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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.

Endothelial dysfunction as an integrating index of the risk factor burden and genetic susceptibility is an early marker of atherothrombotic disease. Therefore, tremendous interest exists in its measurement and determination of the clinical utility of the evaluation of endothelial function. Different invasive and non-invasive techniques exist for exploring various aspects of the pathobiology of the endothelium. As endothelial dysfunction is a diffuse-systemic disorder, the peripheral arteries, because of their accessibility, represent the basis for assessment of endothelial dysfunction.

The measurement of intima-media thickness (IMT) of large superficial arteries, especially the carotid, using high-resolution B-mode ultrasonography has emerged as one of the methods of choice for determining the anatomic extent of atherosclerosis and for assessing cardiovascular risk. IMT measurement obtained by ultrasonography correlates very well with pathohistologic measurements and the reproducibility of this technique is good. Population studies have shown a strong correlation between carotid IMT and several cardiovascular risk factors, and it has also been found to be associated with the extent of atherosclerosis and end-organ damage of high-risk patients. Therefore, increased carotid IMT is a measure of atherosclerotic burden and a predictor of subsequent events. Because of its quantitative value, carotid IMT measurement is more and more frequently used in clinical trials to test the effects of different preventive measures, including drugs. More recently, there has been interest in the clinical use of this technique for detecting preclinical (asymptomatic) atherosclerosis and for identifying subjects at high risk. Measurement of carotid IMT could influence a clinician to intervene with medication and to use more aggressive treatment of risk factors in primary prevention, and in patients with atherosclerotic disease in whom there is evidence of progression and extension of atherosclerotic disease. For more extensive use of this method in clinical practice a consensus concerning the standardization of methods of measurement and precise definition of threshold between normal and pathologic IMT value is urgently needed.

Atherosclerosis is a generalized disease with considerable overlap of its coronary, carotid, and peripheral manifestations. As an indicator of multifocal atherosclerosis, peripheral arterial disease (PAD) is emerging as an important aid in risk stratification of patients with coronary artery (CAD) or cerebrovascular disease (CVD). Therefore, the aim of the study was to assess the prevalence of PAD in high risk subjects and its ability to identify coronary or cerebrovascular patients. A total of 952 (63.3% male; age 63.7 +/-10.7 years) patients at high cardiovascular risk (>or=2 risk factors), or with evidence of CAD or CVD were screened for PAD by means of ankle-brachial index (ABI) assessment; 226 patients were at high risk (>or=2 risk factors), 575 had CAD, and 151 had CVD. A total of 42% of patients with CAD and 36% of patients with CVD had PAD. In patients with CAD one half of cases of PAD were asymptomatic. Asymptomatic PAD (pathological ABI) was strongly associated with CAD and CVD, even after adjustment for age, gender, and other risk factors. No significant differences between CAD, PAD, and CVD patients were observed in terms of risk profiles. In conclusion, our findings confirm a high prevalence of both symptomatic and asymptomatic PAD in patients at high cardiovascular risk and its association with both CAD and CVD.