|Year : 2022 | Volume
| Issue : 1 | Page : 10-14
Effect of white blood cell indices and glycemia on inhospital prognosis of ST-segment elevated myocardial infarction
Dnyaneshwar V Jadhav, Dnyaneshwar Muley, Shweta Deshmukh
Department of Medicine, Government Medical College, Aurangabad, Maharashtra, India
|Date of Submission||25-Oct-2021|
|Date of Decision||05-Jan-2022|
|Date of Acceptance||13-Jan-2022|
|Date of Web Publication||21-Apr-2022|
MD Dnyaneshwar V Jadhav
Department of Medicine, Government Medical College Aurangabad - 431 001, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Early risk stratification is recommended in daily clinical practice to predict adverse outcomes in patients with ST-segment elevation myocardial infarction (STEMI). Complete blood count and blood glucose analysis is routinely performed on admission. Hence, this study was undertaken to find out the predictive value of white blood cell (WBC) indices and glycemia to know adverse outcomes in STEMI. Methods: In an observational study conducted between December 2015 and October 2018 at a tertiary center, 400 patients with acute STEMI were included. Results: We had 400 patients of STEMI. In this study, mean total leukocyte count (TLC), total neutrophil count (TNC), neutrophil-to-lymphocyte ratio (NLR), and plasma glucose were higher in those with complications (13,449.8/mm3, 10,460.5/mm3, 5.20 and 180.8 mg%) than those without complications (11,318.3/mm3, 8581.9/mm3, 4.15, and 151.1 mg%) (P < 0.05). The cutoff point of TLC >13 × 1000 cells/mm3 had a sensitivity of 73.5% and specificity of 63% in predicting postmyocardial infarction mortality (area under the curve = 0.68, P < 0.001). Patients with acute hyperglycemia (≥140 mg%) had higher incidence of hypotension (31.12% vs. 17.64%, P < 0.05), left ventricular failure (32.14% v/s. 21.1%, P < 0.05), ventricular arrhythmias (13.26% vs. 6.86%, P < 0.05), and higher inhospital mortality (P = 0.0001). Multivariate analysis predicting inhospital mortality as dependent variable TLC >13 × 1000 cells/mm3, TNC >10.5 × 1000 cells/mms3, NLR ≥5.20, and plasma glucose >140 mg/dl were the variable found to be statistically significant (P < 0.05). Conclusion: The WBC indices (TLC, TNC, and NLR) and plasma glucose on admission are independent predictors of major cardiovascular events and inhospital mortality in STEMI.
Keywords: Plasma glucose, ST-segment elevation myocardial infarction, white blood cell indices
|How to cite this article:|
Jadhav DV, Muley D, Deshmukh S. Effect of white blood cell indices and glycemia on inhospital prognosis of ST-segment elevated myocardial infarction. J Clin Prev Cardiol 2022;11:10-4
|How to cite this URL:|
Jadhav DV, Muley D, Deshmukh S. Effect of white blood cell indices and glycemia on inhospital prognosis of ST-segment elevated myocardial infarction. J Clin Prev Cardiol [serial online] 2022 [cited 2023 Feb 6];11:10-4. Available from: https://www.jcpconline.org/text.asp?2022/11/1/10/343645
| Introduction|| |
Cardiovascular diseases (CVD) have been the leading cause of morbidity and mortality worldwide. Recent trends indicate that the disease has escalated to younger age groups also. The huge burden of CAD in the Indian subcontinent is the consequence of a large population and high prevalence of cardiovascular risk factors such as smoking, alcohol, low fruit and vegetable intake, physical activity, obesity, high blood pressure, abnormal lipids, and diabetes. Early risk stratification is recommended in daily clinical practice to predict the infarct size, the success of epicardial recanalization, and the risk of adverse outcomes in patients presenting with ST-segment elevation myocardial infarction (STEMI). In addition to the current risk scores, interest has recently been directed to the development of a set of bedside tools obtained from admission data to promptly predict the prognosis of arterial recanalization. The relationship between inflammation and myocardial infarction (MI) was suggested more than 50 years ago. STEMI is usually accompanied by peripheral leukocytosis and stress hyperglycemia., Complete blood count and blood glucose analysis is routinely performed on admission. This study was undertaken to find out the predictive value of white blood cell (WBC) indices and blood glucose to know adverse outcomes in patients presenting with STEMI.
| Methods|| |
A total of 400 patients of acute STEMI were admitted in the Intensive Coronary Care Unit of a tertiary hospital in India from December 2015 to October 2017.
This was an observational study.
Patients with acute STEMI were included in the study.
Patients with (1) active malignancy, (2) end-stage liver and kidney disease, (3) hematological proliferative disorder, (4) active infection, (5) chronic inflammatory disease, (6) on steroid therapy for autoimmune diseases, and (7) history of ischemic heart disease were excluded from the study.
The diagnosis of STEMI was determined by occurrences of classic symptoms of ischemia within 12 h with new ST elevation at the J point in two contiguous leads with the cut points: ≥0.1 mV in all leads other than leads V2–V3 where the following cut points apply: ≥0.2 mV in men ≥40 years; ≥0.25 mV in men <40 years, or ≥0.15 mV in women.
Acute hyperglycemia was defined as blood glucose level on admission ≥140 mg/dl.
Complications include arrhythmia [Ventricular tachycardia /ventricular fibrillation (VT/VF), Supraventricular Tachycardia (SVT), atrial fibrillation(AF)], hypotension, and left ventricularfailure (LVF).
Descriptive statistics were reported as mean (± standard deviation) for continuous normally distributed variables and frequency (%) for dichotomous or discrete variables. For continuous variables, differences between groups were analyzed for statistical significance by ANOVA and two-tailed Student's t-test. Chi-square test and Fisher's exact test were used for comparing categorical variables. Receiver operating characteristics (ROC) curves and area under the curve (AUC) were used to determine the cutoff points for total leukocyte count (TLC), total neutrophil count (TNC), and neutrophil-to-lymphocyte ratio (NLR) in predicting mortality. Multivariate logistic regression analysis was carried out to identify risk factor associated with inhospital mortality such as age, sex, heart rate, site of MI, hypertension (HTN), diabetes, tobacco consumption, alcohol consumption, obesity, hypercholesterolemia, TLC, TNC, NLR, and plasma glucose. The odds ratio and 95% confidence interval (CI) were calculated. P < 0.05 was considered significant.
| Results|| |
We had 400 patients. Maximum number of cases, 314 (78.50%), were seen in the age group of 41–70. Obesity was the most common risk factor observed in 216 cases (54%) followed by tobacco consumption in 130 cases (32.5%). In this study, TLC, TNC, NLR, and plasma glucose ranged from 4200 to 20,000/mm3 (12282.78 ± 3886.73/mm3), 2475–17910/mm3 (9431.96 ± 3508.78/mm3), 1.22–15.33 (4.65 ± 3.03), and 60 mg%–575 mg% (164.56 ± 89.28 mg%), respectively [Table 1]. The mean TLC, TNC, NLR, and plasma glucose was higher in those with complications than without complications (13,449.8 vs. 11,318.3/mm3, 10,460.5 vs. 8581.9/mm3, 5.20 vs. 4.15 and 180.8 vs. 151.1 mg%) [P < 0.05, [Table 2]]. Patients with acute hyperglycemia (≥140 mg% i.e., ≥7.8 mmol, n = 196 [49%]) more often had diabetes (26.53% vs. 8.33%, P < 0.001) as compared to the normoglycemic group (<140 mg% i.e., <7.8 mmol). They also had higher incidence of hypotension (31.12% v/s. 17.64%, P < 0.05), LVF (32.14% v/s. 21.1%, P < 0.05), ventricular arrhythmias (13.26% v/s. 6.86%, P < 0.05), higher TLC (13.2 vs. 11.4 × 1000 cells/mm3, P = 0.0001), high NLR (5.22 vs. 4.1, P = 0.0001), and higher inhospital mortality [P = 0.0001, [Table 3]]. A study of patient variables revealed that nonsurvivors were older and had higher female population. In addition, the mean TLC (14.3 × 1000 cells/mm3 vs. 11.9 × 1000 cells/mm3), TNC (11.6 × 1000 cells/mm3 vs. 8.9 × 1000 cells/mm3), NLR (6.18 vs. 4.34), and plasma glucose (234.5 mg% vs. 150.23 mg%) was found to be high in nonsurvivors than survivors (P < 0.05). However, we did not find any significant difference among the survivors and nonsurvivors with diabetes mellitus, HTN, alcohol, hypercholesterolemia, and tobacco use [P > 0.05, [Table 4]]. The WBC indices were analyzed by ROC in predicting post-MI mortality. TLC >13 × 1000 cells/mm3 had a sensitivity of 73.5% and specificity of 63% (AUC = 0.68, P < 0.001) and TNC >10.5 × 1000 cells/mm3 had a sensitivity of 73.5% and specificity of 69.6% (AUC = 0.71, P < 0.001) in predicting post-MI mortality [Figure 1]. On multivariate analysis age, gender, location of MI, Killip's class ≥II, obesity, TLC >13 × 1000 cells/mm3, TNC >10.5 × 1000 cells/mm3, NLR ≥5.20 and plasma glucose >140 mg% were risk factor associated with higher inhospital mortality. [P < 0.05, [Table 5]].
|Table 1: White blood cell parameters and plasma glucose in the 400 cases studied|
Click here to view
|Table 2: White blood cell indices and plasma glucose level in 400 patients of ST-segment elevation myocardial infarction with and without complications|
Click here to view
|Table 3: Demographic, clinical data, biochemical parameters, and adverse events during hospitalization in normoglycemic and hyperglycemic patients|
Click here to view
|Table 5: Multiple logistic regression analysis using inhospital mortality as dependent variable|
Click here to view
| Discussion|| |
In this study, we evaluated the association between WBC indices and blood glucose at admission and inhospital mortality following acute STEMI in 400 patients at a tertiary care center in India. We observed a strong association between WBC indices and blood glucose inhospital mortality of STEMI patients. After adjustment for patient demographics, medical history, presenting clinical characteristics, and treatment factors, patients with higher TLC, TNC, NLR, and blood glucose count had significantly increased odds of death. Leukocytosis usually accompanies STEMI in proportion to the magnitude of the necrotic process, elevated glucocorticoid levels, and possibly inflammation in the coronary arteries. The elevated leukocyte count is associated with reduced epicardial blood flow, myocardial perfusion, thromboresistance (arteries open later and have a greater thrombus burden), higher incidence of new congestive heart failure, and death. Menon et al. in a study of 6530 patients with AMI observed that an elevated WBC count at the time of hospital presentation was strongly associated with the development of heart failure (odds ratio [OR] = 2.77), cardiogenic shock (OR -= 2.82), and death (OR = 2.14) during hospitalization. In our study, the mean TLC was higher in patients with complications (13,449.8/mm3) than those without complications (11,318.3/mm3) and the difference observed was statistically significant (P < 0.05). Atooshe et al. found that patients with a high WBC count (as defined ≥10,000) had a 5.0-fold increase inhospital congestive heart failure and 2.2 increases in mortality compared with those with a low WBC count. During acute MI (AMI), activated neutrophils infiltrate into the infarcted zone, contributing to fibrotic scar formation, a cause of the arrhythmia.,,, Furthermore, neutrophils aggregate with platelets to exacerbate vascular plugging in the microcirculation and induce a no-reflow phenomenon.,, Among different hematological indices, it has been shown that the neutrophil count has a high predictive value in predicting death in high-risk patients for coronary artery disease. Arruda et al. studied neutrophil count in MI at presentation. They reported for heart failure, the hazard ratio: 1.32 (95% CI, 1.09–1.59) for the middle (5.7–8.5 × 103/L) and 2.12 (95% CI, 1.77–2.53) for the upper tertile (>8.5 × 103/L) and for death, the hazard ratio: 1.44 (95% CI, 1.14–1.81) for the middle tertile and 2.60 (95% CI, 2.10–3.22) for the upper tertile which was statistically significant (P < 0.001). In our study, the mean TNC was higher in patients with complications (10,460.5 mm3) than those without complications (8581.9/mm3) and the difference observed was statistically significant (P < 0.05). Among the inflammatory markers, NLR has gained space as an effective biomarker in the stratification and prognosis of atherosclerotic CVD. Park et al. in a study of 325 patients with STEMI treated with primary percutaneous coronary intervention showed that NLRs ≥5.44 had an increased risk for mortality and had a higher risk of major cardiovascular events. In our study, mean NLR was higher in patients with complications (5.20) than those without complications (4.15) and the difference observed was statistically significant (P < 0.05). Ghaffari et al. studied 404 patients with acute STEMI and showed that neutrophils >9.68-×1000 cells/mm3 had a sensitivity of 60% and specificity of 66.2% in predicting post-MI mortality (AUC = 0.65, P = 0.04). In multivariate analysis, neutrophil count was an independent predictor of mortality (OR = 2.94; 1.1–8.4, P = 0.04), and neutrophil count (OR = 1.1, CI [1.01–1.20], P = 0.02) was independent predictors of heart failure. In our study, the mean TLC (14.3 × 1000 cells/mm3 vs 11.9 × 1000 cells/mm3), TNC (11.6 × 1000 cells/mm3 vs. 8.9 × 1000 cells/mm3), and NLR (6.18 vs. 4.34) was found to be high in nonsurvivors than survivors (P < 0.05). WBC indices were analyzed by ROC in predicting post-MI mortality. TLC >13 × 1000 cells/mm3 had a sensitivity of 73.5% and specificity of 63% (AUC = 0.68, P < 0.001) and TNC >10.5 × 1000 cells/mm3 had a sensitivity of 73.5% and specificity of 69.6% (AUC = 0.71, P < 0.001). Hyperglycemia is common in MI which causes oxidative stress, inflammation, endothelial dysfunction, and activates coagulation. A high blood glucose level has been associated with an increased risk of mortality and morbidity in patients with AMI regardless of their diabetic status.,, Rafael et al. in the study of 834 patients with STEMI showed that glucose ≥140 mg/dl showed higher rates of malignant ventricular tachyarrhythmias (28% vs. 18%, P = 0.001), complicated bundle branch block (5% vs. 2%, P = 0.005), new atrioventricular block (9% vs. 5%, P = 0.05), and inhospital mortality (15% vs. 5%, P < 0.001). In our study, the mean blood glucose was higher in patients with complications (180.8 mg%) than those without complications (151.1 mg%) and the difference observed was statistically significant (P < 0.05). Antonio et al. showed that mean leukocyte counts 12,156 cells/mm3 and blood glucose 176 mg/dl were associated with higher inhospital mortality in AMI (P = 0.004). In our study, the mean plasma glucose was found to be high in nonsurvivors [234.5 mg/dl] than survivors [150.23mg/dl], which was statistically significant (P<0.05).
On multivariate analysis in predicting inhospital mortality, studied risk factors as TLC >13 × 1000 cells/mm3, TNC >10.5 × 1000 cells/mm3, NLR ≥5.20 and plasma glucose >140 mg/dl were the variables found to be statistically significant. [P<0.05].
| Conclusion|| |
This study conclusively demonstrates, high TLC, TNC, NLR, and plasma glucose on admission have a higher incidence of major cardiovascular events and in hospital mortality in patients with STEMI. We suggest that these simple, cheap, and easily available investigations are should be considered in the prognostic stratification of STEMI patients upon presentation.
Limitations of the study
Patients were not followed up after discharge
We are thankful to the patients and their families for their cooperation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Guha S, Sethi R, Ray S, Bahl VK, Shanmugasundaram S, Kerkar P, et al
. Cardiological Society of India: Position statement for the management of ST elevation myocardial infarction in India. Indian Heart J 2017;69 Suppl 1:S63-97.
Yalcinkaya E, Yuksel UC, Celik M, Kabul HK, Barcin C, Gokoglan Y, et al
. Relationship between neutrophil-to-lymphocyte ratio and electrocardiographic ischemia grade in STEMI. Arq Bras Cardiol 2015;104:112-9.
Thomson SP, Gibbons RJ, Smars PA, Suman VJ, Pierre RV, Santrach PJ, et al
. Incremental value of the leukocyte differential and the rapid creatine kinase-MB isoenzyme for the early diagnosis of myocardial infarction. Ann Intern Med 1995;122:335-41.
Capes SE, Hunt D, Malmberg K, Gerstein HC. Stress hyperglycaemia and increased risk of death after myocardial infarction in patients with and without diabetes: A systematic overview. Lancet 2000;355:773-8.
Sahin DY, Gür M, Elbasan Z, Yıldız A, Kaya Z, Içen YK, et al
. Predictors of preinterventional patency of infarct-related artery in patients with ST-segment elevation myocardial infarction: Importance of neutrophil to lymphocyte ratio and uric acid level. Exp Clin Cardiol 2013;18:e77-81.
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.
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.
Rohani A, Akbari V, Moradian K, Malekzade J. Combining white blood cell count and thrombosis for predicting in-hospital outcomes after acute myocardial infraction. J Emerg Trauma Shock 2011;4:351-4.
] [Full text]
Dragu R, Huri S, Zukermann R, Suleiman M, Mutlak D, Agmon Y, et al.
Predictive value of white blood cell subtypes for long-term outcome following myocardial infarction. Atherosclerosis 2008;196:405-12.
Chia S, Nagurney JT, Brown DF, Raffel OC, Bamberg F, Senatore F, et al.
Association of leukocyte and neutrophil counts with infarct size, left ventricular function and outcomes after percutaneous coronary intervention for ST-elevation myocardial infarction. Am J Cardiol 2009;103:333-7.
Sahin DY, Elbasan Z, Gür 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.
Chatterjee S, Chandra P, Guha G, Kalra V, Chakraborty A, Frankel R, et al.
Pre-procedural elevated white blood cell count and neutrophil-lymphocyte (N/L) ratio are predictors of ventricular arrhythmias during percutaneous coronary intervention. Cardiovasc Hematol Disord Drug Targets 2011;11:58-60.
Lee GK, Lee LC, Chong E, Lee CH, Teo SG, Chia BL, et al.
The long-term predictive value of the neutrophil-to-lymphocyte ratio in Type 2 diabetic patients presenting with acute myocardial infarction. QJM 2012;105:1075-82.
Khan HA, Alhomida AS, Sobki SH, Moghairi AA, Koronki HE. Blood cell counts and their correlation with creatine kinase and C-reactive protein in patients with acute myocardial infarction. Int J Clin Exp Med 2012;5:50-5.
Tanboga IH, Topcu S, Aksakal E, Kalkan K, Sevimli S, Acikel M. Determinants of angiographic thrombus burden in patients with ST-segment elevation myocardial infarction. Clin Appl Thromb Hemost 2014;20:716-22.
Arruda-Olson AM, Reeder GS, Bell MR, Weston SA, Roger VL. Neutrophilia predicts death and heart failure after myocardial infarction: A community-based study. Circ Cardiovasc Qual Outcomes 2009;2:656-62.
Baetta R, Corsini A. Role of polymorphonuclear neutrophils in atherosclerosis: Current state and future perspectives. Atherosclerosis 2010;210:1-13.
Park JJ, Jang HJ, Oh IY, Yoon CH, Suh JW, Cho YS, et al.
Prognostic value of neutrophil to lymphocyte ratio in patients presenting with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention. Am J Cardiol 2013;111:636-42.
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 in-hospital mortality and complications after STEMI. J Cardiovasc Thorac Res 2014;6:35-41.
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.
Sanjuán R, Núñez J, Blasco ML, Miñana G, Martínez-Maicas H, Carbonell N, et al.
Prognostic implications of stress hyperglycemia in acute ST elevation myocardial infarction. Prospective observational study. Rev Esp Cardiol 2011;64:201-7.
Pesaro AE, Nicolau JC, Serrano CV Jr., Truffa R, Gaz MV, Karbstein R, et al.
Influence of leukocytes and glycemia on the prognosis of patients with acute myocardial infarction. Arq Bras Cardiol 2009;92:84-93.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]