SARS-CoV-2 Receptor ACE2 Gene Is Associated with Hypertension and Severity of COVID 19: Interaction with Sex, Obesity, and Smoking

Am J Hypertens. 2021 Apr 20;34(4):367-376. doi: 10.1093/ajh/hpaa223.


Background: Angiotensin-converting enzyme 2 (ACE2) has been identified as the entry receptor for coronaviruses into human cells, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that causes coronavirus disease 2019 (COVID-19). Since hypertension (HT) is a leading comorbidity in non-survivors of COVID-19, we tested for association between ACE2 gene and HT in interaction with specific pre-existing conditions known to be associated with COVID-19 severity.

Methods: Genetic analysis of ACE2 gene was conducted in French-Canadian (FC) and British populations.

Results: In FC individuals, the T allele of the single nucleotide polymorphism rs2074192 of ACE2 gene was a risk factor for HT in adult obese males [odds ratio (OR) = 1.39, 95% confidence interval (CI) 1.06-1.83)] and even more so in obese males who smoked (OR = 1.67, CI: 1.24-2.55), but not in lean males, non-smoker males or females. The T allele was significantly associated with severity of HT and with earlier penetrance of HT in obese smoking males. Significant interaction between the T allele and obesity was present in both sexes. The association of ACE2 (rs233575) genotype with blood pressure was also seen in adolescents but the interaction with obesity was present only in females. Several variants in ACE2 gene were found to be associated with HT in obese, smoking males in British individuals of the UK Biobank. In addition, we observed more severe outcomes to COVID-19 in association with ACE2 risk alleles in obese, smoking males.

Conclusions: This is the first report that ACE2 variants are associated with earlier penetrance and more severe HT and with more severe outcomes of COVID-19 in obese smoking males.

Keywords: ACE2; COVID-19; SARS–CoV-2; blood pressure; hypertension; obesity; sex; smoking.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Angiotensin-Converting Enzyme 2 / genetics*
  • Blood Pressure / physiology
  • COVID-19* / epidemiology
  • COVID-19* / therapy
  • Canada / epidemiology
  • Comorbidity
  • Female
  • Genetic Predisposition to Disease
  • Humans
  • Hypertension* / diagnosis
  • Hypertension* / epidemiology
  • Hypertension* / genetics
  • Male
  • Middle Aged
  • Obesity* / diagnosis
  • Obesity* / epidemiology
  • Obesity* / etiology
  • Polymorphism, Single Nucleotide
  • SARS-CoV-2 / physiology
  • Severity of Illness Index
  • Sex Factors
  • Smoking / epidemiology


  • ACE2 protein, human
  • Angiotensin-Converting Enzyme 2