SARS-CoV-2 Receptors are Expressed on Human Platelets and the Effect of Aspirin on Clinical Outcomes in COVID-19 Patients

SARS-CoV-2 Receptors are Expressed on Human Platelets and the Effect of Aspirin on Clinical Outcomes in COVID-19 Patients | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article SARS-CoV-2 Receptors are Expressed on Human Platelets and the Effect of Aspirin on Clinical Outcomes in COVID-19 Patients Aditya Sahai, Rohan Bhandari, Milka Koupenova, Jane Freedman, and 14 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-119031/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Coronavirus disease-2019 (COVID-19) caused by SARS-CoV-2 is an ongoing viral pandemic marked by increased risk of thrombotic events. However, the role of platelets in the elevated observed thrombotic risk in COVID-19 and utility of anti-platelet agents in attenuating thrombosis is unknown. We aimed to determine if human platelets express the known SARS-CoV-2 receptor-protease axis on their cell surface and assess whether the anti-platelet effect of aspirin may mitigate risk of myocardial infarction (MI), cerebrovascular accident (CVA), and venous thromboembolism (VTE) in COVID-19. Expression of ACE2 and TMPRSS2 on human platelets were detected by immunoblotting and confirmed by confocal microscopy. We evaluated 22,072 symptomatic patients tested for COVID-19. Propensity-matched analyses were performed to determine if treatment with aspirin or non-steroidal anti-inflammatory drugs (NSAIDs) affected thrombotic outcomes in COVID-19. Neither aspirin nor NSAIDs affected mortality in COVID-19. However, both aspirin and NSAID therapies were associated with increased risk of the combined thrombotic endpoint of (MI), (CVA), and (VTE). Thus, while platelets clearly express ACE2-TMPRSS2 receptor-protease axis for SARS-CoV-2 infection, aspirin does not prevent thrombosis and death in COVID-19. The mechanisms of thrombosis in COVID-19, therefore, appears distinct and the role of platelets as direct mediators of SARS-CoV-2-mediated thrombosis warrants further investigation. Cardiac & Cardiovascular Systems General Cell Biology & Physiology Platelets SARS-CoV-2 COVID-19 Thrombosis ACE2 TMPRSS2 Figures Figure 1 Figure 2 Figure 3 Figure 4 Full Text Supplementary Files SupplementalFile1221.20.pdf Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-119031","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":6890128,"identity":"d133a9da-e977-43de-806d-4da404a9a510","order_by":0,"name":"Aditya Sahai","email":"","orcid":"","institution":"Cleveland Clinic Lerner College of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Aditya","middleName":"","lastName":"Sahai","suffix":""},{"id":6890129,"identity":"8efe3eb9-19bd-46d4-9d7a-997d2aee0f8e","order_by":1,"name":"Rohan Bhandari","email":"","orcid":"","institution":"Cleveland 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Galveston","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ayman","middleName":"","lastName":"Elbadawi","suffix":""},{"id":6890142,"identity":"d6ba4dae-6566-4aec-8134-02e0f67bec0d","order_by":14,"name":"Lars Svensson","email":"","orcid":"","institution":"Cleveland Clinic","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Lars","middleName":"","lastName":"Svensson","suffix":""},{"id":6890143,"identity":"bfc4f62c-1367-4182-83d1-95944afa95dd","order_by":15,"name":"Samir Kapadia","email":"","orcid":"","institution":"Cleveland Clinic","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Samir","middleName":"","lastName":"Kapadia","suffix":""},{"id":6890144,"identity":"4052a7dd-93fa-46d6-ba1c-ef745e368f97","order_by":16,"name":"Essa Hariri","email":"","orcid":"","institution":"Cleveland 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21:44:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-119031/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-119031/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":4475807,"identity":"cbee23ac-bfb5-4448-b171-832d34db75d6","added_by":"auto","created_at":"2020-12-23 15:47:34","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":78790,"visible":true,"origin":"","legend":"Expression of ACE2 and TMPRSS2 in Platelets by Confocal Microscopy. Platelets isolated\nfrom venous blood of healthy individuals was stained for 1h with the following antibodies: CD41\n(platelet-specific marker), ACE2, TMPRSS2, and DAPI to eliminate any DNA components. Mounted slides were resolved by confocal fluorescent microscopy using a 100x objective lens. Images are representative of n=6 donors for ACE2 and n=3 for TMPRSS2. Each image represents a different donor. The scale bar is noted.","description":"","filename":"Fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-119031/v1/f303179d86cdd799444abf35.jpg"},{"id":4475830,"identity":"7acd66e5-6146-4908-962f-38155cde3c2f","added_by":"auto","created_at":"2020-12-23 15:48:00","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":191229,"visible":true,"origin":"","legend":"A. Expression of TMPRSS2 in Platelets: Washed platelets from healthy individuals (mean age 40.1 ± 2.8 years, n=20) were isolated and proteins separate by SDS-PAGE with molecular weight shown in KiloDaltons (KDa). Immunoblotting was conducted an using an anti-TMPRSS2 antibody or anti-tubulin immunoblotting as a loading control. The ratio of protein to loading control is expressed as a function of age and the correlation coefficient is noted (r ± 95% CI, P=0.30). Human brain lysate served as a positive control for TMPRSS2 migrating at the expected molecular weight (~50 KDa). Data shown are representative of 20 healthy individuals (10 male and 10 female) and 10 patients with coronary artery disease (CAD). The mean ratio of TMPRSS2/Tubulin ± SEM is noted, P=0.145 between healthy and CAD by Mann Whitney U). B. Expression of ACE2 in Platelets: Washed platelets from healthy individuals (mean age 40.1 ± 2.8 years, n=20) were isolated and proteins separate by SDS-PAGE with molecular weight shown in KiloDaltons (KDa). Lane 1 is human platelet lysate, lane 2 is human brain lysate, lane 3 is human placenta lysate, lane 4 is lysate from engineered human heart tissue. Immunoblotting was conducted using an using anti-ACE2 antibody. Anti-tubulin and anti-GAPDH are loading controls. ACE2 migrates at the expected molecular weight (~100 KDa) shown by an arrowhead with glycosylated forms indicated by *. The ratio of ACE2 protein to loading control is expressed as a function of age and the correlation coefficient is noted (r ± 95% CI, P=0.79). Data shown are representative of 20 healthy individuals (10 male and 10 female) and 10 patients with coronary artery disease (CAD). The mean ratio of ACE2/Tubulin ± SEM is noted, P=0.112 between healthy and CAD by Mann Whitney U).","description":"","filename":"Fig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-119031/v1/5a59fce201bd193ecd8faf5b.jpg"},{"id":4475821,"identity":"3c9dc9e2-6625-4434-a6e1-748ccd5e986c","added_by":"auto","created_at":"2020-12-23 15:47:56","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":75121,"visible":true,"origin":"","legend":"Patients Testing Positive for SARS-CoV-2 taking Aspirin or NSAIDs. Patients testing positive for a SARS-CoV-2 amplicon at two Cleveland Clinic hospitals were evaluated. Patients initiated with aspirin or NSAID therapy or continuing aspirin or NSAID if admitted to the hospital were included in this study. Clinical variables in each group where then re-evaluated following careful propensity matching .","description":"","filename":"Fig3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-119031/v1/c5b71e9ab83cd37f1134d803.jpg"},{"id":4475813,"identity":"936c6df1-317b-4370-9689-beef1fa03ee4","added_by":"auto","created_at":"2020-12-23 15:47:52","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":32897,"visible":true,"origin":"","legend":"Mortality for Propensity-matched patients: Propensity-matched data for patients testing positive for COVD-19 and outcomes taking either 81 mg aspirin (n=248 in each group) or NSAIDs (n=444 in each group) at the time of diagnosis. Forest plot representation of data as Odds Ratio (OR) with 95% confidence interval (C.I.) for the primary endpoint of death.","description":"","filename":"Fig4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-119031/v1/cb4c0d3015866339e327e538.jpg"},{"id":13567677,"identity":"d0d82c4a-7787-4a17-9229-2d8446eff413","added_by":"auto","created_at":"2021-09-17 03:33:53","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1552548,"visible":true,"origin":"","legend":"","description":"","filename":"COVIDSciReportsRB122120.pdf","url":"https://assets-eu.researchsquare.com/files/rs-119031/v1_covered.pdf"},{"id":4475759,"identity":"91e09d0e-dfcd-42e3-9034-c170fe9a5e46","added_by":"auto","created_at":"2020-12-23 15:46:16","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2063404,"visible":true,"origin":"","legend":"","description":"","filename":"COVIDSciReportsRB122120.pdf","url":"https://assets-eu.researchsquare.com/files/rs-119031/v1_stamped.pdf"},{"id":4475828,"identity":"93855a1d-69bf-45eb-8ceb-f64fe4736740","added_by":"auto","created_at":"2020-12-23 15:48:00","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":4167550,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementalFile1221.20.pdf","url":"https://assets-eu.researchsquare.com/files/rs-119031/v1/8d2f580692c1159653da96a6.pdf"}],"financialInterests":"","formattedTitle":"SARS-CoV-2 Receptors are Expressed on Human Platelets and the Effect of Aspirin on Clinical Outcomes in COVID-19 Patients","fulltext":[{"header":"Full Text","content":"\u003cp\u003eThis preprint is available for \u003ca href='/article/rs-119031/latest.pdf' target='_blank'\u003edownload as a PDF\u003c/a\u003e.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":true,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Platelets, SARS-CoV-2, COVID-19, Thrombosis, ACE2, TMPRSS2","lastPublishedDoi":"10.21203/rs.3.rs-119031/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-119031/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eCoronavirus disease-2019 (COVID-19) caused by SARS-CoV-2 is an ongoing viral pandemic marked by increased risk of thrombotic events. However, the role of platelets in the elevated observed thrombotic risk in COVID-19 and utility of anti-platelet agents in attenuating thrombosis is unknown. We aimed to determine if human platelets express the known SARS-CoV-2 receptor-protease axis on their cell surface and assess whether the anti-platelet effect of aspirin may mitigate risk of myocardial infarction (MI), cerebrovascular accident (CVA), and venous thromboembolism (VTE) in COVID-19. Expression of ACE2 and TMPRSS2 on human platelets were detected by immunoblotting and confirmed by confocal microscopy. We evaluated 22,072 symptomatic patients tested for COVID-19. Propensity-matched analyses were performed to determine if treatment with aspirin or non-steroidal anti-inflammatory drugs (NSAIDs) affected thrombotic outcomes in COVID-19. Neither aspirin nor NSAIDs affected mortality in COVID-19. However, both aspirin and NSAID therapies were associated with increased risk of the combined thrombotic endpoint of (MI), (CVA), and (VTE). Thus, while platelets clearly express ACE2-TMPRSS2 receptor-protease axis for SARS-CoV-2 infection, aspirin does not prevent thrombosis and death in COVID-19. The mechanisms of thrombosis in COVID-19, therefore, appears distinct and the role of platelets as direct mediators of SARS-CoV-2-mediated thrombosis warrants further investigation.\u003c/p\u003e","manuscriptTitle":"SARS-CoV-2 Receptors are Expressed on Human Platelets and the Effect of Aspirin on Clinical Outcomes in COVID-19 Patients","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-12-23 15:41:39","doi":"10.21203/rs.3.rs-119031/v1","editorialEvents":[{"type":"communityComments","content":1}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b70bd416-1aa6-4d48-a351-41fe6723462d","owner":[],"postedDate":"December 23rd, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":1595449,"name":"Cardiac \u0026 Cardiovascular Systems"},{"id":1595450,"name":"General Cell Biology \u0026 Physiology"}],"tags":[],"updatedAt":"2021-02-05T09:14:21+00:00","versionOfRecord":[],"versionCreatedAt":"2020-12-23 15:41:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-119031","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-119031","identity":"rs-119031","version":["v1"]},"buildId":"FbvkV6FR0MCFSLy54lSbu","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}