|Year : 2019 | Volume
| Issue : 5 | Page : 598-602
Which one predicts mortality better? Hemogram and ST elevation myocardial infarction
A Avci1, BS Avci2, Y Donmez3, M Kocer4, M Gulen1, AI Ozer1, A Bulut3, M Koc3, H Nazik5, S Satar1
1 Department of Emergency Medicine, Health Science University, Adana City Research and Training Hospital, Adana, Turkey
2 Department of Internal Medicine, Health Science University, Adana City Research and Training Hospital, Adana, Turkey
3 Department of Cardiology, Health Science University, Adana City Research and Training Hospital, Adana, Turkey
4 Department of Emergecy Medicine, Balıklıgöl State Hospital, Emergency Service, Şanlıurfa, Turkey
5 Department of Gynecology, Health Science University, Adana City Research and Training Hospital, Adana, Turkey
|Date of Acceptance||10-Jan-2019|
|Date of Web Publication||15-May-2019|
Dr. A Avci
Department of Emergency Medicine, Health Science University, Adana City Research and Training Hospital, Adana - 01240
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objective: The aim of this study was to determine the effectiveness of hematological parameters measured at the moment of admission to the emergency room in predicting in-hospital mortality and to determine cut-off values of strongly predictive values. Subjects and Methods: The study began with approval of the ethics committee. In total, 1,929 patients over 18 years of age, whose date could be obtained, were included in the study. From the hemogram parameters, white blood cells (WBC), red cell distribution width, mean platelet volume, and ratio of neutrophils to lymphocytes (NLR) values were determined and recorded. CK-MB and high-sensitive Troponin T values were recorded as cardiac markers. For statistical analysis, “SPSS for Windows Version 21” package program was used. Findings: About 71.7% (n = 1384) of the patients were male and 28.3% (n = 545) of the patients were female. About 92.5% of the patients (n = 1785) were discharged from the hospital, whereas the remaining 144 patients (7.5%) were exitus in the hospital. When the efficacy of hematological parameters and cardiac markers in predicting mortality was examined by receiver operating charecteristics analysis, NLR was found to be the strongest predictor (area under the curve [AUC], 0.772, standard deviation [SD] = 0.022, 95% confidence interval [CI]). It was found that the WBC value came in second place after NLR as a strong predictor of mortality (AUC, 0.749, SD = 0.024, % 95 CI). Conclusion: The use of predictors for the prediction of mortality for ST elevation myocardial infarction patients is of great importance for faster implementation of treatment modalities. We found that WBC and especially NLR values obtained with a simple method can be used as powerful predictors.
Keywords: Mortality, neutrophils to lymphocytes, ST elevation myocardial infarction, white blood cells
|How to cite this article:|
Avci A, Avci B S, Donmez Y, Kocer M, Gulen M, Ozer A I, Bulut A, Koc M, Nazik H, Satar S. Which one predicts mortality better? Hemogram and ST elevation myocardial infarction. Niger J Clin Pract 2019;22:598-602
|How to cite this URL:|
Avci A, Avci B S, Donmez Y, Kocer M, Gulen M, Ozer A I, Bulut A, Koc M, Nazik H, Satar S. Which one predicts mortality better? Hemogram and ST elevation myocardial infarction. Niger J Clin Pract [serial online] 2019 [cited 2019 May 23];22:598-602. Available from: http://www.njcponline.com/text.asp?2019/22/5/598/258279
| Introduction|| |
Acute myocardial infarction (AMI) is a common emergency worldwide with high mortality and morbidity rates in spite of all the advanced treatment methods in the last 30 years. AMI is essentially an inflammatory disease. The relationship between AMI and inflammation has been expressed in various epidemiological and clinical investigations.,,,
Many hematological parameters are increased in inflammation and studies have been carried out to determine the prognosis associated with this. Among different hematological markers, the ratio of neutrophils to lymphocytes (NLR) is claimed to have the highest value in predicting death in high-risk patients in terms of coronary artery disease. White blood cells (WBC) are involved in the pathogenesis of ST elevation myocardial infarction (STEMI)., It is argued that high WBC values are associated with increased mortality in STEMI patients. Apart from the WBC count, it is stated that the mean platelet volume (MPV) and red cell distribution width (RDW) has prognostic value in STEMI.,,,, Most of the previous studies used these markers in predicting long-term mortality. Additionally, studies investigating these parameters reveal limited data on cut-off values.
The aim of this study was to determine the effectiveness of hematologic parameters measured at the moment of admission to the emergency room in predicting in-hospital mortality and to determine cut-off values of strongly predictive values.
| Subjects and Methods|| |
The study began with approval of the ethics committee. In total, 6,717 patients hospitalized to our hospital's coronary care unit with an STEMI diagnosis between 01 January 2013 and 31 December 2016 were scanned retrospectively and documented from the hospital automation system. Patients' ages, sex, laboratory results, angiography results, and in-hospital outcomes (living and dying) were recorded. In total, 1,929 patients over 18 years of age, whose data could be obtained, were included in the study. In total, 4,788 patients were excluded from the study, who had missing information in their file, were under the age of 18, referred to another center, refused treatment or who were identified as a non-STEMI diagnosis as the final diagnosis. In addition, they should indicate that patients who had medical conditions that could affect the WBC or its subtypes (i.e., acute or chronic infection or inflammatory diseases, hematological disorder, malignancies, end-stage liver or renal disease, and use of steroid therapy or chemotherapy) were excluded from the study.
Hemogram and cardiac marker (CK-MB, high-sensitive Troponin T) measurements of patients included in the study were performed via venous blood sample taken during the initial admission to the emergency room. From the hemogram parameters, WBC, RDW, MPV, and NLR values were determined and recorded. CK-MB and high-sensitive Troponin T values were recorded as cardiac markers. Complete blood count measurements were made using the Sysmex XN 10 (Automated Hematology Analyzer XN series, Sysmex Corporation, 1-5-1 Wakinnohama-Kaigandori Chuo-ku, Kobe 651-0073, Japan) automatic measurement device. CK-MB and high-sensitivity troponin T measurements were made using the Cobas 6000 (Roche Diagnostic GnbH, Manheim, Germany; Hitachi High-Technologies Corporation, Tokyo, Japan) automatic measurement device.
For statistical analysis, “IBM SPSS statistics for windows version 21.0. (Armonk, NY, IBM Corp)” package program was used. Descriptive statistical methods (mean, standard deviation [SD]) and Student's t-test were used in the distribution of the quantitative data. Mann–Whitney U-test was taken into account in the analysis of data with no normal distribution. Chi-square test was used for qualitative evaluation. Statistical significance was accepted when the data had a P value <0.05. Receiver operating charecteristics (ROC) curve analysis and area under the curve (AUC) calculations of hematological parameters and cardiac markers were used to calculate their effectiveness in predicting mortality. The cut-off values of strong predictor parameters were recorded with the most appropriate specificity and sensitivity ratio.
| Results|| |
The mean age of the patients studied was 60.80 ± 12.82. The WBC, RDW, MPV, NLR, platelet, CK-MB, and troponin T values of the patients are shown in [Table 1].
About 71.7% (n = 1,384) of the patients were male and 28.3% (n = 545) of the patients were female. About 92.5% of the patients (n = 1,785) were discharged from the hospital, while the remaining 144 patients (7.5%) were exitus in the hospital. According to the angiography results, the most common localization for the lesion was found to be the anterior descending artery (n = 1,547, 80.2%), and the least common was the left main coronary artery (n = 99, 5.1%) [Table 2].
|Table 2: Distribution of the sex, outcome, and angiography results of patients|
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When the efficacy of hematological parameters and cardiac markers in predicting mortality was examined by ROC analysis, NLR was found to be the strongest predictor (AUC, 0.772, SD = 0,022, % 95 Confidence Interval [CI]). As a result of the analysis, when the cut-off value of NLR was taken as 4.05, it was found that it had 71.0% sensitivity and 68.8% specificity.
It was found that the WBC value came in second place after NLR as a strong predictor of mortality (AUC, 0.749, SD = 0.024, % 95 CI). As a result of the analysis, it was determined that when the cut-off value for WBC was taken as 12,545, it had 70.3% sensitivity and 63.9% specificity [Figure 1] and [Table 3].
|Figure 1: Receiver operating charecteristics analysis of hemogram and cardiac markers|
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Even though MPV (AUC, 0.572, SD = 0.025, 95% CI) and RDW (AUC, 0.52, SD = 0.027, 95% CI) values were found to be statistically significant in mortality prediction, they were found to be weak predictors [Figure 1] and [Table 3].
Platelet counts were not predictive of mortality (AUC, 0.532, SD = 0.028, 95% CI) and the values found were not statistically significant [Figure 1] and [Table 3].
The efficacy of CK-MB and troponin T levels, which are used as cardiac markers, in predicting mortality was examined. CK-MB (AUC, 0.659, SD = 0.022, 95% CI) was found to be a stronger factor compared with Troponin T (AUC, 0.600, SD = 0.023, 95% CI). Both markers were found to be a statistically significant predictor of mortality [Figure 1] and [Table 3].
| Discussion|| |
The hemogram is requested for almost every critically ill patient who are assessed in the emergency room. It is a fast-paced, simple-to-evaluate, and a very basic laboratory test. The NLR value can also be calculated easily from the obtained hemogram results. According to the literature data, it is suggested that many parameters can be used in the evaluation of hemogram for short- and long-term evaluation of mortality of acute STEMI patients. Clinical and meta-analysis studies are available that indicate that NLR and WBC may be independent factors in determining mortality.,, In most of these studies, the number of cases is limited and this is stated as a limiting factor. In addition, the majority of these analyses do not provide cut-off values. In this study, cut-off levels for NLR and WBC were determined using larger series (1,929 patients) and using the highest sensitivity and specificity values of the strong prognostic factors.
Advanced age is a risk factor for coronary artery disease. Ghaffari et al. examined in-hospital mortality and found in a study of 404 patients that older age groups were more mortal. The mean age range in the studies varies between 57.6 ± 11.8 and 62 ± 15.,,, The mean age values obtained in our study are similar to those in the literature.
Age over 45 for men and over 55 for women is a strong risk factor for coronary heart disease. This protection, which is favorable to women, gradually decreases after menopause into the seventh to eighth decade, where the frequency of myocardial infarction is the same in both sexes. In their survey of 418 patients, Akpek et al. found that 78% of the patients were male. In another study in which 2,603 patients were analyzed, male sex was found to be 81.8%. According to the results obtained in our study, the male sex constituted the major group and it was found to be similar to the literature.
Determining the number of peripheral leukocytes is a common and inexpensive method to assess the presence of any inflammation. According to the literature, myocardial infarction is associated with peripheral leukocytosis. At the same time, leukocytosis is associated with cardiac insufficiency and increase in short-term mortality after a myocardial infarction.,,,, Neutrophils are present as major leukocytes in the peripheral blood. There are studies showing that the number of peripheral neutrophils is associated with poor outcomes after short-term myocardial infarction (MI).,, Sawant et al. found a cut-off value of 7.4 for NLR in a study where they evaluated after 30 days of follow-up for short-term mortality, and 2 years of follow-up for long-term mortality evaluation. They have not provided any data on in-hospital work. In another study of 418 patients, NLR was compared with TIMI current scoring and patients with a TIMI current score of 0–2 were compared with patients with a score of 3. The cut-off value for the prognosis of the major cardiac defect was stated as 3.3. However, there was no cut-off value for in-hospital mortality. In a study conducted by Bajari et al. on 435 patients, NLR values higher than 5.25 were found to be strongly predictive of in-hospital mortality. In this study, isolated STEMI patients were not evaluated. In a similar study evaluating 466 patients, in-hospital mortality was calculated and the cut-off value for NLR was found to be 3.7. Again, no data isolated for STEMI patients were stated. Another study also investigated the value of NLR in acute STEMI and found that the AUC of the NLR for in-hospital mortality was higher than those of the WBC count, neutrophils count, and lymphocytes count. However, the number of patients in this study is lower than our study. In our study of 1,929 patients and analysis of STEMI patients only, we found that it was a highly valuable predictor of in-hospital mortality for patients with cut-off values >4.05.
Increased leukocyte count in the peripheral vasculature is a prominent sign, which puts microvascular reperfusion at risk. There is some evidence that inflammation and associated increased WBC values may directly contribute to coronary thrombosis, leading to impaired coronary perfusion and impaired reperfusion. Interleukin-6 (IL-6), IL-8, and CD40 ligands have been shown to regulate monocyte tissue factor production. In this way, it causes activation of the extrinsic coagulation cascade. Leukocytes contain CD11b and CD18 (Mac-1) on their surface and can act as procoagulants directly by catalyzing the conversion of factor X to Xa. Due to their large size and relatively high cytoplasmic viscosities, they can directly cause capillary blockages. Therefore, they have the potential to directly contribute to ischemia. Friedman et al. observed that high WBC values were associated with the risk of developing AMI. Schlant et al. observed that it was a predictor of mortality after AMI. In patients with STEMI, high WBC values are associated with poor epicardial and myocardial perfusion and poor clinical outcome. In the study done by Çiçek et al., along with showing the relationship of increased WBC values and higher mortality, they revealed 14,400 (57.8% sensitivity, 90.3% specificity) as cut-off value. Even though there are studies examining the relationship of WBC and mortality, there are limited data on cut-off values. In our study, we found that WBC values above 12,545 were a strong predictor of mortality with 70.3% sensitivity and 63.9% specificity.
| Conclusion|| |
STEMI is still a condition with very high mortality despite advancing treatment options and angiographic interventions. The use of predictors for the prediction of mortality for these patients is of great importance for faster implementation of treatment modalities. According to the hemogram results, which were acquired with a simple and cheap method, we found that WBC and especially NLR values obtained with a simple method can be used as powerful predictors. We think that the cut-off values abtained may contribute to the literatüre. We also believe that the results of these studies will contribute to large-scale studies that will analyze patients with multicenter, forward-looking, randomized, and isolated STEMI.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Sanchis-Gomar F, Perez-Quilis C, Leischik R, Lucia A. Epidemiology of coronary heart disease and acute coronary syndrome. Ann Transl Med 2016;4:1-12.
White PD, Mallory GK, Salcedo-Salgar J. The speed of healing of myocardial ınfarcts. Trans Am Clin Climatol Assoc 1936;52:97-104.
Bursi F, Weston SA, Killian JM, Gabriel SE, Jacobsen SJ, Roger VL. C-reactive protein and heart failure after myocardial infarction in the community. Am J Med 2007;120:616-22.
Fuster V, Lewis A. Conner Memorial Lecture. Mechanisms leading to myocardial infarction: Insights from studies of vascular biology. Circulation 1994;90:2126-46.
Ross R. Atherosclerosis--an inflammatory disease. N Engl J Med 1999;340:115-26.
Horne BD, Anderson JL, John JM, Weaver A, Bair TL, Jensen KR, et al.
Which white blood cell subtypes predict increased cardiovascular risk? J Am Coll Cardiol 2005;45:1638-43.
Kannel WB, Anderson K, Wilson PW. White blood cell count and cardiovascular disease. Insights from the Framingham Study. JAMA 1992;267:1253-6.
Frossard M, Fuchs I, Leitner JM, Hsieh K, Vlcek M, Losert H, et al.
Platelet function predicts myocardial damage in patients with acute myocardial infarction. Circulation 2004;110:1392-7.
Chung S, Song YB, Hahn JY, Chang SA, Lee SC, Choe YH, et al
. Impact of white blood cell count on myocardial salvage, infarct size, and clinical outcomes in patients undergoing primary percutaneous coronary intervention for ST-segment elevation myocardial infarction: A magnetic resonance imaging study. Int J Cardiovasc Imaging 2014;30:129-36.
Tamura A, Watanabe T, Nasu M. Association between neutrophil counts on admission and left ventricular function in patients successfully treated with primary coronary angioplasty for first anterior wall acute myocardial infarction. Am J Cardiol 2001;88:678-80.
Uyarel H, Ergelen M, Cicek G, Kaya MG, Ayhan E, Turkkan C, et al.
Red cell distribution width as a novel prognostic marker in patients undergoing primary angioplasty for acute myocardial infarction. Coron Artery Dis 2011;22:138-44.
Elbasan Z, Gur M, Sahin DY, Kuloglu O, Icen YK, Turkoglu C, et al.
Association of mean platelet volume and pre- and postinterventional flow with infarct-related artery in ST-segment elevation myocardial infarction. Angiology 2013;64:440-6.
Sahin DY, Elbasan Z, Gur M, Yildiz A, Akpinar O, Icen YK, et al.
Neutrophil to lymphocyte ratio is associated with the severity of coronary artery disease in patients with ST-segment elevation myocardial infarction. Angiology 2013;64:423-9.
Yayla C, Akboga MK, Canpolat U, Akyel A, Yayla KG, Dogan M, et al.
Platelet to lymphocyte ratio can be a predictor of infarct-related artery patency in patients with ST-segment elevation myocardial infarction. Angiology 2015;66:831-6.
Bhat T, Teli S, Rijal J, Bhat H, Raza M, Khoueiry G, et al.
Neutrophil to lymphocyte ratio and cardiovascular diseases: A review. Expert Rev Cardiovasc Ther 2013;11:55-9.
Bajari R, Tak S. Predictive prognostic value of neutrophil–lymphocytes ratio in acute coronary syndrome. Indian Heart J 2017;69:S46-50.
Çiçek G, Açıkgöz SK, Yayla Ç, Kundi H, İleri M. White blood cell count to mean platelet volumeratio: A novel and promising prognostic markerfor ST-segment elevation myocardial infarction. Cardiol J 2016;23:225-35.
Ghaffari S, Nadiri M, Pourafkari L, Sepehrvand N, Movasagpoor A, Rahmatvand N, et al.
The predictive value of total neutrophil count and neutrophil/lymphocyte ratio in predicting ın-hospital mortality and complications after STEMI. J Cardiovasc Thorac Res 2014;6:35-41.
Oncel RC, Ucar M, Karakas MS, Akdemir B, Yanikoglu A, Gulcan AR, et al.
Relation of neutrophil-to-lymphocyte ratio with GRACE risk score to ın-hospital cardiac events in patients with ST-segment elevated myocardial ınfarction. Clin Appl Thromb Hemost 2015;21:383-8.
Sawant AC, Adhikari P, Narra SR, Srivatsa SV, Mills PK, Srivatsa SS. Neutrophil to lymphocyte ratio predicts short- and long-term mortality following revascularization therapy for ST elevation myocardial infarction. Cardiol J 2014;21:500-8.
İç Hastalıkları. Biberoğlu İ, Süleymanlar Ü. Güneş Kitabevi, 2. Baskı, 2003.; syf 449-476.
Basic Pathology, Kumar, Cotran, Robbins Türkçe, Nobel Tıp Kitabevleri Ltd. Şti. Temmuz 2000. Sf: 283-289.
Akpek M, Kaya MG, Lam YY, Sahin O, Elcik D, Celik T, et al.
Relation of neutrophil/lymphocyte ratio to coronary flow to ın-hospital major adverse cardiac events in patients with ST-elevated myocardial ınfarction undergoing primary coronary ıntervention. Am J Cardiol 2012;110:621-7.
Bhatt DL, Chew DP, Lincoff AM, Simoons ML, Harrington RA, Ommen SR, et al.
Effect of revascularization on mortality associated with an elevated white blood cell count in acute coronary syndromes. Am J Cardiol 2003;92:136-40.
Cannon CP, McCabe CH, Wilcox RG, Bentley JH, Braunwald E. Association of white blood cell count with increased mortality in acute myocardial infarction and unstable angina pectoris. OPUS-TIMI 16 Investigators. Am J Cardiol 2001;87:636-9.
Grzybowski M, Welch RD, Parsons L, Ndumele CE, Chen E, Zalenski R, et al.
The association between white blood cell count and acute myocardial infarction in-hospital mortality: Findings from the National Registry of Myocardial Infarction. Acad Emerg Med 2004;11:1049-60.
Menon V, Lessard D, Yarzebski J, Furman MI, Gore JM, Goldberg RJ. Leukocytosis and adverse hospital outcomes after acute myocardial infarction. Am J Cardiol 2003;92:368-72.
Barron HV, Cannon CP, Murphy SA, Braunwald E, Gibson CM. Association between white blood cell count, epicardial blood flow, myocardial perfusion, and clinical outcomes in the setting of acute myocardial infarction: A thrombolysis in myocardial infarction 10 substudy. Circulation 2000;102:2329-34.
Ghaffari S, Golmohammadi A. Correlation between neutrophilia and congestive heart failure after acute myocardial infarction. Med J Ardabil Uni Med Sci 2006;5:352-7.
Kirtane AJ, Bui A, Murphy SA, Barron HV, Gibson CM. Association of peripheral neutrophilia with adverse angiographic outcomes in ST-elevation myocardial infarction. Am J Cardiol 2004;93:532-6.
O'Donoghue M, Morrow DA, Cannon CP, Guo W, Murphy SA, Gibson CM, et al.
Association between baseline neutrophil count, clopidogrel therapy, and clinical and angiographic outcomes in patients with ST-elevation myocardial infarction receiving fibrinolytic therapy. Eur Heart J 2008;29:984-91.
Monteiro Júnior JG, Torres DO, da Silva MC, Martins CM, da Silva IK, do Nascimento ME, et al.
Prognostic value of hematological parameters in patients with acute myocardial infarction: Intrahospital outcomes. PLoS One 2018;13:e0194897.
Tanriverdi Z, Colluoglu T, Dursun H, Kaya D. The Relationship between neutrophil-to-lymphocyte ratio and fragmented QRS in acute STEMI patients treated with primary PCI. J Electrocardiol 2017;50:876-83.
Adam AM, Rizvi AH, Haq A, Naseem R, Rehan A, Shaikh AT, et al.
Prognostic value of blood count parameters in patients with acute coronary syndrome. Indian Heart J 2018;70:233-40.
Libby P, Simon DI. Inflammation and thrombosis: The clot thickens. Circulation 2001;103:1718-20.
Marx N, Neumann FJ, Ott I, Gawaz M, Koch W, Pinkau T, et al
. Induction of cytokine expression in leukocytes in acute myocardial infarction. J Am Coll Cardiol 1997;30:165-70.
Ott I, Neumann FJ, Kenngott S, Gawaz M, Schomig A. Procoagulant inflammatory responses of monocytes after direct balloon angioplasty in acute myocardial infarction. Am J Cardiol 1998;82:938-42.
Engler RL, Schmid-Schonbein GW, Pavelec RS. Leukocyte capillary plugging in myocardial ischemia and reperfusion in the dog. Am J Pathol 1983;111:98-111.
Friedman GD, Klatsky AL, Siegelaub AB. The leukocyte count as a predictor of myocardial infarction. N Engl J Med 1974;290:1275-8.
Schlant RC, Forman S, Stamler J, Canner PL. The natural history of coronary heart disease: Prognostic factors after recovery from myocardial infarction in 2789 men. The 5-year findings of the Coronary Drug Project. Circulation 1982;66:401-14.
Barron HV, Cannon CP, Murphy SA, Braunwald E, Gibson CM. Association between white blood cell count, epicardial blood flow, myocardial perfusion, and clinical outcomes in the setting of acute myocardial infarction. Circulation 2000;102:2329-34.
[Table 1], [Table 2], [Table 3]