The absence of an effective treatment against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has led clinicians to redirect drugs that are known to be effective for other medical conditions to the treatment of Covid-19. Chloroquine and hydroxychloroquine are widely used in the treatment of malaria and rheumatic diseases, and they have been suggested as effective treatments for Covid-19 on the grounds of both anti-inflammatory and antiviral effects [1Biot C. Daher W. Chavain N. Fandeur T. Khalife J. Dive D. De Clercq E Design and synthesis of hydroxyferroquine derivatives with antimalarial and antiviral activities.J Med Chem. 2006; 49: 2845-2849Crossref PubMed Scopus (252) Google Scholar, 2Fox R.I. Mechanism of action of hydroxychloroquine as an antirheumatic drug.Semin Arthritis Rheum. 1993; 23: 82-91Crossref PubMed Scopus (369) Google Scholar, 3Devaux C.A., Rolain J.M., Colson P., Raoult D. New insights on the antiviral effects of chloroquine against coronavirus: what to expect for covid-19? Int J Antimicrob Agents. 2020:105938.Google Scholar, 4Fantini J. Di Scala C. Chahinian H. Yahi N Structural and molecular modelling studies reveal a new mechanism of action of chloroquine and hydroxychloroquine against sars-cov-2 infection.Int J Antimicrob Agents. 2020; 105960Crossref PubMed Scopus (417) Google Scholar]. Mounting data suggest that Covid-19 is burdened by a higher risk of arrhythmic events, with important implications for survival [[5]Driggin E. Madhavan M.V. Bikdeli B. Chuich T. Laracy J. Biondi-Zoccai G. Brown T.S. Der Nigoghossian C. Zidar D.A. Haythe J. Brodie D. Beckman J.A. Kirtane A.J. Stone G.W. Krumholz H.M. Parikh S.A Cardiovascular considerations for patients, health care workers, and health systems during the covid-19 pandemic.J Am Coll Cardiol. 2020; 75: 2352-2371Crossref PubMed Scopus (1429) Google Scholar]. Hydroxychloroquine, with or without a second-generation macrolide, has also been advocated despite limited evidence for its effectiveness and known detrimental effect of prolongation of the QT interval, which could be a mechanism that predisposes to ventricular arrhythmias [6Gautret P., Lagier J.C., Parola P., Hoang V.T., Meddeb L., Mailhe M., Doudier B., Courjon J., Giordanengo V., Vieira V.E., Dupont H.T., Honore S., Colson P., Chabriere E., La Scola B., Rolain J.M., Brouqui P., Raoult D. Hydroxychloroquine and azithromycin as a treatment of covid-19: results of an open-label non-randomized clinical trial. Int J Antimicrob Agents. 2020:105949.Google Scholar, 7Ray W.A. Murray K.T. Hall K. Arbogast P.G. Stein C.M Azithromycin and the risk of cardiovascular death.N Engl J Med. 2012; 366: 1881-1890Crossref PubMed Scopus (784) Google Scholar, 8Giudicessi J.R. Noseworthy P.A. Friedman P.A. Ackerman M.J Urgent guidance for navigating and circumventing the QTC-prolonging and torsadogenic potential of possible pharmacotherapies for coronavirus disease 19 (covid-19).Mayo Clin Proc. 2020; https://doi.org/10.1016/j.mayocp.2020.03.024Abstract Full Text Full Text PDF PubMed Scopus (306) Google Scholar]. In the United States, the FDA issued an Emergency Use Authorization on March 30, 2020, that allowed the use of these drugs in patients with Covid-19 who were not enrolled in clinical trials, and to date, they have been used in many thousands of patients with acute Covid-19 around the world. Although several multicenter randomized controlled trials are underway, there is an urgent clinical need to provide accurate clinical guidance. Also, some countries have stockpiled these drugs, resulting in a shortage of these medications for approved clinical indications [[9]Peschken C.A. Possible consequences of a shortage of hydroxychloroquine for patients with systemic lupus erythematosus amid the covid-19 pandemic.J Rheumatol. 2020; https://doi.org/10.3899/jrheum.200395Crossref Scopus (31) Google Scholar]. Table 1. summarizes the most important studies published as of May 27th on the use of hydroxychloroquine for treatment of Covid-19 infection.Table 1Relevant studies published as of May 27th, 2020 on use of hydroxychloroquine for treatment of Covid-19 infection.StudyJournalPublished DateStudy PopulationTreatment RegimenOutcomeMercuro et al. [14]Mercuro N.J. Yen C.F. Shim D.J. Maher T.R. McCoy C.M. Zimetbaum P.J. Gold H.S Risk of QT interval prolongation associated with use of hydroxychloroquine with or without concomitant azithromycin among hospitalized patients testing positive for coronavirus disease 2019 (covid-19).JAMA cardiol. 2020; https://doi.org/10.1001/jamacardio.2020.1834Crossref Scopus (508) Google Scholar Single center, retrospective, observational studyJAMA CardiologyMay 1st, 202090 hospitalized subjects, mean age 60 years, 49% femaleAll patients Received HCQ, and 53 (59%) received HCQ+ AZM*QTc prolongation (ΔQTc 21 ms), and those taking HCQ+AZM had greater QT prolongation than those taking HCQ alone. One patient developed torsades de pointesMahévas et al. [13]Mahevas M. Tran V.T. Roumier M. Chabrol A. Paule R. Guillaud C. Fois E. Lepeule R. Szwebel T.A. Lescure F.X. Schlemmer F. Matignon M. Khellaf M. Crickx E. Terrier B. Morbieu C. Legendre P. Dang J. Schoindre Y. Pawlotsky J.M. Michel M. Perrodeau E. Carlier N. Roche N. de Lastours V. Ourghanlian C. Kerneis S. Menager P. Mouthon L. Audureau E. Ravaud P. Godeau B. Gallien S. Costedoat-Chalumeau N Clinical efficacy of hydroxychloroquine in patients with covid-19 pneumonia who require oxygen: observational comparative study using routine care data.Bmj. 2020; (369:m1844)Crossref PubMed Scopus (305) Google Scholar Comparative observational studyBMJMay 5th, 2020173 hospitalized subjects, median age 60 years, 28% female84 patients received HCQ and 89 did not (control group)**Rate of survival without transfer to the intensive care unit was not significantly different among those taking HCQ and those who did not (76 vs. 75%)Geleris et al. [11]Geleris J. Sun Y. Platt J. Zucker J. Baldwin M. Hripcsak G. Labella A. Manson D. Kubin C. Barr R.G. Sobieszczyk M.E. Schluger N.W Observational study of hydroxychloroquine in hospitalized patients with covid-19.N Engl J Med. 2020; Crossref PubMed Google Scholar Single center, retrospective, observational studyNEJMMay 7th, 20201376 hospitalized subjects, 60.5% age ≥ 60 years, 43% female811 (58.9%) received HCQ*** and 565 did not (control group).No significant association between HCQ use and the primary outcome of intubation or death (HR 1.04, 95%CI 0.82–1.32). Results were similar in multiple sensitivity analyses.Rosemberg et al. [12]Rosenberg E.S. Dufort E.M. Udo T. Wilberschied L.A. Kumar J. Tesoriero J. Weinberg P. Kirkwood J. Muse A. DeHovitz J. Blog D.S. Hutton B. Holtgrave D.R. Zucker H.A Association of treatment with hydroxychloroquine or azithromycin with in-hospital mortality in patients with covid-19 in new york state.JAMA. 2020; https://doi.org/10.1056/NEJMoa2012410Crossref PubMed Scopus (1199) Google Scholar Multicenter, retrospective, cohort studyJAMAMay 11th, 20201438 hospitalized subjects, median age, 63 years, 40.3% femaleFour groups: 1) HCQ+AZM (n = 735), 2) HCQ alone (n = 271), 3) AZM alone (n = 211), or 4) neither drug (n = 221)¥Overall in-hospital mortality rates in the four groups were 25.7% (1), 19.9% (2), 10.0% (3), and 12.7% (4), respectively, with no significant between-group differences after adjustment for potential confoundersMehra et al. [10]Mehra MR D.S. Ruschitzka F. Patel A.N Hydroxychloroquine or chloroquine with or without a macrolide for treatment of covid-19: a multinational registry analysis.The Lancet. 2020; https://doi.org/10.1016/S0140-6736(20)31180-6Crossref Scopus (606) Google Scholar Multinational registry studyThe LancetMay 22nd, 2020671 hospitals in six continents for a total of 96,032 patients, mean age 53.8 years, 46.3% female14,888 patients were in the treatment groups: 1868 received CQ, 3783 received CQ + macrolide, 3016 received HCQ, and 6221 received HCQ + macrolide§. 81,144 patients were in the control groupAfter controlling for multiple confounding factors when compared with mortality in the control group (9.3%); HCQ (18.0%; HR 1.3, 95%CI 1.2–1.5), HCQ+macrolide (23.8%; HR 1.5, 95%CI 1.4–1.5), CQ (16.4%; HR 1.4, 95%CI 1.2–1.5), and CQ+macrolide (22.2%; HR 1.4, 95%CI 1.3–1.5) were each independently associated with an increased risk of in-hospital mortalityNote: HCQ: hydroxychloroquine, AZM: azithromycin, CQ: chloroquine. HR: hazard ratio, CI: confidence interval. Treatment regimens: * HCQ 400 mg twice on day 1, then 400 mg daily on days 2 through 5; ** HCQ 600 mg/day within 48 h of admission; ** HCQ 600 mg twice on day 1, then 400 mg daily for a median of 5 days; ¥ refer to eTable1 of the original publication; § CQ alone, 765 mg for 6.6 days; HCQ alone, 596 mg for 4.2 days; CQ+macrolide, 790 mg for 6.8 days; and HCQ+macrolide, 597 mg for 4.3 days. Open table in a new tab Note: HCQ: hydroxychloroquine, AZM: azithromycin, CQ: chloroquine. HR: hazard ratio, CI: confidence interval. Treatment regimens: * HCQ 400 mg twice on day 1, then 400 mg daily on days 2 through 5; ** HCQ 600 mg/day within 48 h of admission; ** HCQ 600 mg twice on day 1, then 400 mg daily for a median of 5 days; ¥ refer to eTable1 of the original publication; § CQ alone, 765 mg for 6.6 days; HCQ alone, 596 mg for 4.2 days; CQ+macrolide, 790 mg for 6.8 days; and HCQ+macrolide, 597 mg for 4.3 days. Mehra and colleagues published in the The Lancet, May 22nd, the largest observational study to date on the effects of chloroquine or hydroxychloroquine, with or without a macrolide, in 96,032 hospitalized patients (mean age 54 years, 46% women) who tested positive for SARS-CoV-2 [[10]Mehra MR D.S. Ruschitzka F. Patel A.N Hydroxychloroquine or chloroquine with or without a macrolide for treatment of covid-19: a multinational registry analysis.The Lancet. 2020; https://doi.org/10.1016/S0140-6736(20)31180-6Crossref Scopus (606) Google Scholar]. Data from this international registry comprising 671 hospitals in six continents were used to compare patients with Covid-19 who received chloroquine (n = 1868), hydroxychloroquine (n = 3016), chloroquine with a macrolide (n = 3783), or hydroxychloroquine with a macrolide (n = 6221) within 48 h of Covid-19 diagnosis, with 81,144 controls who did not receive these drugs. The main outcomes of interest were in-hospital mortality and the occurrence of de-novo ventricular arrhythmias. A Cox proportional hazard model, accounting for many confounding variables, showed a significant increase in the risk of in-hospital mortality with the four treatment regimens compared with the control group (hazard ratios [HR] ranging from 1.33 [95%CI 1.22–1.46] to 1.45 [1.37–1.53]). Analyses using propensity score matching by treatment group supported this result and the risk of in-hospital mortality was similar in men and women. Geleris and colleagues recently published in the New England Journal of Medicine a study including 1376 consecutive patients with SARS-CoV-2 who had been admitted to a New York City medical center between March 7 and April 8, 2020 [[11]Geleris J. Sun Y. Platt J. Zucker J. Baldwin M. Hripcsak G. Labella A. Manson D. Kubin C. Barr R.G. Sobieszczyk M.E. Schluger N.W Observational study of hydroxychloroquine in hospitalized patients with covid-19.N Engl J Med. 2020; Crossref PubMed Google Scholar]. Hospital guidance suggested the use of hydroxychloroquine for patients who had a resting oxygen saturation of less than 94% on ambient air. A total of 59% of the patients were treated with hydroxychloroquine, with 60% of those treated with hydroxychloroquine also receiving azithromycin. The authors assessed the association between hydroxychloroquine use and a composite endpoint of intubation or death over a median follow-up of 22.5 days. In the adjusted analyses, there was no evidence of a substantial difference in the rate of the composite endpoint (HR 1.04; 95%CI 0.82–1.32). The findings were confirmed in the sensitivity analyses. In a retrospective multicenter cohort study, recently published in JAMA, the authors describe the association between use of hydroxychloroquine, with or without azithromycin, and in-hospital mortality among inpatients diagnosed with Covid-19 [[12]Rosenberg E.S. Dufort E.M. Udo T. Wilberschied L.A. Kumar J. Tesoriero J. Weinberg P. Kirkwood J. Muse A. DeHovitz J. Blog D.S. Hutton B. Holtgrave D.R. Zucker H.A Association of treatment with hydroxychloroquine or azithromycin with in-hospital mortality in patients with covid-19 in new york state.JAMA. 2020; https://doi.org/10.1056/NEJMoa2012410Crossref PubMed Scopus (1199) Google Scholar]. A random sample of all admitted patients with laboratory-confirmed Covid-19 in 25 hospitals (representing 88.2% of patients with Covid-19 in the New York metropolitan region) was selected. Among 1438 hospitalized patients with Covid-19 (median age 63 years, 40% female) overall in-hospital mortality was 20.3%. The probability of death was significantly increased for all treatment regimens compared to neither drug (Table 1). Further, in logistic models, compared with patients receiving neither drug, cardiac arrest was significantly more likely in patients receiving hydroxychloroquine+azithromycin, but not hydroxychloroquine alone or azithromycin alone. In one comparative observational study published in the BMJ by Mahévas and colleagues, survival at 21 days with or without acute respiratory distress syndrome did not differ between the groups treated with hydroxychloroquine (84 patients) versus the control group (89 patients) [[13]Mahevas M. Tran V.T. Roumier M. Chabrol A. Paule R. Guillaud C. Fois E. Lepeule R. Szwebel T.A. Lescure F.X. Schlemmer F. Matignon M. Khellaf M. Crickx E. Terrier B. Morbieu C. Legendre P. Dang J. Schoindre Y. Pawlotsky J.M. Michel M. Perrodeau E. Carlier N. Roche N. de Lastours V. Ourghanlian C. Kerneis S. Menager P. Mouthon L. Audureau E. Ravaud P. Godeau B. Gallien S. Costedoat-Chalumeau N Clinical efficacy of hydroxychloroquine in patients with covid-19 pneumonia who require oxygen: observational comparative study using routine care data.Bmj. 2020; (369:m1844)Crossref PubMed Scopus (305) Google Scholar]. The authors concluded that hydroxychloroquine in moderately ill patients with Covid-19 was not useful, and perhaps even harmful. In another single center, retrospective, observational study published in JAMA Cardiology, that included 90 hospitalized subjects (mean age 60 years, 49% female) receiving hydroxychloroquine (41%) or hydroxychloroquine+azithromycin (59%), it was observed QTc prolongation (ΔQTc 21 ms), and those taking hydroxychloroquine+azithromycin had greater QT prolongation than those taking hydroxychloroquine alone [[14]Mercuro N.J. Yen C.F. Shim D.J. Maher T.R. McCoy C.M. Zimetbaum P.J. Gold H.S Risk of QT interval prolongation associated with use of hydroxychloroquine with or without concomitant azithromycin among hospitalized patients testing positive for coronavirus disease 2019 (covid-19).JAMA cardiol. 2020; https://doi.org/10.1001/jamacardio.2020.1834Crossref Scopus (508) Google Scholar]. Following current scientific evidence on potential harm related to the use of hydroxychloroquine or chloroquine alone or in combination with azithromycin for the treatment or prevention of Covid-19, the European Medicines Agency (EMA) and the FDA released, on April 23rd and April 24th, respectively, drug safety announcements. The FDA stated "we are warning the public that hydroxychloroquine and chloroquine, either alone or combined with azithromycin, when used for Covid-19 should be limited to clinical trial settings or for treating certain hospitalized patients under the emergency use authorization ". On the same line, the EMA stated: "Healthcare professionals should carefully consider the possibility of side effects, particularly with higher doses, and exercise extra caution when combining treatment with other medicines such as azithromycin that may cause similar side effects on the heart". In conclusion, we strongly believe that a cardinal principle of practicing medicine is "first, do no harm" and even in situations like Covid-19 where you believe a desperate disease calls for desperate measures, good and responsible physicians should take a step back and ask themselves if they are causing harm. As physicians involved in the frontline of this unprecedented emergency, serving hundreds of patients in a dedicated Covid-Hospital, we share with colleagues around the world the burden and the responsibility of taking hard decisions on daily-basis; however, following the World Health Organization global announcement to temporarily halting any ongoing trial of hydroxychloroquine for treating Coronavirus patients, we believe that evidence-based medicine should always come first even in emergency situations like SARS-CoV-2 pandemics. None.
Excessive oxidative stress due to hyperglycemia and glycoxidation leads to an increased production of F2-isoprostanes, one of which, 8-iso-PGF2 alpha, reaches high concentrations in plasma and urine in both insulin-dependent and non-insulin-dependent diabetics. This is associated with an increase in platelet activation, reflected by an increased urinary excretion of platelet-derived TxB2. Improved metabolic control or vitamin E supplementation reduces urinary 8-iso-PGF2 alpha and TxB2, whereas aspirin or indobufen reduces TxB2 but not 8-iso-PGF2 alpha. Since TxB2 in the urine seems to represent the common link between diabetes (as well as other risk factors) and the thrombotic complications of vascular disease, platelet activation due to lipid-glycoxidation is an important aspect in the pathogenesis of vascular complications of diabetes mellitus. Among the various plasma coagulation and fibrinolysis factors that are found to be altered in diabetes, the increased level of plasminogen activator inhibitor (PAI-1) in the plasma and in the vessel wall is of the utmost importance. Indeed, it is suspected that the atherosclerotic plaques formed in the presence of high concentrations of PAI-1 are more prone to rupture and ensuing thrombosis. The thrombosis-oriented modifications of blood platelets, coagulation and fibrinolysis are an important cause behind the high prevalence of vascular events in diabetes.
We note with interest the review of Kunutsor SK. et al.1Kunutsor S.K. Laukkanen J.A. Cardiovascular complications in COVID-19: a systematic review and meta-analysis.J Infect. 2020; 81 (Epub 2020 Jun 3PMID:32504747): e139-e141https://doi.org/10.1016/j.jinf.2020.05.068Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar on cardiovascular implications of coronavirus disease 2019 (COVID-19). Indeed, Sars-Cov-2 infection begins in lungs but moves rapidly to the vascular system with platelet alterations and blood clotting abnormalities, and associates with a high incidence of cardiovascular events and venous thromboembolism (VTE), especially in critically ill patients (10–34%).2Nopp S. Moik F. Jilma B. Pabinger I. Ay C. Risk of venous thromboembolism in patients with COVID-19: a systematic review and meta-analysis.Res Pract Thromb Haemost. 2020; 4: 1178-1191Crossref PubMed Scopus (312) Google Scholar Based on autopsy findings, endothelial injury has been hypothesized to play a crucial role in the Sars-Cov-2 associated pro-coagulant condition.3López Castro J. COVID-19 and thrombosis: beyond a casual association.Med Clin (Engl Ed). 2020; 155: 44PubMed Google Scholar Very few studies, however, have assessed circulating biomarkers of endothelial damage in COVID-19 patients. Among these particularly interesting are circulating endothelial cells (CECs), circulating endothelial progenitor cells (EPCs), endothelial extracellular vesicles (EEVs) and soluble forms of endothelial adhesive proteins (CAM) which are known to be altered in conditions associated with enhanced cardiovascular risk and to be predictive of vascular complications in various conditions, including infectious diseases.4Page A.V. Liles W.C. Biomarkers of endothelial activation/dysfunction in infectious diseases.Virulence. 2013; 4: 507-516https://doi.org/10.4161/viru.24530Crossref PubMed Scopus (210) Google Scholar For these parameters no data are available, to our knowledge, in Sars-Cov-2 infection. Aim of our study was to assess the role of cellular and soluble circulating endothelial derangement parameters as markers of endothelial damage in COVID-19 patients and to unravel if they may identify patients developing VTE or adverse outcome. Fifty-six COVID-19 patients and 36 healthy, age- and sex-matched controls were enrolled in a multicenter study in the Umbria Region, Italy. Peripheral blood was collected for EEVs, CECs and EPCs by flow cytometry and for sVCAM and sICAM by ELISA.5Gresele P. Migliacci R. Procacci A. De Monte P. Bonizzoni E. Prevention by NCX 4016, a nitric oxide-donating aspirin, but not by aspirin, of the acute endothelial dysfunction induced by exercise in patients with intermittent claudication.Thromb Haemost. 2007; 97: 444-450Crossref PubMed Scopus (44) Google Scholar Four of the enrolled patients were reassessed after disease recovery confirmed by 2 negative nasopharyngeal swabs (mean 72.7 days, 95% CI 32.8–112.6, after the second). Statistical analyses were performed using GraphPad Prism 8.4 for Windows software. Data not normally distributed were analyzed with the Mann Whitney test; otherwise with the two-tailed unpaired Student's t-test. P<0.05 was considered statistically significant. The study was approved by the local Ethics Committees (CEAS Umbria n. 3656/20, University of Perugia Bioethics Committee n. 2020–36,346). Demographics, clinical and main laboratory features of the study population are summarized in Table 1. All patients were hospitalized (median hospitalization 26 days) and were studied on average 4.2 ± 0.5 days (95%CI 3.2–5.2) from the last positive nasopharyngeal swab. Sixteen patients (28.5%) were admitted into the intensive care unit (ICU) while the others into non-ICU COVID-19 wards. Five ICU and 3 non-ICU patients died during hospitalization. Of the 56 patients, 19 had a partial pressure of oxygen/fraction of inspiration oxygen ratio (PaO2/FiO2) lower than 300 and 31 required mechanical ventilation (15 invasive and 16 non invasive). Ten (17.8%) developed 11 thrombotic events (one suffered two thrombotic events) during or immediately after hospitalization (median 9.5 days) confirmed by computed tomography pulmonary angiography or compression ultrasonography (6 pulmonary embolism, 4 deep vein thrombosis, 1 cava vein thrombosis): of these, six were under prophylactic low molecular weight heparin (LMWH) (n = 3 standard-dose, n = 3 intermediate-dose) and four under therapeutic-dose LMWH (one for atrial fibrillation and one for a previous pulmonary embolism).Table 1Demographic and clinical characteristics of the study population.COVID-19 patients n = 56Healthy subjects n = 36p value Age (years)72.1 ± 1.868.0 ± 3.0ns Sex (% M)57.1%40.1%ns Leukocytes (x 103/μL)7.0 ± 0.75.7 ± 0.8ns Neutrophil-to-lymphocyte ratio (NLR)8.0 ± 0.92.0 ± 0.2<0.005 Platelets (x 103/μL)211.1 ± 17.0208 ± 17.2ns D-dimer (ng/ml)1663 ± 299.0180.6 ± 21.7<0.0001 Fibrinogen (mg/dL)403.1 ± 27.0323.2 ± 26ns VWF: Ag (%)273.8 ± 26.4104.0 ± 7.0<0.0001 VWF: RCo (%)298.0 ± 28.090.0 ± 4.9<0.0001 Procalcitonin (ng/ml)1.2 ± 0.5N.A. CRP (mg/dL)4.8 ± 1.5N.A. LDH (U/L)247.2 ± 33.3N.A. PaO2/FiO2241.3 ± 27.1N.A. SOFA score (total)6.0 ± 0.4N.A. Days from positive swab4.2 ± 0.5N.A. Thrombotic events (n)11N.A.Comorbidities Hypertension (n)323<0.01 Type 2 Diabetes Mellitus (n)111<0.05 Obesity (n)121<0.05 Smoker (n)63ns Atrial Fibrillation (n)70ns Cirrhosis (n)10ns Kidney failure (n)70ns Stroke (n)40ns Peripheral artery disease (n)70ns COPD (n)40nsDrugsAntihypertensive agents (n)111<0.05Statins (n)110<0.05Antiplatelet treatments: Aspirin (n)90<0.05 Anti P2Y12 (n)30nsAnticoagulant treatments: LMWH (n)450<0.0001 -standard32 -incremented8 -therapeutic5Apixaban (n)60nsCOVID-19 TreatmentsHydroxycloroquine (n)5N.A.Darunavir/Cobicistat (n)2N.A.Tolicizumab (n)1N.A.Results are reported as mean±SEM if not differently indicated. N.A. not applicable; SOFA: sequential organ failure assessment. Open table in a new tab Results are reported as mean±SEM if not differently indicated. N.A. not applicable; SOFA: sequential organ failure assessment. COVID-19 patients had significantly higher CECs and EEVs in comparison with healthy subjects (21.5 ± 2.2 vs 8.1 ± 1.4/μl, p<0.01 and 286.5 ± 38 vs 127.6 ± 21/μl, p<0.05 respectively). CECs correlated with C-reactive protein levels (r = 0.49, p<0.05), neutrophil-to-lymphocyte ratio (r = 0.40, p<0.01) and d-Dimer (r = 0.45, p<0.05), biomarkers of inflammation and hypercoagulability, but did not differ between patients who developed a thrombotic event and those who did not. Three distinct populations of circulating EPCs (CD34+ and CD309+) were detected based on their CD45 expression. CD45 negative (CD45neg), which express the regenerative potential of EPCs against vascular damage, were significantly lower in COVID-19 patients compared to controls (Fig. 1A), while a significant increase of CD45 positive intermediate (CD45+int) (Fig. 1B) and CD45 positive high (CD45+high) was observed, suggesting that these EPCs with high phagocytic capability may represent a reactive mechanism to limit viral proliferation.6Wang Q.R. Wang B.H. Zhu W.B. Huang Y.H. Li Y. Yan Q. An in vitro study of differentiation of hematopoietic cells to endothelial cells.Bone Marrow Res. 2011; 2011846096Crossref PubMed Google Scholar COVID-19 patients also had higher plasma levels of soluble markers of EC disturbance, sVCAM-1 (3122 ± 324 vs 1135 ± 82 ng/ml, p<0.001) and sICAM-1 (Fig. 1C) and VWF:Ag and VWF:RCo (Table 1), as compared with controls. Notably, sICAM-1 was significantly more elevated in COVID-19 patients admitted into ICU compared to those not in ICU (Fig. 1D) and in patients with reduced PaO2/FiO2 ratio compared to those with normal PaO2/FiO2 (Fig. 1E), suggesting that severe respiratory syndrome and hypoxemia are associated with endothelial damage. A significant correlation was also found between sICAM-1 and the SOFA score (r = 0.65, p<0.01), suggesting that elevated sICAM-1 may represent a marker of severe disease evolution in Sars-Cov-2 infection. D-dimer, VWF:Ag (not shown) and sICAM-1 (Fig. 1F) were significantly higher in patients who developed VTE than in patients who did not. ROC curve analysis showed that sICAM-1 >519.06 ng/ml discriminates COVID-19 patients with VTE from those without with moderate accuracy (AUC= 0.83, p<0.01) (Suppl. Fig. 1). Most patients were under standard- (n = 32) or incremented-dose (n = 8) prophylactic LMWH (40/56, 71%) but no differences between treated and untreated patients were found for any of the circulating endothelial dysfunction markers assessed. In patients who had recovered from COVID-19, CECs, EMPs, EPCs, VWF:Ag, VWF:RCo, sICAM-1 and sVCAM-1 returned to levels close to those of healthy controls, suggesting that endothelial damage is strictly dependent on active COVID-19 infection (Suppl. Fig. 2). Our results show that COVID-19 patients have increased circulating CECs, EMPs and phagocytic EPCs and increased plasma levels of sICAM-1, sVCAM-1, VWF:Ag and VWF:RCo, with concomitant decrease of angiogenic EPCs, proving that circulating parameters of endothelial derangement are strongly altered in COVID-19 patients. In particular, plasma levels of sICAM-1 and of sVCAM-1 were more than threefold increased probably reflecting the enhanced adhesiveness of microvascular endothelium mediating the strong leukocyte extravasation in tissue, in particular in lungs. Moreover, the endothelial activation triggered by SARS-CoV-2 probably contributes to the strong in vivo platelet activation found in COVID-19 patients and to platelet adhesion to lung endothelium leading to lung injury. Elevated sICAM-1 predicts cardiovascular events in apparently healthy men and in patients with cardiovascular disease and is associated with recurrent VTE,7Dzikowska-Diduch O. Domienik-Karłowicz J. Górska E. Demkow U. Pruszczyk P. Kostrubiec M. E-selectin and sICAM-1, biomarkers of endothelial function, predict recurrence of venous thromboembolism.Thromb Res. 2017; 157: 173-180Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar and in our study strongly associated with VTE incidence and disease severity, therefore this marker warrants more extensive investigation for prognostic prediction in COVID-19 patients. In our study prophylactic-dose LMWH did not affect biomarkers of endothelial dysfunction, in agreement with low clinical efficacy in preventing VTE in COVID-19 patients.8Al-Ani F. Chehade S. Lazo-Langner A. Thrombosis risk associated with COVID-19 infection. A scoping review.Thromb Res. 2020; 192: 152-160Abstract Full Text Full Text PDF PubMed Scopus (261) Google Scholar A recent study evaluated the impact of therapeutic-dose anticoagulation given to COVID-19 patients prior to hospitalization on endothelial damage, measured by CECs, suggesting that early treatment may prevent COVID-19-associated endothelial lesion.9Khider L. Gendron N. Goudot G. Chocron R. Hauw-Berlemont C. Cheng C. Rivet N. Pere H. Roffe A. Clerc S. Lebeaux D. Debuc B. Veyer D. Rance B. Gaussem P. Bertil S. Badoual C. Juvin P. Planquette B. Messas E. Sanchez O. Hulot J.S. Diehl J.L. Mirault T. Smadja D.M. Curative anticoagulation prevents endothelial lesion in COVID-19 patients.J Thromb Haemost. 2020 Jun 18; (Epub ahead of print. PMID:32558198PMCID: PMC7323356)https://doi.org/10.1111/jth.14968Crossref Scopus (65) Google Scholar Thus sICAM-1 might be used as an indicator to switch to therapeutic dose heparin in high-risk patients. Finally, our data, strongly confirming that COVID-19 is an endothelial disease, provide the rationale for the search of novel therapeutic strategies targeting inflammatory mediators and/or promoting endothelial protection/repair to prevent the thrombotic and systemic complications of COVID-19. The authors declare no conflict of interest. Laura Franco(a), Luca Saccarelli(b), Maria Lapenna(c), Marco D'Abbondanza(d), Stefano Cristallini(f). The contribution of Luisa Golia (Section of Anesthesia, Intensive Care, and Pain Medicine, Azienda Ospedaliera-Universitaria Santa Maria della Misericordia, Perugia, Italy), Valentina Bubba (Division of Internal Medicine, ASL 1 Umbria, Città di Castello, Italy), Pierluigi Piergentili (Section of Anesthesia and Intensive Care, Presidio Alto Chiascio, USL Umbria 1, Gubbio, Italy) with patient enrollment is kindly acknowledged. Stago s.r.l. (Italy) kindly gave some of the reagents used for the study. This work was supported by a fellowship from Fondazione Umberto Veronesi to L. Bury and E. Falcinelli.
Severe acute respiratory syndrome coronavirus 2 infection is associated with hypercoagulability, which predisposes to venous thromboembolism (VTE). We analyzed platelet and neutrophil activation in patients with coronavirus disease 2019 (COVID-19) and their association with VTE.Hospitalized patients with COVID-19 and age- and sex-matched healthy controls were studied. Platelet and leukocyte activation, neutrophil extracellular traps (NETs), and matrix metalloproteinase 9, a neutrophil-released enzyme, were measured. Four patients were restudied after recovery. The activating effect of plasma from patients with COVID-19 on control platelets and leukocytes and the inhibiting activity of common antithrombotic agents on it were studied.A total of 36 patients with COVID-19 and 31 healthy controls were studied; VTE developed in 8 of 36 patients with COVID-19 (22.2%). Platelets and neutrophils were activated in patients with COVID-19. NET, but not platelet activation, biomarkers correlated with disease severity and were associated with thrombosis. Plasmatic matrix metalloproteinase 9 was significantly increased in patients with COVID-19. Platelet and neutrophil activation markers, but less so NETs, normalized after recovery. In vitro, plasma from patients with COVID-19 triggered platelet and neutrophil activation and NET formation, the latter blocked by therapeutic-dose low-molecular-weight heparin, but not by aspirin or dypiridamole.Platelet and neutrophil activation are key features of patients with COVID-19. NET biomarkers may help to predict clinical worsening and VTE and may guide low-molecular-weight heparin treatment.
The effectiveness of vaccination against SARS-CoV-2 in preventing COVID-19 or in reducing severe illness in subjects hospitalized for COVID-19 despite vaccination has been unequivocally shown. However, no studies so far have assessed if subjects who get COVID-19 despite vaccination are protected from SARS-CoV-2-induced platelet, neutrophil and endothelial activation, biomarkers associated with thrombosis and worse outcome. In this pilot study, we show that previous vaccination blunts COVID-19-associated platelet activation, assessed by circulating platelet-derived microvesicles and soluble P-selectin, and neutrophil activation, assessed by circulating neutrophil extracellular trap (NET) biomarkers and matrix metalloproteinase-9, and reduces COVID-19-associated thrombotic events, hospitalization in intensive-care units and death.
Dear Editor, In our recent editorial on the role of hydroxychloroquine during SARS-Cov-2 pandemics [[1]Paliani U Cardona A. Covid-19 and hydroxychloroquine: is the wonder drug failing?.Eur J Intern Med. 2020; https://doi.org/10.1016/j.ejim.2020.06.002Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar], leveraging on the available scientific evidence, we emphasized the need of using extreme caution when it comes to prescribing a potentially toxic drug, especially with higher dose compared to standard drug regimen and on a large scale population. We read with interest a comment from the group of Raoult and colleagues [[2]Matthieu Milliona YR Raoult Didier Chloroquine and COVID-19: a western medical and scientific drift?.Eur J Intern Med. 2020; https://doi.org/10.1016/j.ejim.2020.06.020Google Scholar]. We wish to thank the authors as they clearly understood our goal of stressing the need of being very careful in analyzing the literature at a time when scientific conflicts of this magnitude are taking place. Importantly, after our editorial, one of the papers we cited was retracted [[3]Mehra MR RF Patel AN Retraction—hydroxychloroquine or chloroquine with or without a macrolide for treatment of COVID-19: a multinational registry analysis.Lancet. 2020; (Jun 5)https://doi.org/10.1016/S0140-6736(20)31324-6Google Scholar] and once more, this clearly underlines that, in the era of SARS-Cov-2 pandemics, owing to an unprecedented volume of research being conducted in such a short period of time and the large number of reports submitted to journals, high quality standards and meticulous peer-review process must be undertaken in order to convey objective and unbiased evidence [[4]Bauchner H Fontanarosa PB Golub RM Editorial evaluation and peer review during a pandemic: how journals maintain standards.JAMA. 2020; https://doi.org/10.1001/jama.2020.11764Crossref Scopus (74) Google Scholar]. Nevertheless, the vast majority of the available current scientific evidence, suggest, at the very least, that hydroxychloroquine is not ready for clinical prime time as standard therapy in Covid-19. Tang and colleagues recently published a randomized clinical trial of patients with mainly persistent mild to moderate Covid-19 in which exposure to hydroxychloroquine led to a similar probability of virus elimination compared to the current standard of care [[5]Tang W Cao Z Han M Wang Z Chen J Sun W et al.Hydroxychloroquine in patients with mainly mild to moderate coronavirus disease 2019: open label, randomised controlled trial.BMJ. 2020; (369:m1849)Crossref Scopus (712) Google Scholar]. Therefore, taking together what studies have told so far, it is not surprising that the last update of the "Covid-19 treatment guidelines" (dated June 25th) on the use of chloroquine or hydroxychloroquine published by the National Institutes of Health (NIH) suggest the following:-The Covid-19 Treatment Guidelines Panel recommends against the use of chloroquine or hydroxychloroquine for the treatment of Covid-19, except in a clinical trial – Class of Evidence AII.-The Panel recommends against the use of high-dose chloroquine (600 mg twice daily for 10 days) for the treatment of Covid-19 – Class of Evidence AI. The last recommendation follows results from a randomized clinical trial comparing high-dose chloroquine and low-dose chloroquine in patients with Covid-19; the study was discontinued early when preliminary results showed higher rates of mortality and QTc prolongation in the high-dose chloroquine group [[6]Borba MGS Val FFA Sampaio VS Alexandre MAA Melo GC Brito M et al.Effect of high vs low doses of chloroquine diphosphate as adjunctive therapy for patients hospitalized with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection: a randomized clinical trial.JAMA Network Open. 2020; 3e208857Crossref PubMed Scopus (757) Google Scholar]. Finally, it is important to note that hydroxychloroquine toxic effect is related to its volume of distribution and half-life. Hydroxychloroquine half-life is around 50 days (!) and has prolonged effects even after drug discontinuation ([7]Schrezenmeier E Dorner T. Mechanisms of action of hydroxychloroquine and chloroquine: implications for rheumatology.Nat Rev Rheumatol. 2020; 16: 155-166Crossref PubMed Scopus (867) Google Scholar). In conclusion, as we wrote in our editorial, we stay firm in believing that evidence based medicine is our strongest ally. Now more than ever, in the era of Covid-19 pandemics, where heterogeneous treatments and different drug doses not supported by the evidence can lead to confusion, discordant results, poor reproducibility, and potentially higher mortality, the whole scientific community should stay united in advocating the most meticulous scientific approach. None.
