CLINICAL IMPLICATIONS OF BASIC RESEARCH

Clinical Implications of Basic Research A NGIOTENSIN -C ONVERTING E NZYME 2 A N EW C ARDIAC R EGULATOR

HE reninangiotensin system is a master regulator of human physiology. It controls blood pressure and fluid and electrolyte balance through coordinated effects on the heart, blood vessels, and kidneys. In the classic pathway of the reninangiotensin system, renin is secreted from the juxtaglomerular apparatus of the kidney and acts on the circulating precursor angiotensinogen to generate angiotensin I (Fig. 1). Angiotensin I has little effect on blood pressure and is converted in the lungs by angiotensin-converting enzyme (ACE) to angiotensin II. A potent vasopressor, angiotensin II acts on the heart and the kidneys by binding to the G proteincoupled receptors AT1 and AT2. The AT1 receptor mediates the more deleterious effects of angiotensin II that is, vasoconstriction and cardiac and vessel hypertrophy. The AT2 receptor regulates opposing effects. In addition to the conversion of angiotensin I to angiotensin II, ACE inactivates two vasodilator peptides, bradykinin and kallidin. Inhibition of ACE thus lowers blood pressure through two mechanisms: prevention of the formation of angiotensin II and potentiation of the hypotensive properties of bradykinin. Indeed, ACE inhibition has been the cornerstone of antihypertensive therapies for years. ACE inhibition is now central to the treatment of other cardiovascular disorders as well. Angiotensin II is secreted by vascular endothelial cells in the myocardium after injury. It directly affects the myocardium by mediating myocyte hypertrophy and fibrosis. Basic and clinical studies have demonstrated that ACE inhibitors prevent myocardial fibrosis and improve ventricular remodeling after myocardial infarction and in congestive heart failure. ACE inhibitors are now used clinically to treat congestive heart failure, ventricular dilatation after myocardial infarction, endothelial dysfunction, and renal disease, including diabetic nephropathy. The last two indications blunt the direct vasopressor actions of angiotensin II on blood vessels. Crackower and colleagues1 have now made it clear that the reninangiotensin system is much more complicated than previous research suggested. Their experiments indicate that a recently identified enzyme, angiotensin-converting enzyme 2 (ACE2), has direct effects on cardiac function. This new chapter in the story of the reninangiotensin system began in 2000, with the discovery of ACE2 and its identification as

an enzyme similar to ACE.2,3 ACE2 is expressed predominantly in vascular endothelial cells of the heart and kidney. ACE and ACE2 have different biochemical activities. Angiotensin I is converted to angiotensin 19 (with nine amino acids) by ACE2 but is converted to angiotensin II, which has eight amino acids, by ACE. Whereas angiotensin II is a potent bloodvessel constrictor, angiotensin 19 has no known effect on blood vessels but can be converted by ACE to a shorter peptide, angiotensin 17, which is a blood-vessel dilator. Thus, it has been suggested that ACE2 prevents the formation of the vasopressor angiotensin II. What about the physiology of ACE2? Using genetic approaches, Crackower et al. have demonstrated that ACE2 is a critical regulator of heart function in four ways.1 First, the gene for this enzyme, ACE2, maps to the X chromosome in humans, and a quantitative trait locus was previously mapped to the X chromosome in several rat models of hypertension without a known candidate gene. A quantitative trait locus is a genetic locus influencing the expression of a complex phenotype that varies continuously across a population, such as hypertension. The authors asked whether ace2 could be a candidate gene for this quantitative trait locus, and indeed, the rat ace2 maps to this locus on the X chromosome with a significant logarithm-of-theodds (lod) score in three different rat models of hypertension. In addition, ace2 messenger RNA and protein levels are down-regulated in the kidneys in the three rat models, providing further evidence that ace2 is a candidate gene for this quantitative trait locus on the X chromosome. The second approach undertaken by Crackower and colleagues was to ablate the ace2 gene in mice (ace2/ mice). This allowed the investigators to determine directly whether ACE2 indeed has an essential role in cardiovascular physiology. Loss of ACE2 did not alter blood-pressure homeostasis but did severely impair cardiac function. Mild thinning of the left ventricle and a severe reduction in contractility were observed. However, no interstitial cardiac fibrosis or myocyte hypertrophy was present. The constellation of findings (severe contractile dysfunction, mild dilatation, and no hypertrophy or cardiac fibrosis) was similar to that often observed in cardiac stunning, or hibernation (a reversible decline in cardiac contractility under ischemic conditions), in humans. Crackower et al. then found that loss of ACE2 was associated with up-regulation of hypoxia-inducible genes, suggesting a role for ACE2 in mediating the response to cardiac ischemia. Third, angiotensin II levels were increased in ace2knockout mice, suggesting that ACE2 may counteract the function of ACE. Indeed, ACE generates angiotensin II from angiotensin I, but ACE2 can cleave angiotensin II and compete with ACE for the sub-

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The Ne w E n g l a nd Jo u r n a l o f Me d ic i ne

Angiotensinogen

Renin

Angiotensin I

ACE2

ACE

Angiotensin 19

Angiotensin II

ACE

Aminopeptidases

Angiotensin 17

Angiotensin III

Figure 1. A Simplified Scheme of the ReninAngiotensin System. Angiotensin-converting enzyme 2 (ACE2) converts angiotensin I to angiotensin 19 in the heart and the kidney and may balance the effects of ACE activity. Although angiotensin 19 has no known effect on blood vessels, it is converted by ACE to angiotensin 17, which is a blood-vessel dilator. Angiotensin II and angiotensin III are blood-vessel constrictors.

strate angiotensin I. To determine whether unopposed angiotensin II mediates the observed cardiac-dysfunction phenotype, the investigators generated ace/ace2 double-mutant mice, which lack both ACE and ACE2, as well as angiotensin II. Ablation of ACE expression in the presence of mutant ace2 completely abolished the cardiac-dysfunction phenotype in the ace2-knockout mice. Heart function and blood pressure were normal. This genetic model provided evidence of a direct role of angiotensin II in the cardiac-dysfunction phenotype and suggested further that ACE and ACE2 have counterbalancing functions.

The final genetic approach used by Crackower et al. was to examine the expression pattern of heart-formation markers in drosophila. In drosophila lacking the fly homologue of ACE2, termed ACER, defective formation of the heart tube was observed. Loss of ACER led to a reduction in the number of cardiac progenitor cells and disorganization of the developing mesoderm. Thus, ACE2 also functions in cardiac morphogenesis. Modulation of the reninangiotensin system by ACE inhibition and angiotensin-IIreceptor blockade is a prime strategy for the treatment of cardiovascular diseases. The work of Crackower and colleagues sug-

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CLINICAL IMPLICATIONS OF BASIC RESEARCH

gests that the new member of the reninangiotensin system, ACE2, is a critical regulator of cardiac function and may be an important therapeutic target. Drugs that specifically influence the production of ACE2, as well as dampen the activity of angiotensin II, may therefore have considerable clinical value.
MANFRED BOEHM, M.D. ELIZABETH G. NABEL, M.D.
National Heart, Lung, and Blood Institute Bethesda, MD 20892

REFERENCES
1. Crackower MA, Sarao R, Oudit GY, et al. Angiotensin-converting enzyme 2 is an essential regulator of heart function. Nature 2002;417:822-8. 2. Tipnis SR, Hooper NM, Hyde R, Karran E, Christie G, Turner AJ. A human homolog of angiotensin-converting enzyme: cloning and functional expression as a captopril-insensitive carboxypeptidase. J Biol Chem 2000;275:33238-43. 3. Donoghue M, Hsieh F, Baronas E, et al. A novel angiotensin-converting enzyme-related carboxypeptidase (ACE2) converts angiotensin I to angiotensin 1-9. Circ Res 2000;87:E1-E9.

Copyright 2002 Massachusetts Medical Society.

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