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Daisley H, Acco O, Daisley M, George D, Paul L, James E, Rampersad A, Narinesingh F, Humphrey O, Daisley J, Nathan M. Thrombosis of the vasa vasorum of the large and medium size pulmonary artery and vein leads to pulmonary thromboembolism in COVID-19. Autops Case Rep 2024; 14:e2024491. [PMID: 38803482 PMCID: PMC11129857 DOI: 10.4322/acr.2024.491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 04/06/2024] [Indexed: 05/29/2024]
Abstract
The vasa vasorum of the large pulmonary vessels is involved in the pathology of COVID-19. This specialized microvasculature plays a major role in the biology and pathology of the pulmonary vessel walls. We have evidence that thrombosis of the vasa vasorum of the large and medium-sized pulmonary vessels during severe COVID-19 causes ischemia and subsequent death of the pulmonary vasculature endothelium. Subsequent release of thrombi from the vasa interna into the pulmonary circulation and pulmonary embolism generated at the ischemic pulmonary vascular endothelium site, are the central pathophysiological mechanisms in COVID-19 responsible for pulmonary thromboembolism. The thrombosis of the vasa vasorum of the large and medium-sized pulmonary vessels is an internal event leading to pulmonary thromboembolism in COVID-19.
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Affiliation(s)
| | - Oneka Acco
- The University of the West Indies, Mona, Jamaica
| | | | - Dennecia George
- Scarborough General Hospital, Signal Hill, Trinidad and Tobago
| | - Lilly Paul
- The University of the West Indies, Mona, Jamaica
| | - Errol James
- Beacon Plastic and Cosmetic Surgery, Woodbrook, Port of Spain, Trinidad and Tobago
| | | | | | | | - Johann Daisley
- Scarborough General Hospital, Signal Hill, Trinidad and Tobago
| | - Melissa Nathan
- The University of the West Indies, St Augustine, Trinidad and Tobago
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2
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Zekić T, Belančić A. Antiphospholipid syndrome, thrombosis, and vaccination in the COVID-19 pandemic. Rheumatol Int 2024; 44:749-755. [PMID: 38393386 DOI: 10.1007/s00296-023-05531-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 12/29/2023] [Indexed: 02/25/2024]
Abstract
Thrombosis is one of the many signs of antiphospholipid syndrome (APS) and COVID-19 infection. Although the mechanisms contributing to thrombosis in APS and COVID-19 are relatively similar, this remains an open subject. Even now (when the COVID-19 pandemic has subsided), there is no conclusive solution to APS and COVID-19 co-occurrence. The presence of newly generated antiphospholipid antibodies (aPLs) in COVID-19 infection may or may not be connected to the diagnosis of APS. The prevalence of aPLs is substantial in severe COVID-19 but not related to thrombosis or a worse outcome. Adequate monitoring of antibody positivity over time is recommended for APL diagnosis. On the other hand, thrombosis and thrombocytopenia can rarely occur with vaccination with mRNA vaccines. Some studies have shown that COVID-19 immunization is well tolerated among APS patients who are triple-positive for aPL, which may comfort patients and referring physicians and lessen hesitation in unvaccinated APS/aPL-positive patients. In this narrative review, we will give an overview of the interaction between aPL-APS-COVID-19-thrombosis and related diagnostic insights learned during the pandemic.
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Affiliation(s)
- Tatjana Zekić
- Clinical Hospital Center Rijeka, Department of Rheumatology and Clinical Immunology, University of Rijeka, Faculty of Medicine, Rijeka, Croatia.
- University of Rijeka, Faculty of Medicine, 51000, Rijeka, Croatia.
| | - Andrej Belančić
- Department of Clinical Pharmacology, Clinical Hospital Centre Rijeka, Krešimirova 42, 51000, Rijeka, Croatia
- Department of Basic and Clinical Pharmacology with Toxicology, University of Rijeka, Faculty of Medicine, Braće Branchetta 20, 51000, Rijeka, Croatia
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3
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Kell DB, Lip GYH, Pretorius E. Fibrinaloid Microclots and Atrial Fibrillation. Biomedicines 2024; 12:891. [PMID: 38672245 PMCID: PMC11048249 DOI: 10.3390/biomedicines12040891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 03/27/2024] [Accepted: 04/11/2024] [Indexed: 04/28/2024] Open
Abstract
Atrial fibrillation (AF) is a comorbidity of a variety of other chronic, inflammatory diseases for which fibrinaloid microclots are a known accompaniment (and in some cases, a cause, with a mechanistic basis). Clots are, of course, a well-known consequence of atrial fibrillation. We here ask the question whether the fibrinaloid microclots seen in plasma or serum may in fact also be a cause of (or contributor to) the development of AF. We consider known 'risk factors' for AF, and in particular, exogenous stimuli such as infection and air pollution by particulates, both of which are known to cause AF. The external accompaniments of both bacterial (lipopolysaccharide and lipoteichoic acids) and viral (SARS-CoV-2 spike protein) infections are known to stimulate fibrinaloid microclots when added in vitro, and fibrinaloid microclots, as with other amyloid proteins, can be cytotoxic, both by inducing hypoxia/reperfusion and by other means. Strokes and thromboembolisms are also common consequences of AF. Consequently, taking a systems approach, we review the considerable evidence in detail, which leads us to suggest that it is likely that microclots may well have an aetiological role in the development of AF. This has significant mechanistic and therapeutic implications.
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Affiliation(s)
- Douglas B. Kell
- Department of Biochemistry, Cell and Systems Biology, Institute of Systems, Molecular and Integrative Biology, Faculty of Health and Life Sciences, University of Liverpool, Crown St, Liverpool L69 7ZB, UK
- The Novo Nordisk Foundation Center for Biosustainability, Technical University of Denmark, Søltofts Plads, Building 220, 2800 Kongens Lyngby, Denmark
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Private Bag X1 Matieland, Stellenbosch 7602, South Africa
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool L7 8TX, UK;
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, 9220 Aalborg, Denmark
| | - Etheresia Pretorius
- Department of Biochemistry, Cell and Systems Biology, Institute of Systems, Molecular and Integrative Biology, Faculty of Health and Life Sciences, University of Liverpool, Crown St, Liverpool L69 7ZB, UK
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Private Bag X1 Matieland, Stellenbosch 7602, South Africa
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Duloquin G, Pommier T, Georges M, Giroud M, Guenancia C, Béjot Y, Laurent G, Rabec C. Is COVID-19 Infection a Multiorganic Disease? Focus on Extrapulmonary Involvement of SARS-CoV-2. J Clin Med 2024; 13:1397. [PMID: 38592697 PMCID: PMC10932259 DOI: 10.3390/jcm13051397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 02/20/2024] [Accepted: 02/27/2024] [Indexed: 04/10/2024] Open
Abstract
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.
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Affiliation(s)
- Gauthier Duloquin
- Department of Neurology, CHU Dijon-Bourgogne, 21000 Dijon, France; (G.D.); (M.G.); (Y.B.)
- Laboratory of Cerebro-Vascular Pathophysiology and Epidemiology (PEC2) EA 7460, University of Bourgogne, 21000 Dijon, France; (T.P.); (C.G.); (G.L.)
| | - Thibaut Pommier
- Laboratory of Cerebro-Vascular Pathophysiology and Epidemiology (PEC2) EA 7460, University of Bourgogne, 21000 Dijon, France; (T.P.); (C.G.); (G.L.)
- Department of Cardiology, University Hospital of Dijon, 21000 Dijon, France
| | - Marjolaine Georges
- Department of Pneumology and Intensive Care Unit, Reference Centre for Rare Lung Diseases, Dijon University Hospital, 14 Boulevard Gaffarel, 21000 Dijon, France;
- Centre des Sciences du Goût et de l’Alimentation, INRA, UMR 6265 CNRS 1234, University of Bourgogne Franche-Comté, 21000 Dijon, France
| | - Maurice Giroud
- Department of Neurology, CHU Dijon-Bourgogne, 21000 Dijon, France; (G.D.); (M.G.); (Y.B.)
- Laboratory of Cerebro-Vascular Pathophysiology and Epidemiology (PEC2) EA 7460, University of Bourgogne, 21000 Dijon, France; (T.P.); (C.G.); (G.L.)
| | - Charles Guenancia
- Laboratory of Cerebro-Vascular Pathophysiology and Epidemiology (PEC2) EA 7460, University of Bourgogne, 21000 Dijon, France; (T.P.); (C.G.); (G.L.)
- Department of Cardiology, University Hospital of Dijon, 21000 Dijon, France
| | - Yannick Béjot
- Department of Neurology, CHU Dijon-Bourgogne, 21000 Dijon, France; (G.D.); (M.G.); (Y.B.)
- Laboratory of Cerebro-Vascular Pathophysiology and Epidemiology (PEC2) EA 7460, University of Bourgogne, 21000 Dijon, France; (T.P.); (C.G.); (G.L.)
| | - Gabriel Laurent
- Laboratory of Cerebro-Vascular Pathophysiology and Epidemiology (PEC2) EA 7460, University of Bourgogne, 21000 Dijon, France; (T.P.); (C.G.); (G.L.)
- Department of Cardiology, University Hospital of Dijon, 21000 Dijon, France
| | - Claudio Rabec
- Department of Pneumology and Intensive Care Unit, Reference Centre for Rare Lung Diseases, Dijon University Hospital, 14 Boulevard Gaffarel, 21000 Dijon, France;
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Wang Z, Wang N, Chen R, Tang H, Lin Q, Li X. Urokinase prophylactic anticoagulation in children with nephrotic syndrome: a multicenter retrospective cohort study. BMC Nephrol 2024; 25:68. [PMID: 38408912 PMCID: PMC10895726 DOI: 10.1186/s12882-024-03502-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 02/14/2024] [Indexed: 02/28/2024] Open
Abstract
OBJECTIVE To analyze the clinical effect of urokinase on the prevention of thrombosis in children with primary nephrotic syndrome. METHODS A total of 370 children diagnosed with primary nephrotic syndrome (PNS) in the Children's Hospital of Soochow University and Zibo Maternal and Child Health Hospital from January 2018 to December 2022 were selected as the research objects. The patients were divided into a urokinase adjuvant therapy group and non-urokinase adjuvant therapy group according to the application of drugs. The clinical data of the children were collected, including sex, age, drug application, bleeding during treatment, and telephone follow-up, to record whether thromboembolism occurred in the acute stage and remission stage. The clinical pattern of PNS, renal biopsy, histopathological type, and related laboratory indexes before and after treatment were recorded. RESULTS A total of 313 patients were treated with urokinase and 57 patients were not. More thrombotic events was observed in non-urokinase group compared to the urokinase group(2 versus 0 episodes, p = 0.02). The thrombotic events observed included one patient had pulmonary embolism combined with right ventricular thrombosis, and another had intracranial venous thrombosis. More minor bleeding events occurred in urokinase group compared to the non-urokinase group(7 versus 1 episodes, p = 1.0). No major bleeding events occurred in either group. CONCLUSION The rational prophylactic use of urokinase anticoagulation in children with PNS can prevent the formation of thromboembolism and has good safety.
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Affiliation(s)
- Zhen Wang
- Department of Renal Immunology, Children's Hospital of Soochow University, Soochow, JiangSu, China
- Department of Pediatrics, Zibo Maternal and Child Health Hospital, Zibo ShanDong, China
| | - Nan Wang
- Department of Pediatrics, Zibo Maternal and Child Health Hospital, Zibo ShanDong, China
| | - Ruyue Chen
- Department of Renal Immunology, Children's Hospital of Soochow University, Soochow, JiangSu, China
| | - Hanyun Tang
- Department of Renal Immunology, Children's Hospital of Soochow University, Soochow, JiangSu, China
| | - Qiang Lin
- Department of Renal Immunology, Children's Hospital of Soochow University, Soochow, JiangSu, China
| | - Xiaozhong Li
- Department of Renal Immunology, Children's Hospital of Soochow University, Soochow, JiangSu, China.
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White NJ, Wenthe A. Managing Hemostasis in Space. Arterioscler Thromb Vasc Biol 2023; 43:2079-2087. [PMID: 37795614 DOI: 10.1161/atvbaha.123.318783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 09/06/2023] [Indexed: 10/06/2023]
Abstract
Human space travel requires exposure to weightlessness, ionizing radiation, isolation, and austerity. A recent report of internal jugular vein thrombosis in astronauts in low Earth orbit confirms that these exposures also affect vascular biology to influence diseases of thrombosis and hemostasis. This brief review summarizes the known influences of space travel on inflammation, blood coagulation, and the cardiovascular system and conceptualizes how they might combine to affect thrombosis and hemostasis. In the event of a major thrombotic or bleeding emergency, it is anticipated that the unique physiological influences of the space environment and logistical limitations of providing medical care in space would require a response that is unique from our current experience. We also look towards the future to discuss lessons learned from our current experiences on Earth and in space.
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Affiliation(s)
- Nathan J White
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle (N.J.W.)
- University of Washington Resuscitation Engineering Science Unit (RESCU) (N.J.W., A.W.)
| | - Andrew Wenthe
- University of Washington Resuscitation Engineering Science Unit (RESCU) (N.J.W., A.W.)
- U.S. Navy, Active Duty, Special Operations Combat Medic-SOCM (A.W.)
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7
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Mv P, Auanassova A, Yessirkepov M, Zimba O, Gasparyan AY, Kitas GD, Ahmed S. New-onset systemic vasculitis following SARS-CoV-2 infection and vaccination: the trigger, phenotype, and outcome. Clin Rheumatol 2023; 42:2761-2775. [PMID: 37422611 DOI: 10.1007/s10067-023-06694-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 06/13/2023] [Accepted: 07/02/2023] [Indexed: 07/10/2023]
Abstract
The global health crisis caused by the COVID-19 pandemic overwhelmed the capacity of healthcare systems to cope with the rapidly spreading infection and its associated complications. Among these complications, autoimmune phenomena such as systemic vasculitis emerged as a significant challenge. Both the SARS-CoV-2 virus and the vaccines developed to combat it appeared to induce clinical manifestations resembling various types of systemic vasculitis, affecting large, medium, and small vessels. These virus- or vaccine-induced vasculitides exhibited a distinct natural history and course from de novo vasculitis, as they were more responsive to steroid therapy and some mild cases even resolved spontaneously. Notably, there have been no confirmed cases of SARS-CoV-2 infection or vaccination triggering variable vessel vasculitis like Behcet's disease or Kawasaki disease. IgA vasculitis, which is predominantly a pediatric condition, was more prevalent in adults after COVID-19 infection and they had a favorable outcome with glucocorticoid treatment. The impact of immunosuppression, especially B-cell-depleting agents, on the immunogenicity of the vaccine was evident, but there was no significant increase in the incidence of SARS-CoV-2 infection in these patients compared to the general population. Considering their relatively benign course, these post-COVID or post-vaccine vasculitides seem to be amenable to 0.8 to 1 mg/kg prednisolone or equivalent, which could be gradually tapered. The need for immunosuppression and the duration of steroid therapy should be determined on an individual basis. While the world still reels from the perils of a deadly pandemic, the aftermath continues to haunt. Our narrative review aims to explore the effects of COVID and the vaccine on systemic vasculitis, as well as the effect of disease and immunosuppression on the immunogenicity of the COVID vaccine.
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Affiliation(s)
- Prakashini Mv
- Department of Clinical Immunology and Rheumatology, Kalinga Institute of Medical Sciences, KIIT University, Bhubaneswar, India, 751024
| | - Akerke Auanassova
- Department of Biology and Biochemistry, South Kazakhstan Medical Academy, Shymkent, Kazakhstan
| | - Marlen Yessirkepov
- Department of Biology and Biochemistry, South Kazakhstan Medical Academy, Shymkent, Kazakhstan
| | - Olena Zimba
- Department of Clinical Rheumatology and Immunology, University Hospital in Krakow, Krakow, Poland
- National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
- Department of Internal Medicine N2, Danylo Halytsky Lviv National Medical University, Lviv, Ukraine
| | - Armen Yuri Gasparyan
- Departments of Rheumatology and Research and Development, Dudley Group NHS Foundation Trust (Teaching Trust of the University of Birmingham, UK), Russells Hall Hospital, Dudley, West Midlands, UK
| | - George D Kitas
- Departments of Rheumatology and Research and Development, Dudley Group NHS Foundation Trust (Teaching Trust of the University of Birmingham, UK), Russells Hall Hospital, Dudley, West Midlands, UK
- Centre for Epidemiology Versus Arthritis, University of Manchester, Manchester, UK
| | - Sakir Ahmed
- Department of Clinical Immunology and Rheumatology, Kalinga Institute of Medical Sciences, KIIT University, Bhubaneswar, India, 751024.
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Carney PR, Stevenson DW, Riggs E, Dervisevic M, Carney CX, Gomez CR. Thrombectomy of an Acute Ischemic Stroke in a Child with COVID-19 and MIS-C: Case Analysis and Literature Context. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10050851. [PMID: 37238399 DOI: 10.3390/children10050851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 03/27/2023] [Accepted: 04/27/2023] [Indexed: 05/28/2023]
Abstract
We describe a very young child who developed an acute ischemic stroke from a LAO, while affected by COVID-19 and MIS-C, and whom we treated successfully with thrombectomy. We compare his clinical and imaging findings with those of the existing case reports, and we explore the multifactorial nature of such a neurovascular complication, particularly in the context of the most recent publications regarding the multifactorial endothelial derangements produced by the illness.
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Affiliation(s)
- Paul R Carney
- Department of Child Health, University of Missouri School of Medicine, Columbia, MO 65201, USA
- Department of Neurology, University of Missouri School of Medicine, Colombia, MO 65212, USA
| | - Dakota W Stevenson
- Department of Neurology, University of Missouri School of Medicine, Colombia, MO 65212, USA
| | - Edith Riggs
- Department of Child Health, University of Missouri School of Medicine, Columbia, MO 65201, USA
| | - Matilda Dervisevic
- Department of Child Health, University of Missouri School of Medicine, Columbia, MO 65201, USA
| | - Constanza X Carney
- Department of Epidemiology, George Washington University, Washington, DC 20052, USA
| | - Camilo R Gomez
- Department of Neurology, University of Missouri School of Medicine, Colombia, MO 65212, USA
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Kanuri SH, Jayesh Sirrkay P, Ulucay AS. COVID-19 HEART unveiling as atrial fibrillation: pathophysiology, management and future directions for research. Egypt Heart J 2023; 75:36. [PMID: 37120772 PMCID: PMC10149046 DOI: 10.1186/s43044-023-00359-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 04/22/2023] [Indexed: 05/01/2023] Open
Abstract
BACKGROUND COVID-19 infections are known to cause numerous systemic complications including cardiovascular disorders. In this regard, clinicians recently noticed that patients recovering from COVID-19 infections presented with diverse set of cardiovascular disorders in addition to those admitted to ICU (intensive care unit). COVID-19 heart has multifaceted presentation ranging from dysrhythmias, myocarditis, stroke, coronary artery disease, thromboembolism to heart failure. Atrial fibrillation is the most common cardiac arrhythmia among COVID-19 patients. In the background section, we briefly discussed epidemiology and spectrum of cardiac arrhythmias in COVID-19 patients. MAIN BODY In this state-of-the-art review we present here, we present the information regarding COVID-19-induced A-fib in sections, namely mechanism of action, clinical presentation, diagnosis and treatment. Unfortunately, its occurrence significantly increases the mortality and morbidity with a potential risk of complications such as cardiac arrest and sudden death. We included separate sections on complications including thromboembolism and ventricular arrhythmias. Since its mechanism is currently a gray area, we included a separate section on basic science research studies that are warranted in the future to comprehend its underlying pathogenic mechanisms. CONCLUSIONS Taken together, this review builds upon the current literature of COVID-19-induced A-fib, including pathophysiology, clinical presentation, treatment and complications. Furthermore, it provides recommendations for future research moving forward that can open avenues for developing novel remedies that can prevent as well as hasten clinical recovery of atrial fibrillation in COVID-19 patients.
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10
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Sun C, Wang R, Wang L, Wang P, Qin Y, Zhou Q, Guo Y, Zhao M, He W, Hu B, Yao Z, Zhang P, Wu T, Wang Y, Zhang Q. The interaction effect of transfusion history and previous stroke history on the risk of venous thromboembolism in stroke patients: a prospective cohort study. Thromb J 2023; 21:41. [PMID: 37069620 PMCID: PMC10108449 DOI: 10.1186/s12959-023-00487-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 04/07/2023] [Indexed: 04/19/2023] Open
Abstract
BACKGROUND Blood transfusion and previous stroke history are two independent risk factors of venous thromboembolism (VTE) in stroke patients. Whether the potential interaction of transfusion history and previous stroke history is associated with a greater risk of VTE remains unclear. This study aims to explore whether the combination of transfusion history and previous stroke history increases the risk of VTE among Chinese stroke patients. METHODS A total of 1525 participants from the prospective Stroke Cohort of Henan Province were enrolled in our study. Multivariate logistic regression models were used to explore the associations among transfusion history, previous stroke history and VTE. The interaction was evaluated on both multiplicative and additive scales. The odds ratio (95% CI), relative excess risk of interaction (RERI), attributable proportion (AP), and synergy index (S) of interaction terms were used to examine multiplicative and additive interactions. Finally, we divided our population into two subgroups by National Institutes of Health Stroke Scale (NIHSS) score and re-evaluated the interaction effect in both scales. RESULTS A total of 281 (18.4%) participants of 1525 complicated with VTE. Transfusion and previous stroke history were associated with an increased risk of VTE in our cohort. In the multiplicative scale, the combination of transfusion and previous stroke history was statistically significant on VTE in both unadjusted and adjusted models (P<0.05). For the additive scale, the RERI shrank to 7.016 (95% CI: 1.489 ~ 18.165), with the AP of 0.650 (95% CI: 0.204 ~ 0.797) and the S of 3.529 (95% CI: 1.415 ~ 8.579) after adjusting for covariates, indicating a supra-additive effect. In subgroups, the interaction effect between transfusion history and previous stroke history was pronouncedly associated with the increased risk of VTE in patients with NIHSS score > 5 points (P<0.05). CONCLUSIONS Our results suggest that there may be a potential synergistic interaction between transfusion history and previous stroke history on the risk of VTE. Besides, the percentage of VTE incidence explained by interaction increased with the severity of stroke. Our findings will provide valuable evidence for thromboprophylaxis in Chinese stroke patients.
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Affiliation(s)
- Changqing Sun
- School of Nursing and Health, Zhengzhou University, 101 Kexue Avenue, Zhengzhou, 450001, Henan, PR China
- School of Public Health, Zhengzhou University, Zhengzhou, PR China
| | - Rongrong Wang
- School of Nursing and Health, Zhengzhou University, 101 Kexue Avenue, Zhengzhou, 450001, Henan, PR China
| | - Lianke Wang
- School of Public Health, Zhengzhou University, Zhengzhou, PR China
| | - Panpan Wang
- School of Nursing and Health, Zhengzhou University, 101 Kexue Avenue, Zhengzhou, 450001, Henan, PR China
| | - Ying Qin
- School of Nursing and Health, Zhengzhou University, 101 Kexue Avenue, Zhengzhou, 450001, Henan, PR China
| | - Qianyu Zhou
- School of Public Health, Zhengzhou University, Zhengzhou, PR China
| | - Yuanli Guo
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, PR China
| | - Mingyang Zhao
- School of Public Health, Zhengzhou University, Zhengzhou, PR China
| | - Wenqian He
- School of Nursing and Health, Zhengzhou University, 101 Kexue Avenue, Zhengzhou, 450001, Henan, PR China
| | - Bo Hu
- School of Nursing and Health, Zhengzhou University, 101 Kexue Avenue, Zhengzhou, 450001, Henan, PR China
| | - Zihui Yao
- School of Nursing and Health, Zhengzhou University, 101 Kexue Avenue, Zhengzhou, 450001, Henan, PR China
| | - Peijia Zhang
- School of Nursing and Health, Zhengzhou University, 101 Kexue Avenue, Zhengzhou, 450001, Henan, PR China
| | - Tiantian Wu
- School of Nursing and Health, Zhengzhou University, 101 Kexue Avenue, Zhengzhou, 450001, Henan, PR China
| | - Yu Wang
- School of Nursing and Health, Zhengzhou University, 101 Kexue Avenue, Zhengzhou, 450001, Henan, PR China
| | - Qiang Zhang
- School of Nursing and Health, Zhengzhou University, 101 Kexue Avenue, Zhengzhou, 450001, Henan, PR China.
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11
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Microvascular Thrombosis as a Critical Factor in Severe COVID-19. Int J Mol Sci 2023; 24:ijms24032492. [PMID: 36768817 PMCID: PMC9916726 DOI: 10.3390/ijms24032492] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 01/21/2023] [Accepted: 01/25/2023] [Indexed: 01/31/2023] Open
Abstract
Platelet-endothelial interactions have a critical role in microcirculatory function, which maintains tissue homeostasis. The subtle equilibrium between platelets and the vessel wall is disturbed by the coronavirus disease 2019 (COVID-19), which affects all three components of Virchow's triad (endothelial injury, stasis and a hypercoagulable state). Endotheliitis, vasculitis, glycocalyx degradation, alterations in blood flow and viscosity, neutrophil extracellular trap formation and microparticle shedding are only few pathomechanisms contributing to endothelial damage and microthrombosis resulting in capillary plugging and tissue ischemia. In the following opinion paper, we discuss major pathological processes leading to microvascular endothelial activation and thrombosis formation as a possible major adverse factor driving the deterioration of patient disease course in severe COVID-19.
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12
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Muacevic A, Adler JR. Acute Cerebral Infarct and Saddle Pulmonary Embolism in a Post-COVID-19 Patient Treated With Thrombolytics. Cureus 2023; 15:e33877. [PMID: 36819369 PMCID: PMC9934941 DOI: 10.7759/cureus.33877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2023] [Indexed: 01/19/2023] Open
Abstract
The coronavirus disease 2019 (COVID-19) has been associated with a prothrombotic state during active infection with the severe acute respiratory syndrome coronavirus (SARS-CoV-2). However, reports of delayed multisystemic COVID-19-associated thromboembolic sequelae are limited in the current literature. In addition, the initiation of prophylactic antithrombotic therapy in patients for the prevention of such events during and after infection remains controversial due to conflicting reports. Here, we present evidence to support that patients with comorbid conditions are at higher risk for multisystemic COVID-19-associated thromboembolic events and propose that beginning prophylactic therapy in this population could lead to more favorable outcomes. We describe a 67-year-old male who presented with left-sided weakness and worsening shortness of breath and was diagnosed with COVID-19 approximately one month prior. Initial computed tomography (CT) of the brain showed an age-indeterminate cerebellar infarct. On CT angiography (CTA) of the neck, a saddle embolus was incidentally found and was confirmed on an immediate follow-up chest CT. After consultation with neurology, a decision was made to administer thrombolytics at the standard recommended stroke dosing. The patient was admitted to the ICU and received mechanical thrombectomy two days later. At the time of hospital discharge, the patient still had left-sided weakness on examination and required no additional oxygen support. This report reviews the prevalence of delayed sequelae of COVID-19 and the benefit of prophylactic antithrombotic therapy during active and post-SARS-CoV-2 infection. It is important for emergency medicine physicians to recognize that patients who have recovered from COVID-19 are at high risk for delayed thromboembolic disease, even in the absence of personal or family history of coagulopathy. This underscores the necessity of obtaining imaging studies in high-risk patients who present with acute symptoms that cannot be explained by other probable causes. In addition, patients should be encouraged to follow up with their primary care providers to discuss prophylactic anticoagulation therapy as it could be beneficial during and post-COVID-19.
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Falcinelli E, Petito E, Gresele P. The role of platelets, neutrophils and endothelium in COVID-19 infection. Expert Rev Hematol 2022; 15:727-745. [PMID: 35930267 DOI: 10.1080/17474086.2022.2110061] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION COVID-19 is associated to an increased risk of thrombosis, as a result of a complex process that involves the activation of vascular and circulating cells, the release of soluble inflammatory and thrombotic mediators and blood clotting activation. AREAS COVERED This article reviews the pathophysiological role of platelets, neutrophils and the endothelium, and of their interactions, in the thrombotic complications of COVID-19 patients, and the current and future therapeutic approaches targeting these cell types. EXPERT OPINION Virus-induced platelet, neutrophil and endothelial cell changes are crucial triggers of the thrombotic complications and of the adverse evolution of COVID-19. Both the direct interaction with the virus and the associated cytokine storm concur to trigger cell activation in a classical thromboinflammatory vicious circle. Although heparin has proven to be an effective prophylactic and therapeutic weapon for the prevention and treatment of COVID-19-associated thrombosis, it acts downstream of the cascade of events triggered by SARS-CoV-2. The identification of specific molecular targets interrupting the thromboinflammatory cascade upstream, and more specifically acting either on the interaction of SARS-CoV-2 with blood and vascular cells or on the specific signalling mechanisms associated with their COVID-19-associated activation, might theoretically offer greater protection with potentially lesser side effects.
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Affiliation(s)
- E Falcinelli
- Section of Internal and Cardiovascular Medicine, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - E Petito
- Section of Internal and Cardiovascular Medicine, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - P Gresele
- Section of Internal and Cardiovascular Medicine, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
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Ferdiana KA, Ramlan AAW, Soenarto RF, Alatas A. Thromboelastographic method for early decision on anticoagulant therapy in moderate to severe COVID-19 patients. MEDICAL JOURNAL OF INDONESIA 2022. [DOI: 10.13181/mji.oa.225890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND Coagulopathy is a serious COVID-19 complication that requires rapid diagnosis and anticoagulation. This study aimed to determine the role of coagulation examination using thromboelastography (TEG) on the decision-making time of anticoagulant therapy in COVID-19 patients and its clinical outcomes.
METHODS A prospective observational study was conducted in Cipto Mangunkusumo Hospital, Indonesia, from October 2020 to March 2021. We consecutively recruited moderate and severe COVID-19 patients in the high and intensive care units. Turnaround time, time to anticoagulant therapy decision, and clinical outcomes (length of stay and 30-day mortality) were compared between those who had a TEG examination in addition to the standard coagulation profile examination (thrombocyte count, PT, APTT, D-dimer, and fibrinogen) and those who had only a standard coagulation profile laboratory examination.
RESULTS Among 100 moderate to severe COVID-19 patients recruited, 50 patients had a TEG examination. The turnaround time of TEG was 45 (15–102) min versus 82 (19–164) min in the standard examination (p<0.001). The time to decision was significantly faster in the TEG group than the standard group (75 [42–133] min versus 184 [92–353] min, p<0.001). The turnaround time was positively correlated with time to decision (r = 0.760, p<0.001). However, TEG did not improve clinical outcomes such as length of stay (10.5 [3–20] versus 9 [2–39] days) and 30-day mortality (66% versus 64%).
CONCLUSIONS The TEG method significantly enables quicker decision-making time for moderate to severe coagulation disorder in COVID-19 patients.
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Whiteson JH, Azola A, Barry JT, Bartels MN, Blitshteyn S, Fleming TK, McCauley MD, Neal JD, Pillarisetti J, Sampsel S, Silver JK, Terzic CM, Tosto J, Verduzco‐Gutierrez M, Putrino D. Multi-disciplinary collaborative consensus guidance statement on the assessment and treatment of cardiovascular complications in patients with post-acute sequelae of SARS-CoV-2 infection (PASC). PM R 2022; 14:855-878. [PMID: 35657351 PMCID: PMC9347705 DOI: 10.1002/pmrj.12859] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 05/27/2022] [Accepted: 06/01/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Jonathan H. Whiteson
- Department of Rehabilitation Medicine and Department of MedicineRusk Rehabilitation, NYU Langone HealthNew YorkNew YorkUSA
| | - Alba Azola
- Department of Physical Medicine and RehabilitationJohns Hopkins School of MedicineBaltimoreMarylandUSA
| | - John T. Barry
- Good Shepherd Penn Partners, Penn Therapy & Fitness—University CityPhiladelphiaPennsylvaniaUSA
| | - Matthew N. Bartels
- Department of Rehabilitation Medicine, Montefiore Health SystemAlbert Einstein College of MedicineBronxNew YorkUSA
| | - Svetlana Blitshteyn
- Department of NeurologyUniversity at Buffalo Jacobs School of Medicine and Biomedical SciencesBuffaloNew YorkUSA
| | - Talya K. Fleming
- Department of Physcial Medicine and RehabilitationJFK Johnson Rehabilitation Institute at Hackensack Meridian HealthEdisonNew JerseyUSA
| | - Mark D. McCauley
- Department of Medicine, Section of CardiologyUniversity of Illinois at Chicago and Jesse Brown VA Medical CenterChicagoIllinoisUSA
| | - Jacqueline D. Neal
- Physical Medicine and RehabilitationNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA,Physical Medicine and RehabilitationPhysical Medicine and Rehabilitation, Jesse Brown VA Medical CenterChicagoIllinoisUSA
| | - Jayasree Pillarisetti
- Division of Cardiology, Department of MedicineUniversity of Texas Health San AntonioSan AntonioTexasUSA
| | | | - Julie K. Silver
- Department of Physical Medicine and RehabilitationHarvard Medical School, Spaulding Rehabilitation HospitalBostonMassachusettsUSA
| | - Carmen M. Terzic
- Department of Physical Medicine and Rehabilitation and Department of Cardiovascular MedicineMayo ClinicRochesterMinnesotaUSA
| | - Jenna Tosto
- Department of Rehabilitation and Human Performance, Abilities Research CenterIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | | | - David Putrino
- Department of Rehabilitation and Human PerformanceIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
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COVID-19 and thrombosis: The role of hemodynamics. Thromb Res 2022; 212:51-57. [PMID: 35219932 PMCID: PMC8864963 DOI: 10.1016/j.thromres.2022.02.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 01/24/2022] [Accepted: 02/18/2022] [Indexed: 12/16/2022]
Abstract
Severe coronavirus disease 2019 (COVID-19) is characterized by an increased risk of thromboembolic events, a leading cause for adverse outcomes in patients afflicted by the more serious manifestation of the disease. These thromboembolic complications expressed as sepsis-induced coagulopathy, disseminated intravascular coagulation, venous and arterial thromboembolism, pulmonary embolism, microthrombosis, and thrombotic microangiopathy have been observed to affect different organs such as the lungs, heart, kidneys, and brain. Endothelial injury and dysfunction have been identified as the critical pathway towards thrombogenesis, and contributions of other mechanisms such as hypercoagulability, cytokine storm, neutrophils have been studied. However, the contribution of hemodynamic pathways towards thrombosis in severe COVID-19 cases has not been investigated. From the classical theory of Virchow's triad to the contemporary studies on the effect of shear enhanced platelet activation, it is well established that hemodynamics plays a role in the initiation and growth of thrombosis. This article reviews recent studies on COVID-19 related thrombotic events and offers hypotheses on how hemodynamics may be responsible for some of the adverse outcomes observed in severe COVID-19 cases. While thrombogenesis through endothelial injury and the effects of hypercoagulability on thrombosis are briefly addressed, the crux of the discussion is focused on hemodynamic factors such as stasis, turbulent flow, and non-physiological shear stress and their effects on thrombosis. In addition, hemodynamics-dependent venous, arterial, and microvascular thrombosis in COVID-19 cases is discussed. We also propose further investigation of diagnostic and therapeutic options that address the hemodynamics aspects of COVID-19 thrombus formation to assess their potential in patient care.
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