 2002; 10: 31-44
        • Herman D.S.
        • Hovingh G.K.
        • Iartchouk O.
        • et al.
        Filter-based hybridization capture of subgenomes enables resequencing and copy-number detection.
        Nat Methods. 2009; 6: 507-510
        • McKenna A.
        • Hanna M.
        • Banks E.
        • et al.
        The Genome Analysis Toolkit: a MapReduce framework for analyzing next-generation DNA sequencing data.
        Genome Res. 2010; 20: 1297-1303
        • Schroeder A.
        • Mueller O.
        • Stocker S.
        • et al.
        The RIN: an RNA integrity number for assigning integrity values to RNA measurements.
        BMC Mol Biol. 2006; 7: 3
        • Ballman K.V.
        • Grill D.E.
        • Oberg A.L.
        • Therneau T.M.
        Faster cyclic loess: normalizing RNA arrays via linear models.
        Bioinformatics. 2004; 20: 2778-2786
        • Benjamini Y.
        • Hochberg Y.
        Controlling the false discovery rate: a practical and powerful approach to multiple testing.
        J R Stat Soc. 1995; 57: 289-300
        • Livak K.J.
        • Schmittgen T.D.
        Analysis of relative gene expression data using real-time quantitative PCR and the 2(-Delta Delta C(T)) method.
        Methods. 2001; 25: 402-408
        • Erdmann J.
        • Daehmlow S.
        • Wischke S.
        • et al.
        Mutation spectrum in a large cohort of unrelated consecutive patients with hypertrophic cardiomyopathy.
        Clin Genet. 2003; 64: 339-349
        • Richard P.
        • Charron P.
        • Carrier L.
        • et al.
        • EUROGENE Heart Failure Project
        Hypertrophic cardiomyopathy: distribution of disease genes, spectrum of mutations, and implications for a molecular diagnosis strategy.
        Circulation. 2003; 107: 2227-2232
        • Van Driest S.L.
        • Ommen S.R.
        • Tajik A.J.
        • Gersh B.J.
        • Ackerman M.J.
        Yield of genetic testing in hypertrophic cardiomyopathy.
        Mayo Clin Proc. 2005; 80: 739-744
        • Bos J.M.
        • Will M.L.
        • Gersh B.J.
        • Kruisselbrink T.M.
        • Ommen S.R.
        • Ackerman M.J.
        Characterization of a phenotype-based genetic test prediction score for unrelated patients with hypertrophic cardiomyopathy.
        Mayo Clin Proc. 2014; 89: 727-737
        • Van Driest S.L.
        • Ommen S.R.
        • Tajik A.J.
        • Gersh B.J.
        • Ackerman M.J.
        Sarcomeric genotyping in hypertrophic cardiomyopathy.
        Mayo Clin Proc. 2005; 80: 463-469
        • Van Driest S.L.
        • Vasile V.C.
        • Ommen S.R.
        • et al.
        Myosin binding protein C mutations and compound heterozygosity in hypertrophic cardiomyopathy.
        J Am Coll Cardiol. 2004; 44: 1903-1910
        • Vickers C.
        • Hales P.
        • Kaushik V.
        • et al.
        Hydrolysis of biological peptides by human angiotensin-converting enzyme-related carboxypeptidase.
        J Biol Chem. 2002; 277: 14838-14843
        • Liu Y.
        • Afzal J.
        • Vakrou S.
        • et al.
        Differences in microRNA-29 and pro-fibrotic gene expression in mouse and human hypertrophic cardiomyopathy.
        Front Cardiovasc Med. 2019; 6: 170
        • Geske J.B.
        • Ong K.C.
        • Siontis K.C.
        • et al.
        Women with hypertrophic cardiomyopathy have worse survival.
        Eur Heart J. 2017; 38: 3434-3440
        • Nijenkamp L.L.A.M.
        • Bollen I.A.E.
        • van Velzen H.G.
        • et al.
        Sex differences at the time of myectomy in hypertrophic cardiomyopathy.
        Circ Heart Fail. 2018; 11: e004133
        • Rowin E.J.
        • Maron M.S.
        • Wells S.
        • Patel P.P.
        • Koethe B.C.
        • Maron B.J.
        Impact of sex on clinical course and survival in the contemporary treatment era for hypertrophic cardiomyopathy.
        J Am Heart Assoc. 2019; 8: e012041
        • Kuba K.
        • Imai Y.
        • Rao S.
        • et al.
        A crucial role of angiotensin converting enzyme 2 (ACE2) in SARS coronavirus-induced lung injury.
        Nat Med. 2005; 11: 875-879
        • Li W.
        • Moore M.J.
        • Vasilieva N.
        • et al.
        Angiotensin-converting enzyme 2 is a functional receptor for the SARS coronavirus.
        Nature. 2003; 426: 450-454
        • Shi S.
        • Qin M.
        • Shen B.
        • et al.
        Association of cardiac injury with mortality in hospitalized patients with COVID-19 in Wuhan, China [published online ahead of print March 25, 2020].
        (JAMA Cardiol)
        • Zhou P.
        • Yang X.L.
        • Wang X.G.
        • et al.
        A pneumonia outbreak associated with a new coronavirus of probable bat origin.
        Nature. 2020; 579: 270-273
        • Litviňuková M.
        • Talavera- López C.
        • Maatz H.
        • et al.
        Cells and gene expression programs in the adult human heart [published online ahead of print April 5, 2020].
        (Bioarchives)
        • Tikellis C.
        • Thomas M.C.
        Angiotensin-converting enzyme 2 (ACE2) is a key modulator of the renin angiotensin system in health and disease.
        Int J Pept. 2012; 2012: 256294
        • Zhang H.
        • Penninger J.M.
        • Li Y.
        • Zhong N.
        • Slutsky A.S.
        Angiotensin-converting enzyme 2 (ACE2) as a SARS-CoV-2 receptor: molecular mechanisms and potential therapeutic target.
        Intensive Care Med. 2020; 46: 586-590
        • Yang J.
        • Zheng Y.
        • Gou X.
        • et al.
        Prevalence of comorbidities in the novel Wuhan coronavirus (COVID-19) infection: a systematic review and meta-analysis.
        Int J Infect Dis. 2020; 94: 91-95
        • Wang D.
        • Hu B.
        • Hu C.
        • et al.
        Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China [published online ahead of print February 7, 2020].
        (JAMA)
        • Zou Y.
        • Song L.
        • Wang Z.
        • et al.
        Prevalence of idiopathic hypertrophic cardiomyopathy in China: a population-based echocardiographic analysis of 8080 adults.
        Am J Med. 2004; 116: 14-18
        • Liu P.P.
        • Blet A.
        • Smyth D.
        • Li H.
        The science underlying COVID-19: implications for the cardiovascular system [published online ahead of print April 15, 2020].
        (Circulation)
        • Chen Liang
        • Li Xiangjie
        • Chen Mingquan
        • Feng Yi
        • Xiong Chenglong
        The ACE2 expression in human heart indicates new potential mechanism of heart injury among patients infected with SARS-CoV-2.
        Cardiovasc Res. 2020; 116: 1097-1100
        • Burrell L.M.
        • Risvanis J.
        • Kubota E.
        • et al.
        Myocardial infarction increases ACE2 expression in rat and humans.
        Eur Heart J. 2005; 26 (discussion 322-324): 369-375
        • Ferrario C.M.
        • Jessup J.
        • Chappell M.C.
        • et al.
        Effect of angiotensin-converting enzyme inhibition and angiotensin II receptor blockers on cardiac angiotensin-converting enzyme 2.
        Circulation. 2005; 111: 2605-2610
        • South A.M.
        • Tomlinson L.
        • Edmonston D.
        • Hiremath S.
        • Sparks M.A.
        Controversies of renin-angiotensin system inhibition during the COVID-19 pandemic [published online ahead of print April 3, 2020].
        (Nat Rev Nephrol)
        • Zhang P.
        • Zhu L.
        • Cai J.
        • et al.
        Association of inpatient use of angiotensin converting enzyme inhibitors and angiotensin II receptor blockers with mortality among patients with hypertension hospitalized with COVID-19 [published online ahead of print April 18, 2020].
        (Circ Res)
        • Monteil V.
        • Kwon H.
        • Prado P.
        • et al.
        Inhibition of SARS-CoV-2 infections in engineered human tissues using clinical-grade soluble ACE2 [published online ahead of print April 17, 2020].
        (Cell)
        • Messer A.E.
        • Gallon C.E.
        • McKenna W.J.
        • Dos Remedios C.G.
        • Marston S.B.
        The use of phosphate-affinity SDS-PAGE to measure the cardiac troponin I phosphorylation site distribution in human heart muscle.
        Proteomics Clin Appl. 2009; 3: 1371-1382
        • Hoskins A.C.
        • Jacques A.
        • Bardswell S.C.
        • et al.
        Normal passive viscoelasticity but abnormal myofibrillar force generation in human hypertrophic cardiomyopathy.
        J Mol Cell Cardiol. 2010; 49: 737-745
        • Fermin D.R.
        • Barac A.
        • Lee S.
        • et al.
        Sex and age dimorphism of myocardial gene expression in nonischemic human heart failure.
        Circ Cardiovasc Genet. 2008; 1: 117-125
        • van Dijk S.J.
        • Paalberends E.R.
        • Najafi A.
        • et al.
        Contractile dysfunction irrespective of the mutant protein in human hypertrophic cardiomyopathy with normal systolic function.
        Circ Heart Fail. 2012; 5: 36-46
        • Krüger M.
        • Kötter S.
        • Grützner A.
        • et al.
        Protein kinase G modulates human myocardial passive stiffness by phosphorylation of the titin springs.
        Circ Res. 2009; 104: 87-94