GSJ: Volume 6, Issue , October 8, Online: ISSN î ì...Dr. Ahmad Hasan Dr. Muhammad Waqas Dr....

GSJ: Volume 6, Issue 10, October 2018, Online: ISSN 2320-9186

www.globalscientificjournal.com

PREDICTIVE VALUE OF TOTAL NEUTROPHIL COUNT AND

NEUTROPHIL TO LYMPHOCYTE RATIO IN PREDICTING IN-HOSPITAL MORTALITY AND COMPLICATIONS AFTER ST

SEGMENT ELEVATION MYOCARDIAL INFARCTION. Dr. Ahmad Hasan Dr. Muhammad Waqas Dr. Muhammad Muzamil Dr. Aqib Javed Dr. Muhammad Iqbal Dr. Hassan Irshad Department of cardiology, Jinnah Hospital, Lahore

Address for Correspondence: Ahmad Hasan Assistant Professor Department of Cardiology, Allama Iqbal Medical College, Jinnah Hospital, Lahore 0321-4937381 [email protected]

Abstract:

Background: Myocardial infarction commonly known as a heart attack, occurs when blood

flow stops to a part of the heart causing damage to the heart muscle. Neutrophils are the most

abundant type of granulocytes and the most abundant type of white blood cells in most

mammals. The increased level of neutrophil count may lead to hazardous consequences in ST

elevation myocardial infarction (STEMI) patients, so to find the evidence we conducted this

study. Objective: To determine the association of raised total neutrophil count and neutrophil

/ lymphocyte ratio (NLR) with in-hospital mortality and complications after STEMI.

Material & Methods: Study Design: Cohort study. Setting: Department of Cardiology,

Jinnah Hospital Lahore Duration: 6 months i.e. from July 2017 to December 2017. Data

Collection: After meeting the inclusion criteria 210 subjects were enrolled. Informed consent

and demographic information was taken from all the subjects. Subjects were divided into

exposed and non-exposed. All the information was entered and analyzed on SPSS version 20.

Results : The mean age of patients in raised neutrophil group was 53.04±13.15 years and in

normal neutrophil group was 56.48±15.57 years. The male to female ratio was 0.9:1.

Mortality occurred in 30 cases and complications were noted in 69(32.86%) patients.

Statistically 1.72 times more risk of complications noted in raised neutrophil group compared

to normal neutrophil group i.e. RR=1.71 [95% CI; 1.33-2.22]. Conclusion: There is 1.72

times significantly more risk of in hospital mortality and complications after STEMI in raised

total Neutrophil Count.

Keywords: Mortality, Myocardial Infarction, In-Hospital, Risk, Neutrophil to lymphocyte

ratio

GSJ: Volume 6, Issue 10, October 2018 ISSN 2320-9186

448

GSJ© 2018 www.globalscientificjournal.com

mailto:[email protected]

INTRODUCTION:

Neutrophils are the most abundant type of

granulocytes and the most abundant (40%

to 75%) type of white blood cells in most

mammals. They form an essential part of

the innate immune system. Its functions

vary in different animals. 01

They are formed from stem cells in the

bone marrow. They are short-lived and

highly motile, or mobile, as they can enter

parts of tissue where other cells/molecules

wouldn't be able to enter otherwise.

Neutrophils may be subdivided into

segmented neutrophils and banded

neutrophils (or bands). They form part of

the polymorphonuclear cells family

(PMNs) together with basophils and

eosinophils. 01

Neutrophils are recruited to the site of

injury within minutes following trauma,

and are the hallmark of acute

inflammation; however, due to some

pathogens being indigestible, they can be

unable to resolve certain infections without

the assistance of other types of immune

cells. 01

Determining peripheral leukocyte count is

an inexpensive and widely available way

to assess the presence of any

inflammation. According to the literature,

MI is usually accompanied with peripheral

leukocytosis and the leukocytosis is

associated with higher rates of short-term

mortality and heart failure after myocardial

infarction.02

Neutrophils are the major leukocytes in the

peripheral blood.

Amongst different hematological indices,

it has been shown that the NLR has the

highest predictive value in predicting

death/MI in high risk patients for coronary

artery disease. Also, it has been shown that

NLR predicts the long term mortality in

patients hospitalized with STEMI and in

patients undergoing PCI. 02

OBJECTIVE:

To determine the association of raised

Total Neutrophil Count and

Neutrophil/ Lymphocyte Ratio with in-

hospital mortality and complications after

STEMI

MATERIAL AND METHODS:

Setting:

This study was conducted in the

Department of Cardiology, Jinnah Hospital

Lahore from July 2017 till December

2017.

Study design:

Cohort Study

Sample size:

Sample size of 210 cases (105 each group)

is calculated with 80% power of test, 5%

level of significance and taking expected

percentage of complication in both groups.

i. e 35% in cases and 18%6 in control

group.

Sampling technique:

Non-probability consecutive sampling

Sample selection:

Inclusion Criteria:

Exposed:

1. Patients of STEMI.

2. Age between 30 years to 80 years

3. Patients having raised Neutrophil count or

Neutrophil to lymphocytic (N/L) ratio.

Non Exposed:

4. Patients having criteria 1 & 2 with

5. Patients who do not have raised Neutrophil

count or Neutrophil to lymphocytic (N/L)

ratio

Exclusion criteria:

1. Patients with NSTEMI/Unstable angina

and those with non-specific ECG changes

2. Patients with active inflammation or

chronic inflammatory diseases based on

clinical evaluation and laboratory studied

3. Patients with past history of surgery within

3 months prior to MI based on clinical

evaluation and laboratory studies.

4. Patients with Chronic Kidney Disease with

creatinine >2 mg/dl

5. Patients with Chronic Liver Disease with

Bilirubin > 2 mg/dl

6. Patients with Congestive heart Failure

based on history and Clinical Examination


449


Data collection:

Sample 210 cases after approval from

Ethical Review Board (ERB) of

AIMC/JHL and assessed by SPSS version

20. Selection of sample was from patients

admitted in Cardiology Department,

Jinnah Hospital Lahore. Informed consent

was taken from the participant.

Demographic information e.g. age, sex,

address, past history was obtained.

Complete blood cell count (CBC) was

performed in all patients within 12 to 24

hours of onset of symptoms. After

sampling, blood samples evaluated for

total WBC count, Neutrophil count,

Lymphocytes, and raised NC was noted.

All subjects followed throughout their

hospital stay, for occurrence of

complications or death. Subjects were

divided into exposed and non-exposed as

already defined. A predesigned Performa

was used to record the variables. Data was

entered and analyzed in SPSS version 20.

Frequency and percentage was calculated

for qualitative variables (sex of patients,

socioeconomic status, APE, Cardiogenic

shock, arrythmia and complications).

Mean and standard deviation was

calculated for quantitative variables (age

of patients). Relative risk was calculated to

determine the strength of association

between raised neutrophil count with

complication after STEMI. (RR>1 was

considered as significant, chi square test

was applied. Effect modifiers and

confounders (age, sex) were controlled

through stratification. Post stratification

adjusted relative risk was calculated with

RR>1was considered as significant. Chi

square test was applied.

RESULTS:

In this present study 210 subjects were

enrolled. The mean age of the raised

neutrophil subjects was 53.04±13.15 years

and its mean value in normal neutrophil

subjects was 56.48±15.57 years. Table#1

Table 1 Comparison of age with

Neutrophil count

In this study 101(48.10%) subjects were

male and 109(51.90%) subjects were

females. The male to female ratio of the

subjects was 0.9:1. Fig#1

Fig#1

Frequency distribution of gender

In our study the male subjects were 101 in

which 56 were from raised neutrophil

group and 45 were from normal neutrophil

group, similarly the female subjects were

109 in which 49 were from raised

neutrophil group and 60 were from normal

neutrophil group shown in Table#2

Neutrophil

Total Raised Normal

Gender Male 56 45 101

Female 49 60 109

Total 105 105 210

Table#2

Comparison of gender with neutrophil

The study results showed that the mean

value of neutrophil count in raised

neutrophil group was 10.42±2.09 and its

mean value in normal neutrophil group

subjects was 5.303± 1.16. as seen in

Table#3

Neutrophil

Raised Normal

Neutrophil

count

N 105 105

Mean 10.42 5.303

SD 2.09 1.16

Table#3

Neutrophil

Raised Normal

Age

(years)

N 105 105

Mean 53.04 56.48

SD 13.15 15.57


450


Comparison of neutrophil count with

raised and normal neutrophil

In this study the cardiogenic shock was

noted in 40 subjects in which 28 were

from raised neutrophil group and 12 were

from normal neutrophil group, similarly

the cardiogenic shock not found in 29

subjects in which 20 were from raised



Neutrophil

Total Raised Normal

Cardiogenic

shock

Yes 28 12 40

No 20 9 29

Total 48 21 69

Table#4

Comparison of cardiogenic shock with

neutrophil (n=69)

Out of 69 subjects the pulmonary edema

was noted in 33 subjects in which 23 were


from normal neutrophil group, similarly

the pulmonary edema not found in 36




Neutrophil

Total Raised Normal

Pulmonary

Edema

Yes 23 10 33

No 25 11 36

Total 48 21 69

Table#5

Comparison of pulmonary edema with

neutrophil (n=69)

The study results showed that the

arrhythmia was found in 43 subjects in



group, similarly the arrhythmia not found

in 26 subjects in which 17 were from

raised neutrophil group and 9 were from

normal neutrophil group shown in

Table#6

Neutrophil

Total Raised Normal

Arrhythmia Yes 31 12 43

No 17 9 26

Total 48 21 69

Table#6

Comparison of arrhythmia with

neutrophil (n=69)

In this study the mortality occurred in 30



neutrophil group, similarly the mortality

not occurred in 39 subjects in which 25

were from raised neutrophil group and 14

were from normal neutrophil group shown

in Table#7

Neutrophil

Total Raised Normal

Mortality Yes 23 7 30

No 25 14 39

Total 48 21 69

Table#7

Comparison of mortality with

neutrophil (n=69)

Out of 210 subjects the complications

were noted among 69(32.86%) subjects

and it was not found among 141(67.14%)

subjects shown in Fig#2

Fig#2

Frequency distribution of complications

The study results showed that the

complications found in 69 subjects in



group, similarly the complications not

found in 141 subjects in which 57 were


from normal neutrophil group. Statistically

1.72 times more risk of complications

noted in raised neutrophil group compared

to normal neutrophil group. i. e RR=1.71

[1.33-2.22] shown in Table#8


451


Table#8

Comparison of complications with

neutrophil

Neutrophil Tota

l RR Raise

d

Norma

l

Complicatio

ns

Ye

s 48 21 69

1.72

[1.33

-

2.22]

No 57 84 141

Total 105 105 210

Chi value=15.74

p-value=0.001*

The study results showed that in ≤ 50

years patient the complications found in 28



neutrophil group. Similarly in >50 years

subjects, the complications were found in

41 subjects in which 31 were from raised


neutrophil group. Statistically 2.11 times

more risk of complications noted in raised

neutrophil group compared to normal

neutrophil group in >50 years subjects. i. e

RR=2.11 [1.49-2.97] shown in Table#9

Age

(yea

rs)

Complicat

ions

Neutrophil Tot

al RR

p-

valu

e

Rais

ed

Nor

mal

≤ 50

Yes 17 11 28 1.32

[0.8

8-

1.96

]

0.19

NS No 29 34 63

> 50

Yes 31 10 41 2.11

[1.4

9-

2.97

]

0.00

1* No 28 50 78

Table#9


neutrophil stratified by age

The study results showed that in male

patient the complications found in 35



neutrophil group. Similarly in female

subjects, the complications were found in

34 subjects in which 23 were from raised


neutrophil group. Statistically 1.52 & 1.95

times more risk of complications noted in

raised neutrophil group compared to

normal neutrophil group stratified by

gender. i. e RR=1.52 [1.09-2.12] & 1.95

[1.32-2.87] shown in Table#10

Gend

er

Complicat

ions

Neutrophi

l Tot

al RR

p-

value Rais

ed

Nor

mal

Male

Yes 25 10 35 1.52

[1.0

9-

2.12

]

0.01* No

31 35 66

Fem

ale

Yes 23 11 34 1.95

[1.3

2-

2.87

]

0.001

3* No

26 49 75


neutrophil stratified b gender

DISCUSSION:

In spite of great advances in diagnosis and

management, ST segment elevation

myocardial infarction (STEMI), it remains

a major public health problem in the

industrialized world and is on the rise in

developing countries.

The relationship between myocardial

infarction (MI) and inflammation has been

suggested over 50 years ago.03

Determining the peripheral leukocyte

count is an inexpensive and widely

available way to assess the presence of any

inflammation. Myocardial Infarction is

usually accompanied with peripheral

leukocytosis

and the leukocytosis is

associated with higher rates of short-term

mortality and heart failure after myocardial

infarction.02

Neutrophils are the major leukocytes in the

peripheral blood. 05 06

Various clinical trials have reported an

association between increased neutrophil

count in peripheral blood and short-term

post-MI adverse outcomes and worse

angiographic findings. Amongst different

hematological indices, it has been shown

that the neutrophil/lymphocyte ratio


452


(NLR) has the highest predictive value in

predicting MI/Death in high risk patients

for coronary artery disease04

.

Acute Heart Failure (AHF) is a term used

to describe the rapid onset of or change in

signs and symptoms of heart failure.07

The

prevalence of the Heart Failure is

increasing due to the risk of coronary

artery disease. In addition, AHF is

associated with increased morbidity and

mortality.08

Therefore, the early

identification of patients with high risk of

acute heart failure is important. Also, it has

been shown that raised neutrophil count

and NLR predicts the long term mortality

in patients hospitalized with ST elevation

myocardial infarction (STEMI), and in

patients undergoing percutaneous coronary

intervention (PCI). 09

The study published by Azab B et. al10

also

demonstrated that NLR is an independent

predictor of short-term and long-term

mortalities in patients with STEMI. The

study conducted by Chatterjee S et al 11

suggests a pre-procedural elevated WBC

count, neutrophils and elevated N/L ratio

are predictors of significant ventricular

arrhythmias in patients undergoing

percutaneous coronary intervention (PCI).

In our study the complications were noted

among 69(32.86%) subjects in whom 48

were from raised neutrophil group and 21

were from normal neutrophil group.

According to our study results 1.72 times

more risk of complications noted in raised

neutrophil group compared to normal

neutrophil group. i. e RR=1.71 [1.33-

2.22].

Various clinical trials have reported an

association between increased neutrophil

count in peripheral blood and short-term

post-MI adverse outcomes and worse

angiographic findings.12-14

A study by

Ghaffari S. et. al02

presented that the

leukocyte (P<0.03) and neutrophil counts

(P<0.03) and higher NLR (P=0.01) were

predictors of failure. The frequency of

ventricular tachyarrhythmias (VT/VF) at

the first day was associated with higher

neutrophil count (P<0.001) and higher

NLR level (P<0.001). 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].

Another study by Zahoor Ahmed Khan et

al 15

concluded that Patients with Non ST

Segment elevation Myocardial Infarction

with high Neutrophil to lymphocyte ratio,

is a good predictor of In-hospital mortality,

atrial fibrillation and ST segment

deviation.

The study published by Azab B et al.10

also

demonstrated that NLR is an independent

predictor of short-term and long-term

mortalities in patients with STEMI.

The study conducted by Chatterjee S et

al11

suggests a pre-procedural elevated

WBC count, neutrophils and elevated N/L

ratio are predictors of significant

ventricular arrhythmias in patients

undergoing PCI.

Barron et al. demonstrated that there was

an association between high leukocyte

count and incidence of cardiogenic shock

or congestive heart failure. They reported a

higher mortality in patients with more

intense increase in WBC count.16

One study by Uzma Gul et al17

revealed

that the NLR an independent predictor of

mortality (OR 1.131 at 95% CI, p =

0.029). A high NLR predicted increased in

hospital complication rate, and in-hospital

as well as 30-day mortality in STEMI

patients thrombolysed with streptokinase.

Chia et al. showed that elevated leukocyte

and neutrophil counts after primary PCI in

patients with STEMI were associated with

larger myocardial infarct size and lower

LVEF and were independent predictors of

cardiovascular outcome.09

CONCLUSION:

It has been proved in our study that there is

1.72 times significantly more risk of in

hospital mortality and complications after

STEMI in raised total Neutrophil Count

than to normal Neutrophil Count.


453


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