Red blood cell distribution width as a link between ineffective erythropoiesis and chronic inflammation in heart failure

Relationship between Preoperative Red Cell Distribution Width and Prolonged Postoperative Use of Catecholamines in Minimally Invasive Mitral Valve Surgery Patients: A Retrospective Cohort Study

Background/Objectives: Elevated RDW has emerged in cardiac surgery as a potential means of preoperative risk stratification with the capacity to predict short- and long-term postoperative mortality, acute kidney injury, and postoperative atrial fibrillation. The question as to whether perioperative hemodynamic instability may be predicted by such a marker remains a topic of ongoing debate. The aim of this study was to explore the relationship between preoperative RDW and prolonged postoperative catecholamine use in minimally invasive mitral valve surgery. Methods: We performed a retrospective monocentric cohort study in an academic hospital; we enrolled patients who had undergone minimally invasive mitral valve surgery (including both robot-assisted and non-robot-assisted procedures) between January 2019 and December 2022. We considered the use of inotropes and/or vasopressors for at least twelve hours after post-surgery ICU admission to qualify as the prolonged postoperative use of catecholamines (PPUC). The RDW was obtained from the routine full blood count analysis performed upon admission or a maximum of 72 h before surgery. We also performed a multivariable logistic regression analysis with PPUC as the dependent variable. Results: We finally enrolled 343 patients. Upon multivariate analysis, RDW >14.4% was independently associated with prolonged postoperative catecholamine use when compared to the reference group (OR 2.62 [1.06-4.84]; p = 0.03). Moreover, the EuroSCORE II score (OR 1.38 [1.03-1.85]; p = 0.03), the cross-clamp time (OR 1.01 [1.01-1.02]; p < 0.01), and robot-assisted mitral valve surgery (OR 0.53 [0.30-0.93]; p < 0.03) were independently associated with the prolonged postoperative use of catecholamines. Conclusions: This study identified that an elevated preoperative RDW (>14.4%), the EuroSCORE II score, and the cross-clamp time independently predict prolonged postoperative catecholamine use in minimally invasive mitral valve surgery patients. Conversely, the robot-assisted approach was associated with a smaller hemodynamic impairment.

Association of red cell distribution width with pulmonary arterial hypertension in patients with mixed connective tissue disease

BACKGROUND

Pulmonary arterial hypertension (PAH) is a severe complication of mixed connective tissue disease (MCTD) and contributes to increased morbidity and mortality. Still, the demographic characteristics and risk factors of PAH in MCTD remain poorly understood. This study explored risk factors for PAH development in MCTD.

METHODS

Data from patients with MCTD and PAH hospitalized from May 2009 to December 2022 in a single center were collected and compared with patients with MCTD without PAH. The variables were analyzed by logistic regression to identify the factors associated with PAH in patients with MCTD. The receiver-operating characteristic (ROC) curve was used to assess the diagnostic value of the identified factors.

RESULTS

Finally, 119 patients with MCTD were included; 46 had PAH. The mean age at PAH onset and diagnosis was 38.9 ± 13.4 and 39.9 ± 13.7 years, respectively. The median pulmonary arterial systolic pressure (PASP) was 67.0 mmHg. The median brain natriuretic peptide (BNP) level was 180.0 pg/ml at PAH diagnosis. Red cell distribution width (RDW) (OR: 2.128; 95% confidence interval: 1.497-3.026; P < 0.001) was associated with PAH in patients with MCTD. There was a positive correlation between RDW and PASP (r = 0.716, P < 0.001). At a cutoff of 15.2%, RDW had the best sensitivity (80.4%) and specificity (82.2%) for PAH.

CONCLUSION

RDW may serve as a sensitive index to predict PAH in patients with MCTD.

Red Blood Cell Distribution Width as Novel Biomarker in Cardiovascular Diseases: A Literature Review

Red blood cell distribution width (RDW) is a measure of the change in size of red blood cells and it is used in combination with other hematological parameters for the differential diagnosis of anemias. Recent evidence suggested that the change in RDW level may be a predictive biomarker of morbidity and mortality in cardiovascular diseases (CVDs). Cardiovascular diseases are the most common cause of death globally as compared to cancer and communicable diseases. Early diagnosis and prompt intervention of these diseases are very important to minimize their complications. Nowadays, the diagnosis of most cardiovascular diseases majorly depends on clinical judgment, electrocardiography and biochemical parameters. Red blood cell distribution width as a new predictive biomarker may play a pivotal role in assessing the severity and progression of CVDs. However, the underlying mechanisms for the association between RDW and CVDs are not clear. A deeper understanding of their association could help the physicians in more careful identification, early prevention, intervention, and treatment to prevent adverse cardiovascular events. This review aims to elaborate on the recent knowledge on the association between RDW and cardiovascular diseases and some possible pathophysiological mechanisms.

Red blood cell distribution width-to-albumin ratio: a new inflammatory biomarker to predict contrast-induced nephropathy after emergency percutaneous coronary intervention

PURPOSE

Contrast-induced nephropathy (CIN) remains a dreaded complication in the cardiac diagnostic and interventional area. We investigated the relationship between red blood cell distribution width-to-albumin ratio (RAR) and CIN in elderly patients with ST-segment elevation myocardial infarction (STEMI) undergoing emergency percutaneous coronary intervention (PCI).

METHODS

A total of 1532 elderly patients were enrolled and divided into the CIN group and the non-CIN group. The risk factors of CIN were evaluated by univariate and multivariate regression analysis. Receiver-operating characteristic (ROC) curve analysis was used to identify the best predictive value.

RESULTS

CIN occurred in 129 (8.42%) patients. Patients in the CIN group had significantly higher RAR than those in the non-CIN group (4.69 ± 0.73 vs. 3.18 ± 0.64, P < 0.001). In multivariate regression analysis, RAR was an independent risk factor for the development of CIN (OR: 1.506, 95% CI: 1.227-2.083, P = 0.025), along with age, creatinine, eGFR, hs-CRP and contrast agent dose. The AUC of RAR was 0.755 (95% CI 0.703-0.807), and an optimal cutoff value of 3.64 or higher predicted CIN with a sensitivity of 76.2% and specificity of 65.7%.

CONCLUSION

As a combined inflammatory-related index, RAR was an independent risk factor for the development of CIN in elderly patients with STEMI undergoing emergency PCI. The RAR could be a simple but relatively reliable parameter for identifying high-risk patients.

Association between red blood cell distribution width and long-term mortality in acute respiratory failure patients

The red cell distribution width (RDW) has been reported to be positively correlated with short-term mortality of pulmonary disease in adults. However, it is not clear whether RDW was associated with the long-term prognosis for acute respiratory failure (ARF). Thus, an analysis was conducted to evaluate the association between RDW and 3-year mortality of patients by the Cox regression analysis, generalized additives models, subgroup analysis and Kaplan–Meier analysis. A total of 2999 patients who were first admitted to hospital with ARF were extracted from the Medical Information Mart for Intensive Care III database (MIMIC-III). The Cox regression analysis showed that the high RDW was associated with 3-year mortality (HR 1.10, 95% CI 1.07, 1.12, P < 0.0001) after adjusting for age, gender, ethnicity and even co-morbid conditions. The ROC curve illustrated the AUC of RDW was 0.651 (95% CI 0.631, 0.670) for prediction of 3-year mortality. Therefore, there is an association between the RDW and survival time of 3 years follow-up, particularly a high RDW on admission was associated with an increased risk of long-term mortality in patients with ARF. RDW may provide an alternative indicator to predict the prognosis and disease progression and more it is easy to get.

A narrative review of red blood cell distribution width as a marker for pulmonary embolism

Red blood cell distribution width (RDW) is a marker of variability in red blood cell size, and is routinely reported as part of a patient's complete blood count. RDW has been shown to be associated with the prediction, severity and prognosis of pulmonary embolism (PE) in recent studies. The underlying biomolecular mechanism of the relationship of RDW to PE is largely unknown, but is thought to be due to the relationship of RDW with acute inflammatory markers and variations in blood viscosity. This review substantiates that a high RDW level, defined using either an arbitrary number or according to receiver operator curve statistics, is associated with a higher risk of acute PE, increased severity (massive vs. submassive) of PE and increased mortality in patients with PE. Nevertheless, the comparison of current studies is limited due to the definition of high RDW (each study uses a different RDW cutoff level), the broad range of exclusion criteria and the inclusion of differing modalities used to diagnose a PE (computed tomography angiogram, ventilation-perfusion study, or clinical diagnosis). Despite the above limitations, these studies provide a promising future clinical use for RDW as a marker of PE.

Diagnostic and Prognostic Relevance of Red Blood Cell Distribution Width for Vascular Aging and Cardiovascular Diseases

Evidence suggests association of red blood cell distribution width (RDW) with cardiovascular diseases (CVDs). On the contrary, we underline that the sole RDW values cannot represent a valid CVD biomarker. High RDW values are expression of biological effects of a lot of both endogenous and exogenous factors (i.e., age, sex, genetic background, inflammation, hormones, drugs, diet, exercise, hematological analyzers, and ranges of values), modulating the biology and physiology of erythrocytes. Thus, the singular monitoring of RDW cannot be used to predict cardiovascular disorders. Accordingly, we have reviewed the evidence for potential relationship of RDW values with alterations in the cardiovascular system (i.e., regenerative capacity, endothelial turnover, and senescence of cardiovascular cells), associated with vascular aging and disease. In addition, we highlight the inevitable impact of biases in clinical application of RDW related to CVDs. Based on our thorough review of literature, we suggest a combined evaluation of RDW with other emerging biomarkers related to vascular aging and the diagnosis and prognosis of CVDs, including telomere length of leukocytes, circulating nucleated red blood cells (nRBCs) and endothelial progenitor cells (EPCs) in future large scale studies.

Red blood cell distribution width as a potential predictor of survival of pulmonary arterial hypertension associated with primary Sjogren's syndrome: a retrospective cohort study

Pulmonary arterial hypertension (PAH) is a severe complication and leading cause of mortality in patients with primary Sjogren's syndrome (pSS). This study was to investigate the overall survival rates and the utility of red blood cell distribution width (RDW) as a potential prognostic factor of pSS-PAH. This cohort study retrospectively enrolled 55 patients with pSS-PAH who were followed up at the Department of Rheumatology of Peking Union Medical College Hospital (PUMCH) between August 2007 and May 2017. The patients were stratified according to the level of RDW (≤ 15.0 and > 15.0%). Baseline demographics, laboratory results, pulmonary function conditions, hemodynamic assessments, and treatment regimens were analyzed. Cox proportional hazards regression analysis was used to identify whether RDW level is a factor related to adverse outcome. A total of 55 patients were recruited, with an average age of 38.9 ± 9.3 years. Fifty-four were female (98.2%), and the average duration at the time of PAH diagnosis was 25.5 ± 33.2 months. Higher RDW levels were found in patients who deceased in follow-up (13.8 ± 2.6 vs 16.5 ± 1.6%, p = 0.003) and with higher NYHA classes (13.8 ± 1.8 vs 16.5 ± 2.9%, p < 0.001). Patients with RDW > 15% had a significantly worse overall survival than patients with RDW ≤ 15% (3-year survival rate 59.5 vs. 88.7% log-rank p = 0.015). Cox regression analysis identified RDW > 15% as a prognostic factor for adverse outcome (HR 1.786, 95% CI 1.137-2.803, p = 0.012). RDW can serve as a potential negative prognostic factor of pSS-PAH.

Red cell distribution width and common disease onsets in 240,477 healthy volunteers followed for up to 9 years

Higher Red Blood Cell Distribution Width (RDW or anisocytosis) predicts incident coronary artery disease (CAD) plus all-cause and cardiovascular mortality, but its predictive value for other common diseases in healthy volunteers is less clear. We aimed to determine the shorter and longer term associations between RDW and incident common conditions in participants free of baseline disease, followed for 9 years. We undertook a prospective analysis of RDW% using 240,477 healthy UK Biobank study volunteers aged 40–70 years at baseline, with outcomes ascertained during follow-up (≤9 years). Participants were free of anemia, CAD, type-2 diabetes, stroke, hypertension, COPD, and any cancer (except non-melanoma skin cancer) at baseline. Survival models (with competing Hazards) tested associations with outcomes from hospital admission records and death certificates. High RDW (≥15% variation, n = 6,050) compared to low (<12.5% n = 20,844) was strongly associated with mortality (HR 3.10: 95% CI 2.57 to 3.74), adjusted for age, sex, smoking status, education level, mean cell volume and hemoglobin concentration. Higher RDW was also associated with incident CAD (sub-HR 1.67: 1.40 to 1.99), heart failure, peripheral vascular disease, atrial fibrillation, stroke, and cancer (sHR 1.37: 1.21 to 1.55; colorectal cancer sHR 1.92: 1.36 to 2.72), especially leukemia (sHR 2.85: 1.63 to 4.97). Associations showed dose-response relationships, and RDW had long-term predictive value (≥4.5 years after assessment) for the majority of outcomes, which were similar in younger and older persons. In conclusion, higher RDW predicted onsets of a wide range of common conditions as well as mortality in a large healthy volunteer cohort. RDW is not just a short term predictor, as high levels were predictive 4.5 to 9 years after baseline in healthy volunteers. The wide range of outcomes reflects known RDW genetic influences, including diverse disease risks. RDW may be a useful clinical marker for inclusion in wellness assessments.

Combined Assessment of the Red Cell Distribution Width and B-type Natriuretic Peptide: A More Useful Prognostic Marker of Cardiovascular Mortality in Heart Failure Patients

Objective An increased red cell distribution width (RDW) has been reported to be associated with adverse outcomes in patients with heart failure (HF). This study aimed to evaluate the prognostic power of the combined measurement of RDW and B-type natriuretic peptide (BNP) concentrations in patients with HF. Methods and Results We retrospectively studied 116 patients (mean age, 63.7±14.3 years) who were admitted for the treatment of HF. Data including demographic information, vital signs, and laboratory and echocardiographic measurements at admission were collected from medical records. The observational period was defined as the number of days from hospitalization, and the study endpoint was defined as cardiovascular death. The mean RDW and BNP concentration at admission were 14.5±2.0% and 626±593 pg/mL, respectively. During a median observation period of 1,046 days, 22 patients died of cardiovascular disease. A univariate Cox proportional hazard analysis revealed that both RDW [hazard ratio (HR) 1.252, p = 0.0391] and BNP (HR 1.001, p = 0.0445) were significant prognostic indices for cardiovascular death. A receiver operating characteristic curve analysis revealed that the optimal cut-off RDW and BNP values for cardiovascular death were 14.9% and 686 pg/mL, respectively. The Kaplan-Meier survival curve revealed that the survival rate of patients with both RDW ≥ 14.9% and BNP ≥ 686 pg/mL showed the poorest prognosis in comparison to the patients in the other groups. Conclusion The combined assessment of the RDW and BNP concentrations may be useful for predicting mortality in patients with HF.

Higher risk of myocardial injury in chest pain patients with elevated red blood cell distribution width

BACKGROUND

High level of red blood cell distribution width (RDW) has been associated with adverse outcomes in coronary artery disease patients. We aimed to investigate the relationship between RDW and the risk of myocardial injury in chest pain patients.

METHODS AND RESULTS

We retrospectively reviewed 2078 chest pain patients with suspected acute myocardial infarction. Myocardial injury was defined as high-sensitivity cardiac troponin T (hs-cTnT) >14 ng/L. RDW was associated with hs-cTnT (r = 0.607) and the risk of myocardial injury stepwise increased across increasing RDW quartiles in all subgroups based on age and sex. The receiver operating characteristic curve analysis was calculated to assess the elevated RDW to predict myocardial injury, with the cutoff value of 13.25%. RDW had a high sensitivity (78.10%), specificity (87.44%), as well as positive predictive value (77.48%). The area under the curve (AUC) for all patients was 0.88 (95%CI 0.87, 0.90) and there is no statistical significant in AUCs for all subgroups.

CONCLUSIONS

Elevated RDW was significantly associated with a higher risk of myocardial injury in chest pain patients with potential acute myocardial infarction. The RDW may be helpful to identify myocardial injury in such patients.

Association between red cell distribution width and thromboembolic events in patients with atrial fibrillation

BACKGROUND

We investigated whether an increase in the value of red cell distribution width (RDW) was associated with thromboembolic outcomes in patients with atrial fibrillation (AF).

METHODS

We performed a retrospective analysis of 5082 consecutive patients with non-valvular AF. Thromboembolic events (N=723, 14.2%) were recorded and analysed according to RDW value.

RESULTS

The peak RDW value during follow-up was higher in patients with thromboembolic events than in those without thromboembolic events (15.1% vs. 14.2%, p<0.001). The RDW value showed similar power in predicting thromboembolic outcomes compared with the factor of age. The risk of thromboembolic events was higher in patients with a peak RDW≥13.9% than in patients with a peak RDW<13.9% (hazard ratio 1.63, p<0.001), and increased with each quartile increase of RDW. In a subgroup of 739 patients with congestive heart failure (CHF), there were 112 (15.2%) thromboembolic events. The peak RDW value of patients with CHF with thromboembolic events was also significantly higher (16.4% vs. 15.6%, p=0.019) compared to that of those without thromboembolic events.

CONCLUSION

An increased RDW value during follow-up could be associated with thromboembolic events in patients with non-valvular AF. The suggested cut-off values for RDW used to predict an increased thromboembolic risk in were ≥13.9% in patients with AF in general, ≥15% in patients with co-existing AF and CHF.

Red blood cell distribution width: Genetic evidence for aging pathways in 116,666 volunteers

INTRODUCTION

Variability in red blood cell volumes (distribution width, RDW) increases with age and is strongly predictive of mortality, incident coronary heart disease and cancer. We investigated inherited genetic variation associated with RDW in 116,666 UK Biobank human volunteers.

RESULTS

A large proportion RDW is explained by genetic variants (29%), especially in the older group (60+ year olds, 33.8%, <50 year olds, 28.4%). RDW was associated with 194 independent genetic signals; 71 are known for conditions including autoimmune disease, certain cancers, BMI, Alzheimer's disease, longevity, age at menopause, bone density, myositis, Parkinson's disease, and age-related macular degeneration. Exclusion of anemic participants did not affect the overall findings. Pathways analysis showed enrichment for telomere maintenance, ribosomal RNA, and apoptosis. The majority of RDW-associated signals were intronic (119 of 194), including SNP rs6602909 located in an intron of oncogene GAS6, an eQTL in whole blood.

CONCLUSIONS

Although increased RDW is predictive of cardiovascular outcomes, this was not explained by known CVD or related lipid genetic risks, and a RDW genetic score was not predictive of incident disease. The predictive value of RDW for a range of negative health outcomes may in part be due to variants influencing fundamental pathways of aging.

Predictive Values of Red Blood Cell Distribution Width in Assessing Severity of Chronic Heart Failure

Background

This retrospective study was performed to evaluate the value of baseline red blood cell distribution width (RDW) for predicting the severity of chronic heart failure (CHF) compared with N-terminal prohormone brain natriuretic peptide (NT-ProBNP) and other hematological and biochemical parameters.

Material/Methods

Hematological and biochemical parameters were obtained from 179 patients with New York Heart Association (NYHA) CHF class I (n=44), II (n=39), III (n=41), and IV (n=55). Receiver operator characteristic (ROC) curves were used for assessing predictive values.

Results

RDW increased significantly in class III and IV compared with class I (14.3±2.3% and 14.3±1.7% vs. 12.9±0.8%, P<0.01). Areas under ROCs (AUCs) of RDW and NT-ProBNP for class IV HF were 0.817 and 0.840, respectively. RDW was markedly elevated in the mortality group compared with the survival group (13.7±1.7 vs. 15.8±1.8, P<0.01). The predictive value of RDW was lower than that of NT-ProBNP but was comparable to white blood cell (WBC), neutrophil (NEU), lymphocyte (L), and neutrophil/lymphocyte ratio (N/L) for mortality during hospitalization, with AUCs of 0.837, 0.939, 0.858, 0.891, 0.885, and 0.885, respectively. RDW and NT-proBNP showed low predictive values for repeated admission (≥3). RDW was an independent risk factor for mortality (OR=2.531, 95% CI: 1.371–4.671).

Conclusions

RDW increased significantly in class III and IV patients and in the mortality group. The predictive value of RDW is comparable to NT-proBNP for class IV and lower than that of NT-proBNP for mortality. Elevated RDW is an independent risk factor for mortality.

Red blood cell distribution width and cardiovascular diseases

BACKGROUND

The red blood cell distribution width (RDW) is a rather simple measure of red blood cell (RBC) size heterogeneity (i.e., anisocytosis), which is easily calculated by dividing the standard deviation (SD) of erythrocyte volumes for the mean corpuscular volume (MCV). Emerging evidence suggests that, besides RBC abnormalities, many human disorders may be frequently associated with a high degree of anisocytosis.

METHODS

In this narrative review, we analyzed the current scientific literature about the putative role and the potential epidemiologic association between RDW and cardiovascular diseases. The findings of the most representative epidemiological studies were summarized and discussed.

RESULTS

Overall, considerable and convincing evidence has been brought that an increased RDW value is associated with acute coronary syndrome (ACS) [including acute myocardial infarction (AMI)], ischemic cerebrovascular disease (including stroke), peripheral artery disease (PAD), as well as with atrial fibrillation (AF), heart failure (HF) and hypertension. Higher anisocytosis also significantly and independently predicts adverse outcomes in patients with these conditions.

CONCLUSIONS

Although the role of anisocytosis in the pathogenesis of cardiovascular diseases remains uncertain, the considerable evidence available so far suggests that the clinical use of RDW may be broadened beyond the conventional boundaries of erythrocyte disorders, in particular for assisting the diagnosis and prognostication of patients with ACS, ischemic cerebrovascular disease, PAD, HF and AF.