Vascular Dysfunction of COVID-19 Is Partially Reverted in the Long-Term

Vascular Alterations Following COVID-19 Infection: A Comprehensive Literature Review

SARS-CoV-2, the causative agent of the ongoing COVID-19 pandemic, has revealed a broader impact beyond the respiratory system, predominantly affecting the vascular system with various adverse manifestations. The infection induces endothelial dysfunction and immune system dysregulation, creating an inflammatory and hypercoagulable state. It affects both microvasculature and macrovasculature, leading to thromboembolic events, cardiovascular manifestations, impaired arterial stiffness, cerebrovascular complications, and nephropathy, as well as retinopathy-frequently observed in cases of severe illness. Evidence suggests that SARS-CoV-2 infection may result in persistent effects on the vascular system, identified as long-term COVID-19. This is characterized by prolonged inflammation, endotheliopathy, and an increased risk of vascular complications. Various imaging modalities, histopathological studies, and diagnostic tools such as video capillaroscopy and magnetic resonance imaging have been employed to visualize vascular alterations. This review aims to comprehensively summarize the evidence concerning short and long-term vascular alterations following COVID-19 infection, investigating their impact on patients' prognosis, and providing an overview of preventive strategies to mitigate associated vascular complications.

COVID-19 with high-sensitivity CRP associated with worse dynamic clinical parameters and outcomes

Objective

This study aimed to evaluate the relationship between high-sensitivity C-reactive protein (hsCRP) in hospitalized COVID-19 patients and their clinical outcomes, including trajectory of hsCRP changes during hospitalization.

Method and results

Patients with positive COVID-19 tests between 2021 and 2023 were admitted to two hospitals. Among 184 adult patients, approximately half (47.3%) had elevated hsCRP levels upon admission, which defined as exceeding the laboratory-specific upper limit of test (> 5.0 mg/L). Clinical outcomes included critical illness, acute kidney injury, thrombotic events, intensive care unit (ICU) requirement, and death during hospitalization. Elevated hsCRP levels had a higher risk of ICU requirement than those with normal, 39.1% versus 16.5%; adjusted odds ratio (aOR), 2.3 [95% CI, 1.05-5.01]; p = 0.036. Patients with extremely high (≥2 times) hsCRP levels had aOR, 2.65 [95% CI, 1.09-6.45]; p < 0.001. On the fifth day hospitalization, patients with high hsCRP levels associated with acute kidney injury (aOR, 4.13 [95% CI, 1.30-13.08]; p = 0.016), ICU requirement (aOR, 2.67 [95%CI, 1.02-6.99]; p = 0.044), or death (aOR, 4.24 [95% CI, 1.38-12.99]; p = 0.011). The likelihood of worse clinical outcomes increased as hsCRP levels rose; patients with elevated hsCRP had lower overall survival rate than those with normal (p = 0.02). The subset of high hsCRP patients with high viral load also had a shorter half-life compared to those with normal hsCRP level (p = 0.003).

Conclusion

Elevated hsCRP levels were found to be a significant predictor of ICU requirement, acute kidney injury, or death within 5 days after hospitalization in COVID-19 patients. This emphasized the importance of providing more intensive care management to patients with elevated hsCRP.

Is COVID-19 Infection a Multiorganic Disease? Focus on Extrapulmonary Involvement of SARS-CoV-2

First described in December 2019 in Wuhan (China), COVID-19 disease rapidly spread worldwide, constituting the biggest pandemic in the last 100 years. Even if SARS-CoV-2, the agent responsible for COVID-19, is mainly associated with pulmonary injury, evidence is growing that this virus can affect many organs, including the heart and vascular endothelial cells, and cause haemostasis, CNS, and kidney and gastrointestinal tract abnormalities that can impact in the disease course and prognosis. In fact, COVID-19 may affect almost all the organs. Hence, SARS-CoV-2 is essentially a systemic infection that can present a large number of clinical manifestations, and it is variable in distribution and severity, which means it is potentially life-threatening. The goal of this comprehensive review paper in the series is to give an overview of non-pulmonary involvement in COVID-19, with a special focus on underlying pathophysiological mechanisms and clinical presentation.

Post-COVID dysautonomias: what we know and (mainly) what we don't know

Following on from the COVID-19 pandemic is another worldwide public health challenge that is referred to variously as long COVID, post-COVID syndrome or post-acute sequelae of SARS-CoV-2 infection (PASC). PASC comes in many forms and affects all body organs. This heterogeneous presentation suggests involvement of the autonomic nervous system (ANS), which has numerous roles in the maintenance of homeostasis and coordination of responses to various stressors. Thus far, studies of ANS dysregulation in people with PASC have been largely observational and descriptive, based on symptom inventories or objective but indirect measures of cardiovascular function, and have paid little attention to the adrenomedullary, hormonal and enteric nervous components of the ANS. Such investigations do not consider the syndromic nature of autonomic dysfunction. This Review provides an update on the literature relating to ANS abnormalities in people with post-COVID syndrome and presents a theoretical perspective on how the ANS might participate in common features of PASC.

Ongoing Effects of SARS-CoV-2 Infection on Arterial Stiffness in Healthy Adults

There are limited data on the arterial stiffness changes after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The present study evaluated the changes in arterial stiffness in completely healthy patients who had a SARS-CoV-2 infection using the cardio-ankle vascular index (CAVI). The study included 70 patients with SARS-CoV-2 infection between December 2020 and June 2021. A cardiac evaluation was carried out, including chest X-ray, electrocardiography (ECG), and echocardiography in all patients. Within the 1st month and 7th month CAVI was measured. Mean age was 37.8 ± 10.0 years, and 41/70 were female. Mean height was 168.6 ± 9.5 cm, mean weight 73.2 ± 15.1 kg, and mean body mass index (BMI) of the group was 25.6 ± 4.2, respectively. CAVI results from the right arm were 6.45 ± .95 at 1-month follow-up and 6.68 ± 1.05 at 7 months follow-up (P = .016) and from the left arm were 6.43 ± 1.0 at 1-month follow-up, 6.70 ± 1.05 at 7-month follow-up (P = .005). Our results showed an ongoing injury in the arterial system after healthy SARS-COV-2 patients during 7 months, as represented by CAVI measurements.

Damage to endothelial barriers and its contribution to long COVID

The world continues to contend with COVID-19, fueled by the emergence of viral variants. At the same time, a subset of convalescent individuals continues to experience persistent and prolonged sequelae, known as long COVID. Clinical, autopsy, animal and in vitro studies all reveal endothelial injury in acute COVID-19 and convalescent patients. Endothelial dysfunction is now recognized as a central factor in COVID-19 progression and long COVID development. Different organs contain different types of endothelia, each with specific features, forming different endothelial barriers and executing different physiological functions. Endothelial injury results in contraction of cell margins (increased permeability), shedding of glycocalyx, extension of phosphatidylserine-rich filopods, and barrier damage. During acute SARS-CoV-2 infection, damaged endothelial cells promote diffuse microthrombi and destroy the endothelial (including blood-air, blood-brain, glomerular filtration and intestinal-blood) barriers, leading to multiple organ dysfunction. During the convalescence period, a subset of patients is unable to fully recover due to persistent endothelial dysfunction, contributing to long COVID. There is still an important knowledge gap between endothelial barrier damage in different organs and COVID-19 sequelae. In this article, we mainly focus on these endothelial barriers and their contribution to long COVID.

Association of COVID-19 and Arterial Stiffness Assessed using Cardiovascular Index (CAVI)

BACKGROUND

COVID-19 is characterized by an acute inflammatory response with the formation of endothelial dysfunction and may affect arterial stiffness. Studies of cardio-ankle vascular index in COVID-19 patients with considered cardiovascular risk factors have not been conducted.

OBJECTIVE

The purpose of our study was to assess the association between cardio-ankle vascular index and COVID-19 in hospitalized patients adjusted for known cardiovascular risk factors.

METHODS

A cross-sectional study included 174 people hospitalized with a diagnosis of moderate COVID-19 and 94 people without COVID-19. Significant differences in the cardio-ankle vascular index values measured by VaSera VS - 1500N between the two groups were analyzed using parametric (Student's t-criterion) and nonparametric (Mann-Whitney) criteria. Independent association between COVID-19 and an increased cardio-ankle vascular index ≥ 9.0 adjusted for known cardiovascular risk factors was assessed by multivariate logistic regression.

RESULTS

There were significantly higher values of the right cardio-ankle vascular index 8.10 [7.00;9.40] and the left cardio-ankle vascular index 8.10 [6.95;9.65] in patients undergoing inpatient treatment for COVID-19 than in the control group - 7.55 [6.60;8.60] and 7.60 [6.60;8.70], respectively. A multivariate logistic regression model adjusted for age, hypertension, plasma glucose level, glomerular filtration rate and diabetes mellitus showed a significant association between increased cardio-ankle vascular index and COVID-19 (OR 2.41 [CI 1.09;5.30]).

CONCLUSION

Hospitalized patients with COVID-19 had significantly higher cardio-ankle vascular index values compared to the control group. An association between an increased cardio-ankle vascular index and COVID-19 was revealed, independent of age, hypertension, plasma glucose level, glomerular filtration rate and diabetes mellitus.

Vascular "Long COVID": A New Vessel Disease?

Vascular sequelae following (SARS-CoV-2 coronavirus disease) (COVID)-19 infection are considered as "Long Covid (LC)" disease, when occurring 12 weeks after the original infection. The paucity of specific data can be obviated by translating pathophysiological elements from the original Severe Acute Respiratory Syndrome-Corona Virus (SARS-CoV-2) infection (In a microcirculatory system, a first "endotheliitis," is often followed by production of "Neutrophil Extracellular Trap," and can evolve into a more complex leukocytoklastic-like and hyperimmune vasculitis. In medium/large-sized vessels, this corresponds to endothelial dysfunction, leading to an accelerated progression of pre-existing atherosclerotic plaques through an increased deposition of platelets, circulating inflammatory cells and proteins. Associated dysregulated immune and pro-coagulant conditions can directly cause thrombo-embolic arterial or venous complications. In order to implement appropriate treatment, physicians need to consider vascular pathologies observed after SARS-Cov-2 infections as possible "LC" disease.

New-Onset Diabetes Mellitus in COVID-19: A Scoping Review

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic became superimposed on the pre-existing obesity and diabetes mellitus (DM) pandemics. Since COVID-19 infection alters the metabolic equilibrium, it may induce pathophysiologic mechanisms that potentiate new-onset DM, and we evaluated this issue.

METHOD

A systematic review of the literature published from the 1 January 2020 until the 20 July 2023 was performed (PROSPERO registration number CRD42022341638). We included only full-text articles of both human clinical and randomized controlled trials published in English and enrolling adults (age > 18 years old) with ongoing or preceding COVID-19 in whom hyperglycemia was detected. The search was based on the following criteria: "(new-onset diabetes mellitus OR new-onset DM) AND (COVID-19) AND adults".

RESULTS

Articles on MEDLINE (n = 70) and the Web of Science database (n = 16) were included and analyzed by two researchers who selected 20 relevant articles. We found evidence of a bidirectional relationship between COVID-19 and DM.

CONCLUSIONS

This link operates as a pathophysiological mechanism supported by epidemiological data and also by the clinical and biological findings obtained from the affected individuals. The COVID-19 pandemic raised the incidence of DM through different pathophysiological and psychosocial factors.

Leukocyte and Platelet Related Inflammatory Indicators and Risk of Carotid and Femoral Plaques: A Population-Based Cross-Sectional Study in Southeast China

The associations between several blood inflammatory indicators and risk of vascular plaques remain inconclusive. A total of 4596 native rural residents in Southeast China were enrolled from the Fuqing cohort study. Blood cell counts and their composite indexes including the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and 2 novel indicators (systemic immune inflammation index (SII) and systemic immune inflammation response index (SIRI)) were considered as inflammatory indicators. Common carotid and femoral intima-media thickness (IMT) and plaques were assessed using B-mode ultrasound. Unconditional or multinomial logistic regression was used to evaluate potential associations. The prevalence of multiple femoral plaques (defined as IMT ≥1.5 mm) was significantly higher among participants with the highest tertile of total leukocyte count (odds ratio, 1.78), neutrophil count (1.88), monocyte count (2.51), platelet count (1.68), NLR (1.93), PLR (1.57), SII (2.10), and SIRI (2.94). Higher levels of neutrophil count, platelet count, NLR, and SII were also found to have significant linear dose-response relationships with the prevalence of stenosis, especially in femoral arteries. In conclusion, several blood inflammatory biomarkers may contribute to, or are associated with, the presence of IMT ≥1.5 mm or stenosis especially in femoral arteries.

The long-term health outcomes, pathophysiological mechanisms and multidisciplinary management of long COVID

There have been hundreds of millions of cases of coronavirus disease 2019 (COVID-19), which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). With the growing population of recovered patients, it is crucial to understand the long-term consequences of the disease and management strategies. Although COVID-19 was initially considered an acute respiratory illness, recent evidence suggests that manifestations including but not limited to those of the cardiovascular, respiratory, neuropsychiatric, gastrointestinal, reproductive, and musculoskeletal systems may persist long after the acute phase. These persistent manifestations, also referred to as long COVID, could impact all patients with COVID-19 across the full spectrum of illness severity. Herein, we comprehensively review the current literature on long COVID, highlighting its epidemiological understanding, the impact of vaccinations, organ-specific sequelae, pathophysiological mechanisms, and multidisciplinary management strategies. In addition, the impact of psychological and psychosomatic factors is also underscored. Despite these crucial findings on long COVID, the current diagnostic and therapeutic strategies based on previous experience and pilot studies remain inadequate, and well-designed clinical trials should be prioritized to validate existing hypotheses. Thus, we propose the primary challenges concerning biological knowledge gaps and efficient remedies as well as discuss the corresponding recommendations.

A pilot study: Exploring the influence of COVID-19 on cardiovascular physiology and retinal microcirculation

BACKGROUND

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) affects the cardiovascular system. The current study investigated changes in heart rate (HR), blood pressure (BP), pulse wave velocity (PWV), and microcirculation in patients recovering from Coronavirus disease 2019 (COVID-19) infection.

METHODOLOGY

Out of 43 initially contacted COVID-19 patients, 35 (30 males, 5 females; age: 60 ± 10 years; and body mass index (BMI): 31.8 ± 4.9) participated in this study. Participants were seen on two occasions after hospital discharge; the baseline measurements were collected, either on the day of hospital discharge if a negative PCR test was obtained, or on the 10th day after hospitalization if the PCR test was positive. The second measurements were done 60 days after hospitalization. The vascular measurements were performed using the VICORDER® device and a retinal blood vessel image analysis.

RESULTS

A significant increase in systolic BP (SBP) (from 142 mmHg, SD: 15, to 150 mmHg, SD: 19, p = 0.041), reduction in HR (from 76 bpm, SD: 15, to 69 bpm, SD: 11, p = 0.001), and narrower central retinal vein equivalent (CRVE) (from 240.94 μm, SD: 16.05, to 198.05 μm, SD: 17.36, p = 0.013) were found. Furthermore, the trends of increasing PWV (from 11 m/s, SD: 3, to 12 m/s, SD: 3, p = 0.095) and decreasing CRAE (from 138.87 μm, SD: 12.19, to 136.77 μm, SD: 13.19, p = 0.068) were recorded.

CONCLUSION

The present study investigated cardiovascular changes following COVID-19 infection at two-time points after hospital discharge (baseline measurements and 60 days post-hospitalization). Significant changes were found in systolic blood pressure, heart rate, and microvasculature indicating that vascular adaptations may be ongoing even weeks after hospitalization from COVID-19 infection. Future studies could involve conducting additional interim assessments during the active infection and post-infection periods.

Baroreflex sensitivity is impaired in survivors of mild COVID-19 at 3-6 months of clinical recovery; association with carotid artery stiffness

The association between the stiffening of barosensitive regions of central arteries and the derangements in baroreflex functions remains unexplored in COVID-19 survivors. Fifty-seven survivors of mild COVID-19 (defined as presence of upper respiratory tract symptoms and/or fever without shortness of breath or hypoxia; SpO2 > 93%), with an age range of 22-66 years (27 females) participated at 3-6 months of recovering from the acute phase of RT-PCR positive COVID-19. Healthy volunteers whose baroreflex sensitivity (BRS) and arterial stiffness data were acquired prior to the onset of the pandemic constituted the control group. BRS was found to be significantly lower in the COVID survivor group for the systolic blood pressure-based sequences (BRSSBP ) [9.78 (7.16-17.74) ms/mmHg vs 16.5 (11.25-23.78) ms/mmHg; p = 0.0253]. The COVID survivor group showed significantly higher carotid β stiffness index [7.16 (5.75-8.18) vs 5.64 (4.34-6.96); (p = 0.0004)], and pulse wave velocity β (PWVβ ) [5.67 (4.96-6.32) m/s vs 5.12 (4.37-5.41) m/s; p = 0.0002]. BRS quantified by both the sequence and spectral methods showed an inverse correlation with PWVβ in the male survivors. Impairment of BRS in the male survivors of mild COVID-19 at 3-6 months of clinical recovery shows association with carotid artery stiffness.

Recovery of Endothelium-dependent vascular relaxation impairment in convalescent COVID-19 patients: Insight from a pilot study

BACKGROUND

Endothelial dysfunction is a key-feature in acute COVID-19. However, follow-up data regarding endothelial dysfunction and injury after COVID-19 infection are lacking. We aimed to investigate the changes in endothelium-dependent vasorelaxation at baseline and four months after hospital discharge in COVID-19 patients.

METHODS

Twenty COVID-19 patients were compared to 24 healthy controls. Clinical and morphological data were collected after hospital admission for SARS-CoV-2 infection and reactive hyperaemia index (RHI) measurement was performed with a delay between 24 and 48 h after hospital admission and four months after hospital discharge in the outpatient clinics. Blood tests including inflammatory markers and measurement of post-occlusive vasorelaxation by digital peripheral arterial tonometry were performed at both visits.

RESULTS

At baseline, COVID-19 patients exhibited reduced RHI compared to controls (p < 0.001), in line with an endothelial dysfunction. At four months follow-up, there was a 51% increase in the RHI (1.69 ± 0.32 to 2.51 ± 0.91; p < 0.01) in favor of endothelium-dependent vascular relaxation recovery. RHI changes were positively correlated with baseline C-reactive protein (r = 0.68; p = 0.02). Compared to COVID-19 patients with a decrease in RHI, COVID-19 patients with an increase in RHI beyond the day-to-day variability (i.e. >11%) had less severe systemic inflammation at baseline.

CONCLUSION

Convalescent COVID-19 patients showed a recovery of systemic artery endothelial dysfunction, in particular patients with lower inflammation at baseline. Further studies are needed to decipher the interplay between inflammation and endothelial dysfunction in COVID-19 patients.

Arterial Stiffness and its Impact on Cardiovascular Health

PURPOSE OF REVIEW

Cardiovascular diseases are the leading cause of mortality globally. Identifying patients at risk is important to initiate preventive strategies. Over the last few decades, the role of the endothelium and its impact on arterial stiffness have been recognised as playing a pivotal role in cardiovascular disease. This review will focus on the effect of arterial stiffness in different patient cohorts with regard to cardiovascular morbidity and mortality, as well as its use in clinical practice.

RECENT FINDINGS

Arterial stiffness is associated with a range of cardiovascular risk factors and is an independent predictor of cardiovascular mortality. The gold standard for evaluating arterial stiffness is pulse wave velocity. Recently, cardio-ankle vascular index has been implemented as an easy and highly reproducible measure of arterial stiffness. Moreover, certain pharmacologic agents may modify arterial stiffness and alter progression of cardiovascular disease. The endothelium plays an important role in cardiovascular disease. Implementing assessment of arterial stiffness in clinical practice will improve stratification of patients at risk of cardiovascular disease and help modify disease progression.

Pathophysiological Aspects of COVID-19-Associated Vasculopathic Diseases

Since the beginning of coronavirus disease 2019 (COVID-19) pandemic, numerous data reported potential effects on the cardiovascular system due to infection by severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2), which may lead to COVID-19-associated vasculopathies during the acute phase and measurable vascular changes in the convalescent phase. Infection by SARS-CoV-2 seems to have specific direct and indirect effects on the endothelium, immune and coagulation systems thus promoting endothelial dysfunction, immunothrombosis, and formation of neutrophil extracellular traps although the exact mechanisms still need to be elucidated. This review represents a recent update of pathophysiological pathways of the respective three major mechanisms contributing to COVID-19 vasculopathies and vascular changes and includes clinical implications and significance of outcome data.

Relationship between the structure, function and endothelial damage, and vascular ageing and the biopsychological situation in adults diagnosed with persistent COVID (BioICOPER study). A research protocol of a cross-sectional study

Background: SARS-CoV-2 infection affects the vascular endothelium, which mediates the inflammatory and thrombotic cascade. Moreover, alterations in the endothelium are related to arterial stiffness, which has been established as a marker of cardiovascular disease. The objective of this study is to analyse how the structure, vascular function, vascular ageing and endothelial damage are related to the biopsychological situation in adults diagnosed with persistent COVID and the differences by gender. Methods: This cross-sectional, descriptive, observational study will be carried out in the Primary Care Research Unit of Salamanca (APISAL) and in the BioSepsis laboratory of the University of Salamanca. The sample will be selected from the persistent COVID monographic office at the Internal Medicine Service of the University Hospital of Salamanca, and from the population of subjects diagnosed with persistent COVID in the clinical history of Primary Care. Through consecutive sampling, the study will include 300 individuals diagnosed with persistent COVID who meet the diagnosis criteria established by the WHO, after they sign the informed consent. Endothelial damage biomarkers will be measured using ELLA-SimplePlexTM technology (Biotechne). Their vascular structure and function will be analysed by measuring the carotid intima-media thickness (Sonosite Micromax); the pulse wave and carotid-femoral pulse wave velocity (cfPWV) will be recorded with Sphygmocor System®. Cardio Ankle Vascular Index (CAVI), brachial-ankle pulse wave velocity (baPWV) and ankle-brachial index will be analysed with Vasera VS-2000®. The integral assessment of the subjects with persistent COVID will be conducted with different scales that evaluate fatigue, sleep, dyspnea, quality of life, attention, nutrition state, and fragility. We will also evaluate their lifestyles (diet, physical activity, smoking habits and alcohol consumption), psychological factors, and cognitive deterioration, which will be gathered through validated questionnaires; moreover, physical activity will be objectively measured using a pedometer for 7 days. Body composition will be measured through impedance using an Inbody 230. Vascular ageing will be calculated with 10 and 90 percentiles of cfPWV and baPWV. Furthermore, we will analyse the presence of vascular injury in the retina, heart, kidneys and brain, as well as cardiovascular risk. Demographic and analytical variables will also be gathered. Discussion: Arterial stiffness reflects the mechanic and functional properties of the arterial wall, showing the changes in arterial pressure, blood flow, and vascular diameter that occur with each heartbeat. SARS-CoV-2 affects the endothelial cells that are infected with this virus, increasing the production of pro-inflammatory cytokines and pro-thrombotic factors, which can cause early vascular ageing and an increase of arterial stiffness. Persistent COVID is a complex heterogeneous disorder that affects the lives of millions of people worldwide. The identifications of potential risk factors to better understand who is at risk of developing persistent COVID is important, since this would enable early and appropriate clinical support. It is unknown whether vascular alterations caused by COVID-19 resolve after acute infection or remain over time, favouring the increase of arterial stiffness and early vascular ageing. Therefore, it is necessary to propose studies that analyse the evolution of persistent COVID in this group of patients, as well as the possible variables that influence it. Clinical Trial registration: ClinicalTrials.gov, identifier NCT05819840.

The Impact of COVID-19 on Carotid-Femoral Pulse Wave Velocity: A Systematic Review and Meta-Analysis

COVID-19 is a complex multisystemic disease that can result in long-term complications and, in severe cases, death. This study investigated the effect of COVID-19 on carotid-femoral pulse wave velocity (cfPWV) as a measurement to evaluate its impact on arterial stiffness and might help predict COVID-19-related cardiovascular (CV) complications. PubMed, Web of Science, Embase, and the Cochrane Library were searched for relevant studies, and meta-analysis was performed. The study protocol was registered in PROSPERO (nr. CRD42023434326). The Newcastle-Ottawa Quality Scale was used to evaluate the quality of the included studies. Nine studies reported cfPWV among COVID-19 patients and control groups. The pooled analysis showed that cfPWV in COVID-19 patients was 9.5 ± 3.7, compared to 8.2 ± 2.2 in control groups (MD = 1.32; 95% CI: 0.38-2.26; p = 0.006). A strong association between COVID-19 infection and increased cfPWV suggests a potential link between the virus and increased arterial stiffness. A marked increase in arterial stiffness, a known indicator of CV risk, clearly illustrates the cardiovascular implications of COVID-19 infection. However, further research is required to provide a clearer understanding of the connection between COVID-19 infection, arterial compliance, and subsequent CV events.

Incidence and predictors of development of new onset hypertension post COVID-19 disease

AIMS

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 virus) affects vital organs and causes vascular injury. There are concerns that this injury may have long-term consequences on the cardiovascular system after recovery from COVID-19. We investigated the incidence and predictors of new-onset hypertension at 1-year follow-up post-COVID-19 disease.

METHODS

In this prospective observational study, 393 patients hospitalised and diagnosed with COVID-19 disease at a tertiary cardiac care hospital during 27th March 2021 to 27th May 2021. Eligible 248 patients whose baseline characteristics, laboratory findings, treatment and outcome data were received systematically. Patients were followed up at 1 year of COVID-19 disease recovery.

RESULTS

We found that 32.3% of the population had new onset of hypertension at 1 year follow-up post-COVID-19 disease recovery. More hypertensive patients had severe computed tomography (CT) score severity (28.7 vs 14.9%; P 0.02). More number of patients in the hypertensive group were treated with steroids (73.8% vs 39%; p < 0.0001) during hospital stay. In-hospital complications were higher (12.5 vs 4.2%; P 0.03) in the hypertensive group. Patients who developed new-onset hypertension had statistically significantly higher baseline values of serum ferritin and C-reactive protein (CRP) (P 0.02 and 0.03 respectively). Vascular age was found 12.5 ± 3.96 years more than chronological age in hypertensive patients.

CONCLUSION

New onset of hypertension was detected in 32.3% of patients at one-year follow-up post-COVID-19 disease recovery. Severe inflammation at the time of admission and severe CT severity score were associated with the development of new onset of hypertension on follow-up.

Impact of Environmental Factors on Hypertension and Associated Cardiovascular Disease

Hypertension is the primary cause of cardiovascular diseases and is responsible for nearly 9 million deaths worldwide annually. Increasing evidence indicates that in addition to pathophysiologic processes, numerous environmental factors, such as geographic location, lifestyle choices, socioeconomic status, and cultural practices, influence the risk, progression, and severity of hypertension, even in the absence of genetic risk factors. In this review, we discuss the impact of some environmental determinants on hypertension. We focus on clinical data from large population studies and discuss some potential molecular and cellular mechanisms. We highlight how these environmental determinants are interconnected, as small changes in one factor might affect others, and further affect cardiovascular health. In addition, we discuss the crucial impact of socioeconomic factors and how these determinants influence diverse communities with economic disparities. Finally, we address opportunities and challenges for new research to address gaps in knowledge on understanding molecular mechanisms whereby environmental factors influence development of hypertension and associated cardiovascular disease.

Atherosclerosis Associated With COVID-19: Acute, Tends to Severely Involve Peripheral Arteries, and May be Reversible

Arterial stiffness was reported with corona virus disease 2019 (COVID-19). We studied atherosclerosis in COVID-19 directly through duplex ultrasound measurements and their relation to co-morbidities, clinical and laboratory severity markers, and serum interleukin (IL) 6 and 17. Serum IL 6 and 17, average carotid intima-media thickness (cIMT), diameter and peak systolic velocities (PSV) of tibial, ulnar, radial arteries, and ankle brachial index (ABI) were measured in 44 COVID-19 patients and 44 healthy controls. Serum IL6, IL17, PSV, and cIMT were higher while diameter was lower (P ≤ .01) in cases. Clinical severity index correlated positively with age, co-morbidities, ferritin, IL6, IL17, cIMT, and PSV (P ≤ .04) and negatively with diameter and ABI (P = .04). Patients with severe lymphopenia had higher PSV, IL6, and IL17 and lower diameter (P < .00001). Ferritin positively correlated with PSV and negatively with diameter and ABI (P ≤ .01). Those who received an IL6 inhibitor (tocilizumab) showed lower PSV and higher diameter (P ≤ .01). In multiple regression analysis, IL17 and (age, co-morbidities) were related to (PSV, diameter) and cIMT (P ≤ .001, ≤0.02), respectively. COVID-19 may be associated with subclinical acute and may be reversible atherosclerosis severely involving peripheral arteries.

Associations of Serum Calprotectin, Arterial Stiffness and Long COVID Symptoms in Dalmatian Kidney Transplant Recipients

We aimed to explore long COVID symptoms, serum calprotectin levels, and the parameters of arterial stiffness in Dalmatian kidney transplant recipients (KTRs) and their possible associations. A cross-sectional, single-center case-control study on 98 KTRs who had recovered from COVID-19 was performed. Long COVID symptoms were explored via standardized questionnaires assessing quality of life, and serum calprotectin was also measured. Out of 98 KTRs with a mean age of 62 years, 63 (64.3%) were men. Medical history, clinical and laboratory parameters, and arterial stiffness measurements were obtained for each study participant. Difficulties with mobility were present in 44.3% of the KTRs, while difficulties with self-care were present in 6.2%, difficulties with usual activities were demonstrated by 35.1%, pain in the extremities was present in 52.5%, and anxiety and depression were present in 26.8%. Our results showed significant differences regarding serum calprotectin levels in clinical manifestations of acute COVID-19 and follow-up laboratory parameters. The most significant positive predictors of the serum calprotectin value in the KTRs were respiratory insufficiency, acute kidney failure, the prescription of antihypertensives, leukocyte and neutrophil counts, the neutrophil/lymphocyte ratio and lactate dehydrogenase levels. Negative predictors were the time since COVID-19, high-density lipoprotein levels, kidney function parameters, and the lymphocyte count. To conclude, serum calprotectin has emerged as a possible promising biomarker for subclinical allograft rejection; however, further studies are needed to better understand this subject.

Autonomic modulation, spontaneous baroreflex sensitivity and fatigue in young men after COVID-19

Impaired autonomic modulation and baroreflex sensitivity (BRS) have been reported during and after COVID-19. Both impairments are associated with negative cardiovascular outcomes. If these impairments were to exist undetected in young men after COVID-19, they could lead to negative cardiovascular outcomes. Fatigue is associated with autonomic dysfunction during and after COVID-19. It is unclear if fatigue can be used as an indicator of impaired autonomic modulation and BRS after COVID-19. This study aims to compare parasympathetic modulation, sympathetic modulation, and BRS between young men who had COVID-19 versus controls and to determine if fatigue is associated with impaired autonomic modulation and BRS. Parasympathetic modulation as the high-frequency power of R-R intervals (lnHFR-R), sympathetic modulation as the low-frequency power of systolic blood pressure variability (LFSBP), and BRS as the -index were measured by power spectral density analysis. These variables were compared between 20 young men who had COVID-19 and 24 controls. Independent t-tests and Mann-Whitney U tests indicated no significant difference between the COVID-19 and the control group in: lnHFR-R, P=0.20; LFSBP, P=0.11, and -index, P=0.20. Fatigue was not associated with impaired autonomic modulation or BRS. There is no difference in autonomic modulations or BRS between young men who had COVID-19 compared to controls. Fatigue did not seem to be associated with impaired autonomic modulation or impaired BRS in young men after COVID-19. Findings suggest that young men might not be at increased cardiovascular risk from COVID-19-related dysautonomia and impaired BRS.

Distinct Features of Vascular Diseases in COVID-19

The Coronavirus Disease 2019 (COVID-19) pandemic was declared in early 2020 after several unexplained pneumonia cases were first reported in Wuhan, China, and subsequently in other parts of the world. Commonly, the disease comprises several clinical features, including high temperature, dry cough, shortness of breath, and hypoxia, associated with findings of interstitial pneumonia on chest X-ray and computer tomography. Nevertheless, severe forms of acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2) are not limited to the respiratory tract but also may be extended to other systems, including the cardiovascular system. The bi-directional relationship between atherosclerosis and COVID-19 is accompanied by poor prognosis. The immune response hyperactivation due to SARS-CoV-2 infection causes an increased secretion of cytokines, endothelial dysfunction, and arterial stiffness, which promotes the development of atherosclerosis. Also, due to the COVID-19 pandemic, access to healthcare amenities was reduced, resulting in increased morbidity and mortality in patients at risk. Furthermore, as lockdown measures were largely adopted worldwide, the sedentary lifestyle and the increased consumption of processed nutrients or unhealthy food increased, and in the consequence, we might observe even 70% of overweight and obese population. Altogether, with the relatively low ratio of vaccinated people in many countries, and important health debt appeared, which is now and will be for next decade a large healthcare challenge. However, the experience gained in the COVID-19 pandemic and the new methods of patients' approaching have helped the medical system to overcome this crisis and will hopefully help in the case of new possible epidemics.

Assessing Humoral Immuno-Inflammatory Pathways Associated with Respiratory Failure in COVID-19 Patients

All severe cases of SARS-CoV-2 infections are characterized by a high risk of disease progression towards ARDS, leading to a bad outcome. Respiratory symptoms in COVID-19 patients often do not correspond to disease's worsening. In our sample, median age was 74 years (72-75) and 54% were men. The median period of hospitalization was 9 days. Firstly, we observed a significant asynchronous trend of neutrophil-to-lymphocyte ratio (NLR) and C-reactive protein (CRP) in 764 selected among 963 patients, who were consecutively recruited in two hospitals (Cannizzaro, S. Marco) in Catania, Italy. NLR values in deceased patients showed an increase from baseline over time. By contrast, CRP tended to fall from baseline to median day of hospitalization in all three subgroups, but steeply increased at the end of hospitalization only in ICU-admitted patients. Then, we evaluated the relationships between NLR and CRP as continuous variables with PaO₂/FiO₂ ratio (P/F). NLR was an independent predictor of mortality (HR: 1.77, p < 0.0001), while ICU admission was more significantly associated with CRP (HR: 1.70, p < 0.0001). Finally, age, neutrophils, CRP, and lymphocytes are significantly and directly linked to P/F, while the influence of inflammation on P/F, reflected by CRP, was also mediated by neutrophils.

Beyond Acute COVID-19: A Review of Long-term Cardiovascular Outcomes

Statistics Canada estimated that approximately 1.4 million Canadians suffer from long COVID. Although cardiovascular changes during acute SARS-CoV-2 infection are well documented, long-term cardiovascular sequelae are less understood. In this review, we sought to characterize adult cardiovascular outcomes in the months after acute COVID-19 illness. In our search we identified reports of outcomes including cardiac dysautonomia, myocarditis, ischemic injuries, and ventricular dysfunction. Even in patients without overt cardiac outcomes, subclinical changes have been observed. Cardiovascular sequelae after SARS-CoV-2 infection can stem from exacerbation of preexisting conditions, ongoing inflammation, or as a result of damage that occurred during acute infection. For example, myocardial fibrosis has been reported months after hospital admission for COVID-19 illness, and might be a consequence of myocarditis and myocardial injury during acute disease. In turn, myocardial fibrosis can contribute to further outcomes including dysrhythmias and heart failure. Severity of acute infection might be a risk factor for long-term cardiovascular consequences, however, cardiovascular changes have also been reported in young, healthy individuals who had asymptomatic or mild acute disease. Although evolving evidence suggests that previous SARS-CoV-2 infection might be a risk factor for cardiovascular disease, there is heterogeneity in existing evidence, and some studies are marred by measured and unmeasured confounders. Many investigations have also been limited by relatively short follow-up. Future studies should focus on longer term outcomes (beyond 1 year) and identifying the prevalence of outcomes in different populations on the basis of acute and long COVID disease severity.

Long-Term Impact of COVID-19 on Heart Rate Variability: A Systematic Review of Observational Studies

Coronavirus disease 2019 (COVID-19) sequelae (or long COVID) has become a clinically significant concern. Several studies have reported the relationship between heart rate variability (HRV) parameters and COVID-19. This review investigates the long-term association between COVID-19 and HRV parameters. Four electronic databases were searched up to 29 July 2022. We included observational studies comparing HRV parameters (measurement durations: 1 min or more) in participants with and without a history of COVID-19. We used assessment tools developed by the National Heart, Lung, and Blood Institute group to evaluate the methodological quality of included studies. Eleven cross-sectional studies compared HRV parameters in individuals who recovered from acute COVID-19 infection to controls (n = 2197). Most studies reported standard deviation of normal-to-normal intervals (SDNN) and root mean square of the successive differences. The methodological quality of the included studies was not optimal. The included studies generally found decreased SDNN and parasympathetic activity in post-COVID-19 individuals. Compared to controls, decreases in SDNN were observed in individuals who recovered from COVID-19 or had long COVID. Most of the included studies emphasized parasympathetic inhibition in post-COVID-19 conditions. Due to the methodological limitations of measuring HRV parameters, the findings should be further validated by robust prospective longitudinal studies.

Current topic of vascular function in hypertension

Vascular function assessment is useful for the evaluation of atherosclerosis severity, which may provide additional information for cardiovascular risk stratification. In addition, vascular function assessment is helpful for a better understanding of pathophysiological associations between vascular dysfunction and cardiometabolic disorders. In 2020 and 2021, although coronavirus disease 2019 (COVID-19) was still a worldwide challenge for health care systems, many excellent articles regarding vascular function were published in Hypertension Research and other major cardiovascular and hypertension journals. In this review, we summarize new findings on vascular function and discuss the association between vascular function and COVID-19, the importance of lifestyle modifications for the maintenance of vascular function, and the usefulness of vascular function tests for cardiovascular risk assessment. We hope this review will be helpful for the management of cardiovascular risk factors, including hypertension and cardiovascular diseases, in clinical practice.

COVID-19-related arterio-ureteral fistula formation in a post-transplant patient

Arterio-ureteral fistulas (AUF) are extremely rare and are not commonly suspected in the setting of patients with post-renal allograft transplantation. The diagnosis, while uncommon, can be potentially lethal which is only exacerbated by the clinical conundrum associated with their under-recognition and various treatment algorithms. This case identifies a unique patient with a history of 2 failed renal transplants who presents with new onset intermittent hematuria after contracting coronavirus disease 2019 (COVID-19). Despite the patient having his second renal transplant graft embolized, the patient continued to present with refractory hematuria, leading to the realization and identification of an AUF to his right renal graft. This sequence of events brings forth a case of unique significance, underscoring the potential ramifications that COVID-19 poses to the renal transplant population.

Correspondence between Aortic and Arterial Stiffness, and Diastolic Dysfunction in Apparently Healthy Female Patients with Post-Acute COVID-19 Syndrome

(1) Background: Abnormally increased arterial and aortic stiffness (AS and AoS), which are often associated with diastolic dysfunction (DD), represent common alterations in COVID-19. In this study, we aimed to assess, by transthoracic echocardiography (TTE) and pulse-wave velocity (PWV), the frequency of these dysfunctions in patients with post-acute COVID-19 syndrome and to highlight potential correlations between their severity and multiple clinical and laboratory parameters. (2) Methods: In total, 121 women were included in our study, all of whom were younger than 55 and had been diagnosed with post-COVID-19 syndrome. Of those women, 67 also had metabolic syndrome (MS) (group A), whereas the other 54 did not (group B); 40 age-matched healthy subjects were used as controls (group C). (3) Results: Patients in group A had worse values of indexes characterizing AS and AoS and had more frequent DD compared to those from group B and group C (p < 0.0001). The statistical analysis evidenced significant associations between these indexes and the time that had elapsed since COVID-19 diagnosis, the factors that characterize the severity of the acute disease and those that specify MS. Multivariate regression analysis identified the following as the main independent predictors for DD: values of the AoS index, the C-reactive protein, and the triglyceride-glucose index. (4) Conclusions: Altered AS, AoS, and DD are common in patients with post-COVID-19 syndrome, especially with concurrent MS, and these parameters are apparently associated not only with the severity and time elapsed since COVID-19 diagnosis but also with MS.

Impact of COVID-19 on cardiac autonomic function in healthy young adults: potential role of symptomatology and time since diagnosis

Emerging evidence suggests that COVID-19 may affect cardiac autonomic function; however, the limited findings in young adults with COVID-19 have been equivocal. Notably, symptomology and time since diagnosis appear to influence vascular health following COVID-19, but this has not been explored in the context of cardiac autonomic regulation. Therefore, we hypothesized that young adults who had persistent symptoms following COVID-19 would have lower heart rate variability (HRV) and cardiac baroreflex sensitivity (BRS) compared with those who had COVID-19 but were asymptomatic at testing and controls who never had COVID-19. Furthermore, we hypothesized that there would be relationships between cardiac autonomic function measures and time since diagnosis. We studied 27 adults who had COVID-19 and were either asymptomatic (ASYM; n = 15, 6 females); 21 ± 4 yr; 8.4 ± 4.0 wk from diagnosis) or symptomatic (SYM; n = 12, 9 females); 24 ± 3 yr; 12.3 ± 6.2 wk from diagnosis) at testing, and 20 adults who reported never having COVID-19 (24 ± 4 yr, 11 females). Heart rate and beat-to-beat blood pressure were continuously recorded during 5 min of rest to assess HRV and cardiac BRS. HRV [root mean square of successive differences between normal heartbeats (RMSSD); control, 73 ± 50 ms; ASYM, 71 ± 47 ms; and SYM, 84 ± 45 ms; P = 0.774] and cardiac BRS (overall gain; control, 22.3 ± 10.1 ms/mmHg; ASYM, 22.7 ± 12.2 ms/mmHg; and SYM, 24.3 ± 10.8 ms/mmHg; P = 0.871) were not different between groups. However, we found correlations with time since diagnosis for HRV (e.g., RMSSD, r = 0.460, P = 0.016) and cardiac BRS (overall gain, r = 0.470, P = 0.014). These data suggest a transient impact of COVID-19 on cardiac autonomic function that appears mild and unrelated to persistent symptoms in young adults.NEW & NOTEWORTHY The potential role of persistent COVID-19 symptoms on cardiac autonomic function in young adults was investigated. We observed no differences in heart rate variability or cardiac baroreflex sensitivity between controls who never had COVID-19 and those who had COVID-19, regardless of symptomology. However, there were significant relationships between measures of cardiac autonomic function and time since diagnosis, suggesting that COVID-19-related changes in cardiac autonomic function are transient in young, otherwise healthy adults.

The Role of the Coagulation System in Peripheral Arterial Disease: Interactions with the Arterial Wall and Its Vascular Microenvironment and Implications for Rational Therapies

Peripheral artery disease (PAD) is a clinical manifestation of atherosclerotic disease with a large-scale impact on the economy and global health. Despite the role played by platelets in the process of atherogenesis being well recognized, evidence has been increasing on the contribution of the coagulation system to the atherosclerosis formation and PAD development, with important repercussions for the therapeutic approach. Histopathological analysis and some clinical studies conducted on atherosclerotic plaques testify to the existence of different types of plaques. Likely, the role of coagulation in each specific type of plaque can be an important determinant in the histopathological composition of atherosclerosis and in its future stability. In this review, we analyze the molecular contribution of inflammation and the coagulation system on PAD pathogenesis, focusing on molecular similarities and differences between atherogenesis in PAD and coronary artery disease (CAD) and discussing the possible implications for current therapeutic strategies and future perspectives accounting for molecular inflammatory and coagulation targets. Understanding the role of cross-talking between coagulation and inflammation in atherosclerosis genesis and progression could help in choosing the right patients for future dual pathway inhibition strategies, where an antiplatelet agent is combined with an anticoagulant, whose role, despite pathophysiological premises and trials' results, is still under debate.

Clinical implications of vascular dysfunction in acute and convalescent COVID-19: A systematic review

BACKGROUND

Accumulating evidence suggests that endothelial dysfunction is implicated in the pathogenesis and severity of coronavirus disease 2019 (COVID-19). In this context, vascular impairment in COVID-19 might be associated with clinical manifestations and could refine risk stratification in these patients.

METHODS

This systematic review aims to synthesize current evidence on the frequency and the prognostic value of vascular dysfunction during acute and post-recovery COVID-19. After systematically searching the MEDLINE, clinicaltrials.gov and the Cochrane Library from 1 December 2019 until 05 March 2022, we identified 24 eligible studies with laboratory confirmed COVID-19 and a thorough examination of vascular function. Flow-mediated dilation (FMD) was assessed in 5 and 12 studies in acute and post-recovery phase respectively; pulse wave velocity (PWV) was the marker of interest in three studies in the acute and four studies in the post-recovery phase.

RESULTS

All studies except for one in the acute and in the post-recovery phase showed positive association between vascular dysfunction and COVID-19 infection. Endothelial dysfunction in two studies and increased arterial stiffness in three studies were related to inferior survival in COVID-19.

DISCUSSION

Overall, a detrimental effect of COVID-19 on markers of endothelial function and arterial stiffness that could persist even for months after the resolution of the infection and provide prognostic value was congruent across published studies. Further research is warranted to elucidate clinical implications of this association.