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
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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
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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
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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 group and 9 were from normal
neutrophil group shown in Table#4
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 raised neutrophil group and 10 were
from normal neutrophil group, similarly
the pulmonary edema not found in 36
subjects in which 25 were from raised
neutrophil group and 11 were from normal
neutrophil group shown in Table#5
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
which 31 were from raised neutrophil
group and 12 were from normal neutrophil
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
subjects in which 23 were from raised
neutrophil group and 7 were from normal
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
which 48 were from raised neutrophil
group and 21 were from normal neutrophil
group, similarly the complications not
found in 141 subjects in which 57 were
from raised neutrophil group and 84 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
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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
subjects in which 17 were from raised
neutrophil group and 11 were from normal
neutrophil group. Similarly in >50 years
subjects, the complications were found in
41 subjects in which 31 were from raised
neutrophil group and 10 were from normal
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
Comparison of complications with
neutrophil stratified by age
The study results showed that in male
patient the complications found in 35
subjects in which 25 were from raised
neutrophil group and 10 were from normal
neutrophil group. Similarly in female
subjects, the complications were found in
34 subjects in which 23 were from raised
neutrophil group and 11 were from normal
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
Comparison of complications with
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
GSJ: Volume 6, Issue 10, October 2018 ISSN 2320-9186
452
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(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.
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