COVID-19 is also manifested with hypercoagulability, pulmonary intravascular coagulation, microangiopathy, and venous thromboembolism (VTE) or arterial thrombosis. Predisposing risk factors to severe COVID-19 are male sex, underlying cardiovascular disease, or cardiovascular risk factors including noncontrolled diabetes mellitus or arterial hypertension, obesity, and advanced age. The VAS-European Independent Foundation in Angiology/Vascular Medicine draws attention to patients with vascular disease (VD) and presents an integral strategy for the management of patients with VD or cardiovascular risk factors (VD-CVR) and COVID-19. VAS recommends (1) a COVID-19-oriented primary health care network for patients with VD-CVR for identification of patients with VD-CVR in the community and patients' education for disease symptoms, use of eHealth technology, adherence to the antithrombotic and vascular regulating treatments, and (2) close medical follow-up for efficacious control of VD progression and prompt application of physical and social distancing measures in case of new epidemic waves. For patients with VD-CVR who receive home treatment for COVID-19, VAS recommends assessment for (1) disease worsening risk and prioritized hospitalization of those at high risk and (2) VTE risk assessment and thromboprophylaxis with rivaroxaban, betrixaban, or low-molecular-weight heparin (LMWH) for those at high risk. For hospitalized patients with VD-CVR and COVID-19, VAS recommends (1) routine thromboprophylaxis with weight-adjusted intermediate doses of LMWH (unless contraindication); (2) LMWH as the drug of choice over unfractionated heparin or direct oral anticoagulants for the treatment of VTE or hypercoagulability; (3) careful evaluation of the risk for disease worsening and prompt application of targeted antiviral or convalescence treatments; (4) monitoring of D-dimer for optimization of the antithrombotic treatment; and (5) evaluation of the risk of VTE before hospital discharge using the IMPROVE-D-dimer score and prolonged post-discharge thromboprophylaxis with rivaroxaban, betrixaban, or LMWH.
Abstract. Regarding the clinical diagnosis of Raynaud’s phenomenon and its associated conditions, investigations and treatment are substantial, and yet no international consensus has been published regarding the medical management of patients presenting with this condition. Most knowledge on this topic derives from epidemiological surveys and observational studies; few randomized studies are available, almost all relating to drug treatment, and thus these guidelines were developed as an expert consensus document to aid in the diagnosis and management of Raynaud’s phenomenon. This consensus document starts with a clarification about the definition and terminology of Raynaud’s phenomenon and covers the differential and aetiological diagnoses as well as the symptomatic treatment.
Objective-To assess the possible role of proinflammatory CD28Ϫ T cells in abdominal aortic aneurysms (AAAs). Animal studies and human tissue studies suggest a role for interferon (IFN)-␥-producing T cells in the development and progression of AAAs. Methods and Results-Fluorescence-activated cells sorter analysis of peripheral blood samples and measurement of AAA size using sonography were performed in 101 AAA patients and 38 healthy controls. Key Words: aortic disease Ⅲ aneurysms Ⅲ leukocytes Ⅲ immune system Ⅲ human A bdominal aortic aneurysm (AAA) is a common disease with a prevalence of 3% of individuals aged 60 years and older and is a potentially lethal disorder causing Ϸ15 000 deaths annually in the United States. 1 Recent human tissue studies and animal models have led now to a paradigm shift in the pathogenetic concept of AAAs. Rather than a simple degenerative process, the majority of AAAs has proven to be a complex and dynamic remodeling process. In brief, studies of human AAA tissues have identified extensive inflammatory infiltrates in both the media and the adventitia, 2 leading to an increased expression of proinflammatory cytokines and C-reactive protein (CRP) in aneurysmal tissue. [3][4][5] The presence of vascular-associated lymphoid tissue (VALT) with lymphoid follicles and lymph node-like structures in the adventitia of AAAs suggests a role for immunocompetent and antigen presenting cells not only in atherosclerosis 6 but also in AAA disease. 2 The role for T cells has been further supported by immunogenetic findings with associations between AAA and human leukocyte antigen class II molecules. 7 Infiltration of the adventitia usually occurs together with medial thinning. This inflammatory process triggers the production of metalloproteinases and apoptosis of medial smooth muscle cells thus explaining the disruption of the orderly lamellar structure in aortic aneurysms.Recently, a subgroup of proinflammatory T cells has been identified in patients with immune-mediated disorders including rheumatoid arthritis, 8 -9 ankylosing spondylitis, 10 multiple sclerosis, 11 Wegener granulomatosis, 12 and unstable angina, 13 which lack the costimulatory molecule CD28 on their surface and are considered as markers for chronic inflammation and early aging. 14 Under these circumstances the CD28 Ϫ T cells are part of the CD4 ϩ as well as the CD8 ϩ T cell compartment, persist over years, and include most of the oligoclonally expanded T cells. Phenotypically, CD4 ϩ CD28 Ϫ T cells from rheumatoid arthritis and ankylosing spondylitis patients and CD8 ϩ CD28 Ϫ T cells from aged persons, rheumatoid arthritis, and melanoma patients share the expression of various natural killer (NK) cell receptors and lack the expression of the lymphocyte marker CD7. 9,15-16 Functionally these T cells are capable to release large amounts of interferon (IFN)-␥, perforin, and granzyme B, providing them with the possibility to lyse target cells. 17 In the pathogenesis of coronary arteriosclerosis, the critical role of IFN-␥ was alread...
Background: Bilirubin has antioxidative and cytoprotective properties. Low plasma concentrations of bilirubin are reportedly associated with the development of coronary and cerebrovascular disease, and bilirubin concentrations are strongly correlated with the enzyme activity of the hepatic uridine diphosphate glucuronosyltransferase (UGT1A1). The activity of UGT1A1 is influenced by a TA-repeat polymorphism in the promoter of the UGT1A1 gene (UDP glucuronosyltransferase 1 family, polypeptide A1). In a case-control study, we investigated the association between the UGT1A1 polymorphism, bilirubin concentration, and intermittent claudication. Methods: We included 255 consecutive male patients presenting with intermittent claudication in the investigation and matched the patients by age and diabetes mellitus with 255 control individuals. Results: Plasma bilirubin concentrations were significantly lower in patients than in controls [mean (SD), 12.5 (5.3) μmol/L vs 15.4 (7.9) μmol/L; P < 0.001]. We found a clear association between the number of TA repeats and plasma bilirubin concentration. Considering the 6/6 TA-repeat genotype as the wild type, we observed a slight increase in bilirubin concentration individuals with the heterozygous 6/7 genotype and pronounced increases for those with the homozygous 7/7 genotype. This association occurred in both controls and patients; however, patients and controls were not significantly different with respect to UGT1A1 TA-repeat genotype frequencies. Conclusions: Our study of a well-phenotyped group of patients with intermittent claudication and control individuals revealed a clear association between low bilirubin concentrations and peripheral arterial disease but no association between the UGT1A1 polymorphism and the disease.
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