Abstract
Background
Long COVID, also known as post-acute sequelae of COVID-19 (PASC), is characterized by persistent clinical symptoms following COVID-19.
Objective
To correlate biomarkers of endothelial dysfunction with persistent clinical symptoms and pulmonary function defects at distance from COVID-19.
Methods
Consecutive patients with long COVID-19 suspicion were enrolled. A panel of endothelial biomarkers was measured in each patient during clinical evaluation and pulmonary function test (PFT).
Results
The study included 137 PASC patients, mostly male (68%), with a median age of 55 years. A total of 194 PFTs were performed between months 3 and 24 after an episode of SARS-CoV-2 infection. We compared biomarkers evaluated in PASC patients with 20 healthy volunteers (HVs) and acute hospitalized COVID-19 patients (n = 88). The study found that angiogenesis-related biomarkers and von Willebrand factor (VWF) levels were increased in PASC patients compared to HVs without increased inflammatory or platelet activation markers. Moreover, VEGF-A and VWF were associated with persistent lung CT scan lesions and impaired diffusing capacity of the lungs for carbon monoxide (DLCO) measurement. By employing a Cox proportional hazards model adjusted for age, sex, and body mass index, we further confirmed the accuracy of VEGF-A and VWF. Following adjustment, VEGF-A emerged as the most significant predictive factor associated with persistent lung CT scan lesions and impaired DLCO measurement.
Conclusion
VEGF-A is a relevant predictive factor for DLCO impairment and radiological sequelae in PASC. Beyond being a biomarker, we hypothesize that the persistence of angiogenic disorders may contribute to long COVID symptoms.
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Abbreviations
- Ang:
-
Angiopoietin
- AP-HP:
-
Assistance Publique - Hôpitaux de Paris
- ARDS:
-
Acute respiratory distress syndrome
- ATS:
-
American Thoracic Society
- AUC:
-
Area under the curve
- BMI:
-
Body mass index
- CRP:
-
C-reactive protein
- CT:
-
Computer Tomography
- DLCO:
-
Diffusing capacity of the lung for carbon monoxide
- FGF-2:
-
Fibroblast growth factor 2
- FRC:
-
Functional residual capacity
- GLI:
-
Global Lung Function Initiative
- GGO:
-
Ground glass opacities
- HR-CT:
-
High-resolution computed tomography
- Hs-cTnI:
-
High-sensitivity cardiac troponin I
- IPF:
-
Idiopathic pulmonary fibrosis
- IQR:
-
Interquartile range
- 6-MWD:
-
6-minute walk distance
- PAH:
-
Pulmonary arterial hypertension
- PASC:
-
Post-acute sequelae of COVID-19
- PH:
-
Pulmonary hypertension
- PIGF:
-
Placental growth factor
- PFT:
-
Pulmonary function test
- PPP:
-
Platelet-poor plasma
- ROC:
-
Receiver operator characteristics
- SARS-CoV-2:
-
Severe acute respiratory syndrome coronavirus-2
- SD:
-
Standard deviation
- sP-sel:
-
Soluble P-selectin
- VCAM-1:
-
Vascular cell adhesion protein 1
- VEGF-A:
-
Vascular endothelial growth factor A
- VWF:
-
von Willebrand factor
- TLC:
-
Total lung capacity
References
Centers for disease control and prevention (CDC). Post-COVID Conditions: Information for Healthcare Providers. :https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care/post-covid-conditions.html.
Soriano JB, Murthy S, Marshall JC, Relan P, Diaz JV (2022) WHO clinical case definition working group on post-COVID-19 condition. a clinical case definition of post-COVID-19 condition by a Delphi consensus. Lancet Infect Dis 22(4):e102-7
Montani D, Savale L, Noel N, Meyrignac O, Colle R, Gasnier M et al (2022) Post-acute COVID-19 syndrome. Eur Respir Rev Off J Eur Respir Soc 31(163):210185
Carfì A, Bernabei R, Landi F (2020) Gemelli against COVID-19 Post-acute care study group. persistent symptoms in patients after acute COVID-19. JAMA 324(6):603–5
Xiong Q, Xu M, Li J, Liu Y, Zhang J, Xu Y et al (2021) Clinical sequelae of COVID-19 survivors in Wuhan, China: a single-centre longitudinal study. Clin Microbiol Infect Off Publ Eur Soc Clin Microbiol Infect Dis 27(1):89–95
Ballering AV, van Zon SKR, Olde Hartman TC, Rosmalen JGM (2022) Lifelines corona research initiative persistence of somatic symptoms after COVID-19 in the Netherlands: an observational cohort study. Lancet Lond Engl 400(10350):452–61
Huang L, Yao Q, Gu X, Wang Q, Ren L, Wang Y et al (2021) 1-year outcomes in hospital survivors with COVID-19: a longitudinal cohort study. Lancet Lond Engl 398(10302):747–758
Huang L, Li X, Gu X, Zhang H, Ren L, Guo L et al (2022) Health outcomes in people 2 years after surviving hospitalisation with COVID-19: a longitudinal cohort study. Lancet Respir Med 10(9):863–876
Global Burden of Disease Long COVID Collaborators, Wulf Hanson S, Abbafati C, Aerts JG, Al-Aly Z, Ashbaugh C et al (2022) Estimated global proportions of individuals with persistent fatigue, cognitive, and respiratory symptom clusters following symptomatic COVID-19 in 2020 and 2021. JAMA 328(16):1604–1615
Mateu L, Tebe C, Loste C, Santos JR, Lladós G, López C, et al. Determinants of the Onset and Prognosis of the Post-COVID-19 Condition: A 2-Year Prospective Cohort Study [Internet]. SSRN; 2023. Retrieved July 13, 2023, from https://www.ssrn.com/abstract=4505315
Yang C, Zhao H, EspÃn E, Tebbutt SJ (2023) Association of SARS-CoV-2 infection and persistence with long COVID. Lancet Respir Med. https://doi.org/10.1016/S2213-2600(23)00142-X
Swank Z, Senussi Y, Manickas-Hill Z, Yu XG, Li JZ, Alter G et al (2023) Persistent Circulating severe acute respiratory syndrome coronavirus 2 spike is associated with post-acute coronavirus disease 2019 sequelae. Clin Infect Dis Off Publ Infect Dis Soc Am 76(3):e487–e490
Patel MA, Knauer MJ, Nicholson M, Daley M, Van Nynatten LR, Cepinskas G et al (2023) Organ and cell-specific biomarkers of Long-COVID identified with targeted proteomics and machine learning. Mol Med 29(1):26
Gyöngyösi M, Alcaide P, Asselbergs FW, Brundel BJJM, Camici GG, da Costa Martins P et al (2023) Long COVID and the cardiovascular system-elucidating causes and cellular mechanisms in order to develop targeted diagnostic and therapeutic strategies: a joint Scientific Statement of the ESC Working Groups on cellular biology of the heart and myocardial and pericardial diseases. Cardiovasc Res 119(2):336–56
Chioh FW, Fong SW, Young BE, Wu KX, Siau A, Krishnan S et al (2021) Convalescent COVID-19 patients are susceptible to endothelial dysfunction due to persistent immune activation. eLife 10:e64909
Ackermann M, Verleden SE, Kuehnel M, Haverich A, Welte T, Laenger F et al (2020) Pulmonary vascular endothelialitis, thrombosis, and angiogenesis in Covid-19. N Engl J Med 383(2):120–128
Smadja DM, Mentzer SJ, Fontenay M, Laffan MA, Ackermann M, Helms J et al (2021) COVID-19 is a systemic vascular hemopathy: insight for mechanistic and clinical aspects. Angiogenesis 24(4):755–788
Philippe A, Chocron R, Gendron N, Bory O, Beauvais A, Peron N et al (2021) Circulating Von Willebrand factor and high molecular weight multimers as markers of endothelial injury predict COVID-19 in-hospital mortality. Angiogenesis 24(3):505–517
Werlein C, Ackermann M, Stark H, Shah HR, Tzankov A, Haslbauer JD et al (2022) Inflammation and vascular remodeling in COVID-19 hearts. Angiogenesis 12:1–16
Smadja DM, Philippe A, Bory O, Gendron N, Beauvais A, Gruest M et al (2021) Placental growth factor level in plasma predicts COVID-19 severity and in-hospital mortality. J Thromb Haemost JTH 19(7):1823–1830
Faconti L, Farukh B, McNally RJ, Brett S, Chowienczyk PJ (2023) Impaired β2-adrenergic endothelium-dependent vasodilation in patients previously hospitalized with coronavirus disease 2019. J Hypertens. https://doi.org/10.1097/HJH.0000000000003420
Fogarty H, Townsend L, Morrin H, Ahmad A, Comerford C, Karampini E et al (2021) Persistent endotheliopathy in the pathogenesis of long COVID syndrome. J Thromb Haemost JTH 19(10):2546–2553
Fogarty H, Ward SE, Townsend L, Karampini E, Elliott S, Conlon N et al (2022) Sustained VWF-ADAMTS-13 axis imbalance and endotheliopathy in long COVID syndrome is related to immune dysfunction. J Thromb Haemost 20(10):2429–2438
Quanjer PH, Stanojevic S, Cole TJ, Baur X, Hall GL, Culver BH et al (2012) Multi-ethnic reference values for spirometry for the 3–95-yr age range: the global lung function 2012 equations. Eur Respir J 40(6):1324–1343
Stanojevic S, Graham BL, Cooper BG, Thompson BR, Carter KW, Francis RW et al (2017) Official ERS technical standards: global lung function initiative reference values for the carbon monoxide transfer factor for Caucasians. Eur Respir J 50(3):1700010
ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med. 2002 Jul 1; 166(1):111–7
Enright PL, Sherrill DL (1998) Reference equations for the six-minute walk in healthy adults. Am J Respir Crit Care Med 158(5 Pt 1):1384–1387
Bernheim A, Mei X, Huang M, Yang Y, Fayad ZA, Zhang N et al (2020) Chest CT findings in coronavirus disease-19 (COVID-19): relationship to duration of infection. Radiology 295(3):200463
Wang Y, Dong C, Hu Y, Li C, Ren Q, Zhang X et al (2020) Temporal changes of CT findings in 90 patients with COVID-19 pneumonia: a longitudinal study. Radiology 296(2):E55-64
Guerin CL, Guyonnet L, Goudot G, Revets D, Konstantinou M, Chipont A et al (2021) Multidimensional proteomic approach of endothelial progenitors demonstrate expression of KDR restricted to CD19 Cells. Stem Cell Rev Rep 17(2):639–651
Dudley AC, Griffioen AW (2023) Pathological angiogenesis: mechanisms and therapeutic strategies. Angiogenesis 15:1–35
Ackermann M, Kamp JC, Werlein C, Walsh CL, Stark H, Prade V et al (2022) The fatal trajectory of pulmonary COVID-19 is driven by lobular ischemia and fibrotic remodelling. EBioMedicine 4(85):104296
Kamp JC, Werlein C, Plucinski EKJ, Neubert L, Welte T, Lee PD et al (2023) Novel insight into pulmonary fibrosis and long COVID. Am J Respir Crit Care Med 207(8):1105–1107
Barratt S, Medford AR, Millar AB (2014) Vascular endothelial growth factor in acute lung injury and acute respiratory distress syndrome. Respir Int Rev Thorac Dis 87(4):329–342
Miao H, Qiu F, Zhu L, Jiang B, Yuan Y, Huang B et al (2021) Novel angiogenesis strategy to ameliorate pulmonary hypertension. J Thorac Cardiovasc Surg 161(6):e417–e434
Eddahibi S, Humbert M, Sediame S, Chouaid C, Partovian C, Maître B et al (2000) Imbalance between platelet vascular endothelial growth factor and platelet-derived growth factor in pulmonary hypertension. effect of prostacyclin therapy. Am J Respir Crit Care Med 162:1493–9
Christou H, Yoshida A, Arthur V, Morita T, Kourembanas S (1998) Increased vascular endothelial growth factor production in the lungs of rats with hypoxia-induced pulmonary hypertension. Am J Respir Cell Mol Biol 18(6):768–776
Smadja DM, Gaussem P, Mauge L, Israël-Biet D, Dignat-George F, Peyrard S et al (2009) Circulating endothelial cells: a new candidate biomarker of irreversible pulmonary hypertension secondary to congenital heart disease. Circulation 119(3):374–381
Godinas L, Guignabert C, Seferian A, Perros F, Bergot E, Sibille Y et al (2013) Tyrosine kinase inhibitors in pulmonary arterial hypertension: a double-edge sword? Semin Respir Crit Care Med 34(5):714–724
Papaioannou AI, Kostikas K, Kollia P, Gourgoulianis KI (2006) Clinical implications for vascular endothelial growth factor in the lung: friend or foe? Respir Res 7(1):128
Smadja DM, Nunes H, Juvin K, Bertil S, Valeyre D, Gaussem P et al (2014) Increase in both angiogenic and angiostatic mediators in patients with idiopathic pulmonary fibrosis. Pathol Biol (Paris) 62(6):391–394
Fukihara J, Kondoh Y (2016) Nintedanib (OFEV) in the treatment of idiopathic pulmonary fibrosis. Expert Rev Respir Med 10(12):1247–1254
Alfadda AA, Rafiullah M, Alkhowaiter M, Alotaibi N, Alzahrani M, Binkhamis K et al (2022) Clinical and biochemical characteristics of people experiencing post-coronavirus disease 2019-related symptoms: a prospective follow-up investigation. Front Med 9:1067082
Patel MA, Knauer MJ, Nicholson M, Daley M, Van Nynatten LR, Martin C et al (2022) Elevated vascular transformation blood biomarkers in Long-COVID indicate angiogenesis as a key pathophysiological mechanism. Mol Med 28(1):122
Patterson BK, Guevara-Coto J, Yogendra R, Francisco EB, Long E, Pise A et al (2021) Immune-based prediction of COVID-19 severity and Chronicity decoded using machine learning. Front Immunol 28(12):700782
Patterson BK, Yogendra R, Guevara-Coto J, Mora-Rodriguez RA, Osgood E, Bream J et al (2023) Case series: maraviroc and pravastatin as a therapeutic option to treat long COVID/Post-acute sequelae of COVID (PASC). Front Med 10:1122529
Gupta A, Konnova A, Smet M, Berkell M, Savoldi A, Morra M et al (2023) Host immunological responses facilitate development of SARS-CoV-2 mutations in patients receiving monoclonal antibody treatments. J Clin Invest 133(6):e166032
Vojdani A, Vojdani E, Saidara E, Maes M (2023) Persistent SARS-CoV-2 infection, EBV, HHV-6 and other factors may contribute to inflammation and autoimmunity in long COVID. Viruses 15(2):400
Osiaevi I, Schulze A, Evers G, Harmening K, Vink H, Kümpers P et al (2023) Persistent capillary rarefication in long COVID syndrome. Angiogenesis 26(1):53–61
Ebina M, Shimizukawa M, Shibata N, Kimura Y, Suzuki T, Endo M et al (2004) Heterogeneous increase in CD34-positive alveolar capillaries in idiopathic pulmonary fibrosis. Am J Respir Crit Care Med 169(11):1203–1208
Charfeddine S, Ibn Hadj Amor H, Jdidi J, Torjmen S, Kraiem S, Hammami R et al (2021) Long COVID 19 syndrome: is it related to microcirculation and endothelial dysfunction? insights from TUN-EndCOV study. Front Cardiovasc Med 8:745758
Charfeddine S, Ibnhadjamor H, Jdidi J, Torjmen S, Kraiem S, Bahloul A et al (2022) Sulodexide significantly improves endothelial dysfunction and alleviates chest pain and palpitations in patients with long-COVID-19: insights from TUN-EndCOV study. Front Cardiovasc Med 9:866113
Willems LH, Nagy M, Ten Cate H, Spronk HMH, Groh LA, Leentjens J et al (2022) Sustained inflammation, coagulation activation and elevated endothelin-1 levels without macrovascular dysfunction at 3 months after COVID-19. Thromb Res 209:106–114
Willems LH, Jacobs LMC, Groh LA, Ten Cate H, Spronk HMH, Wilson-Storey B et al (2023) Vascular function, systemic inflammation, and coagulation activation 18Â months after COVID-19 infection: an observational cohort study. J Clin Med 12(4):1413
Fan BE, Wong SW, Sum CLL, Lim GH, Leung BP, Tan CW et al (2022) Hypercoagulability, endotheliopathy, and inflammation approximating 1 year after recovery: assessing the long-term outcomes in COVID-19 patients. Am J Hematol 97(7):915–923
Philippe A, Gendron N, Bory O, Beauvais A, Mirault T, Planquette B et al (2021) Von Willebrand factor collagen-binding capacity predicts in-hospital mortality in COVID-19 patients: insight from VWF/ADAMTS13 ratio imbalance. Angiogenesis 24(3):407–411
Constantinescu-Bercu A, Kessler A, de Groot R, Dragunaite B, Heightman M, Hillman T et al (2023) Analysis of thrombogenicity under flow reveals new insights into the prothrombotic state of patients with post-COVID syndrome. J Thromb Haemost 21(1):94–100
Prasannan N, Heightman M, Hillman T, Wall E, Bell R, Kessler A et al (2022) Impaired exercise capacity in post-COVID-19 syndrome: the role of VWF-ADAMTS13 axis. Blood Adv 6(13):4041–4048
Lorenzi O, Frieden M, Villemin P, Fournier M, Foti M, Vischer UM (2008) Protein kinase C-delta mediates von Willebrand factor secretion from endothelial cells in response to vascular endothelial growth factor (VEGF) but not histamine. J Thromb Haemost 6(11):1962–1969
Yang X, Jian Sun H, Rong Li Z, Zhang H, Jun Yang W, Ni B et al (2015) Gastric cancer-associated enhancement of von Willebrand factor is regulated by vascular endothelial growth factor and related to disease severity. BMC Cancer 15:80
Matsushita K, Yamakuchi M, Morrell CN, Ozaki M, O’Rourke B, Irani K et al (2005) Vascular endothelial growth factor regulation of Weibel-Palade-body exocytosis. Blood 105(1):207–214
Geindreau M, Ghiringhelli F, Bruchard M (2021) Vascular endothelial growth factor, a key modulator of the anti-tumor immune response. Int J Mol Sci 22(9):4871
Pang J, Xu F, Aondio G, Li Y, Fumagalli A, Lu M et al (2021) Efficacy and tolerability of bevacizumab in patients with severe Covid-19. Nat Commun 12(1):814
Funding
This work was funded with grants from French national agency for research ANR SARCODO (Fondation de France). Aurélien Philippe was funded with grants from Mécénat Crédit Agricole Ile de France programme jeune talent.
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DMS, SG, and JLD designed the study. AP and DMS analyzed the data and wrote the manuscript. AP and PC performed statistical analysis. All authors reviewed and approved the final manuscript for publication.
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Philippe, A., Günther, S., Rancic, J. et al. VEGF-A plasma levels are associated with impaired DLCO and radiological sequelae in long COVID patients. Angiogenesis (2023). https://doi.org/10.1007/s10456-023-09890-9
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DOI: https://doi.org/10.1007/s10456-023-09890-9