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Although COVID-19 is most well known for causing substantial respiratory pathology, it can also result in several extrapulmonary manifestations. These conditions include thrombotic complications, myocardial dysfunction and arrhythmia, acute coronary syndromes, acute kidney injury, gastrointestinal symptoms, hepatocellular injury, hyperglycemia and ketosis, neurologic illnesses, ocular symptoms, and dermatologic complications. Given that ACE2, the entry receptor for the causative coronavirus SARS-CoV-2, is expressed in multiple extrapulmonary tissues, direct viral tissue damage is a plausible mechanism of injury. In addition, endothelial damage and thromboinflammation, dysregulation of immune responses, and maladaptation of ACE2-related pathways might all contribute to these extrapulmonary manifestations of COVID-19. Here we review the extrapulmonary organ-specific pathophysiology, presentations and management considerations for patients with COVID-19 to aid clinicians and scientists in recognizing and monitoring the spectrum of manifestations, and in developing research priorities and therapeutic strategies for all organ systems involved.

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Extrapulmonary manifestations of COVID-19.

Kidney disease is associated with in-hospital death of patients with COVID-19.

This case series describes the clinical presentation, characteristics, and outcomes of patients with coronavirus disease 2019 (COVID-19) admitted to the intensive care unit at a public hospital in Washington State in February 2020, including initial reports of cardiomyopathy in one-third of the patients.

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Characteristics and Outcomes of 21 Critically Ill Patients With COVID-19 in Washington State.

Epidemiology, clinical course, and outcomes of critically ill adults with COVID-19 in New York City: a prospective cohort study.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infects host cells through ACE2 receptors, leading to coronavirus disease (COVID-19)-related pneumonia, while also causing acute myocardial injury and chronic damage to the cardiovascular system. Therefore, particular attention should be given to cardiovascular protection during treatment for COVID-19.

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COVID-19 and the cardiovascular system.

Background In approximately 80% of cardiovascular disease-related deaths, patients suffer from coronary atherosclerotic heart disease. Ezetimibe is the first intestinal cholesterol absorption inhibitor. Its combination with statins for treating coronary atherosclerotic heart disease has attracted attention worldwide. Methods The study group comprised 106 patients with coronary atherosclerotic heart disease and hyperlipidaemia. Each was randomly assigned to one of two groups: (1) Ezetimibe (10mg, once a night) plus rosuvastatin (10mg, once a night) ( n =55) or (2) Rosuvastatin alone (10mg, once a night) ( n =51). The primary endpoint was new or recurrent myocardial infarction, unstable angina pectoris, cardiac death, and stroke. Blood lipid, high-sensitivity C-reactive protein (hsCRP), interleukin-6 (IL-6), and matrix metalloproteinase-9 (MMP-9) levels were measured before treatment and at one, six and 12 months after treatment. Coronary plaque size and compositional changes were determined using intravascular ultrasonography. Results The combination of ezetimibe plus rosuvastatin decreased total cholesterol, low-density lipoprotein cholesterol, hsCRP, IL-6, and MMP-9 levels at six and 12 months after treatment. Statistical significance was detected between two groups. At 12 months, the plaque burden, plaque cross-sectional area, and percentage of necrotic plaque composition were significantly lower in the combination group than in rosuvastatin alone group ( P Conclusions The combination of ezetimibe and rosuvastatin apparently diminishes lipid levels and plaque burden and improves plaque stability, which may be associated with the potent inhibitory effects of ezetimibe and rosuvastatin on inflammatory cytokines.

Effects of Combination of Ezetimibe and Rosuvastatin on Coronary Artery Plaque in Patients with Coronary Heart Disease.

Background
Previous studies suggest the higher the red blood cell distribution width (RDW) the greater the risk of mortality in patients with coronary artery disease (CAD). However, the relationship between RDW and long-term outcome in CAD patients undergoing percutaneous coronary intervention (PCI) with a drug-eluting stent (DES) remains unclear. This study was designed to evaluate the long-term effect of RDW in patients treated with drug-eluting stent for CAD.

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Red blood cell distribution width and long-term outcome in patients undergoing percutaneous coronary intervention in the drug-eluting stenting era: a two-year cohort study.

Tailoring of cardiovascular stent material surface by immobilizing exosomes for better pro-endothelialization function

tive Correspondence (Interaction between RAAS inhibitors and ACE2 in the context of COVID-19. Nat. Rev. Cardiol. https://doi.org/ 10.1038/s41569-020-0368-x (2020))1 on our Comment article (COVID-19 and the cardiovascular system. Nat. Rev. Cardiol. https://doi. org/10.1038/s41569-020-0360-5 (2020))2. We agree with their comments and acknowledge that different renin–angiotensin–aldosterone system (RAAS) inhibitors have different effects on angiotensin-converting enzyme 2 (ACE2) levels. Ferrario and colleagues3 reported that administration of either ACE inhibitors or angiotensinreceptor blockers (ARBs) increased the levels of Ace2 mRNA in Lewis rats compared with rats receiving placebo. In particular, cardiac levels of Ace2 mRNA increased by 4.7fold or 2.8fold in rats given either lisinopril (an ACE inhibitor) or losartan (an ARB), respectively. Furthermore, the researchers found that losartan treatment, but not lisinopril treatment, increased ACE2 activity compared with placebo. However, the researchers did not shed light on the mechanisms that might account for these differences. Nevertheless, Li and colleagues4 found that treatment with captopril (an ACE inhibitor) can significantly increase ACE2 protein expression in rats with acute lung injury. Furthermore, Wöstenvan Asperen and colleagues5 reported that, in a rat model of acute respiratory distress syndrome, ACE activity and angiotensin II expression are increased, whereas ACE2 activity and angiotensin-(1–7) levels are reduced. The protective effects of the ACE2– angiotensin-(1–7)–Mas receptor axis are primarily mediated by reductions in angiotensin II level6. Both ACE inhibitors and ARBs can reduce angiotensin II levels7. The former of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) infection, given that aliskiren can reduce the expression of ACE2. Although ACE2 has been identified as the functional receptor for SARSCoV-2, the role of ACE2 in the progression of COVID-19 after SARSCoV-2 infection is still controversial, so the benefits of aliskiren use in patients with COVID-19 needs further investigation.

Jin-Ying Zhang

Papers

COVID-19 and the cardiovascular system.

Effects of Combination of Ezetimibe and Rosuvastatin on Coronary Artery Plaque in Patients with Coronary Heart Disease.

Red blood cell distribution width and long-term outcome in patients undergoing percutaneous coronary intervention in the drug-eluting stenting era: a two-year cohort study.

Tailoring of cardiovascular stent material surface by immobilizing exosomes for better pro-endothelialization function

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