Prognostic value of leukocytosis in acute coronary syndromes: the cinderella of the inflammatory markers

Systemic immune-inflammation index is associated with ulcerative plaque in patients with acute ischemic stroke: A single center exploratory study

PURPOSE

This study explored the correlation between inflammatory markers and ulcerative plaques based on carotid doppler ultrasound (CDU) in individuals with acute ischemic stroke (AIS).

METHODS

A total of 202 cases diagnosed with AIS associated with atherosclerotic plaque (AP) in the carotid artery were enrolled in this research. Collecting clinical baseline data, laboratory data (such as the complete blood count) and imaging data (CDU and Brain magnetic resonance imaging [MRI]). Then the correlation between Systemic immune-inflammation index (SII, SII = P N/L, where P, N, and L were the peripheral blood platelet, neutrophil and lymphocyte counts, respectively), the shape and position of AP, the degree of carotid artery stenosis, and the presence of ulcerative plaques. Cutoff values were determined accordingly.

RESULTS

SII and high sensitivity CRP (hs-CRP) were independent risk factors for the presence of vulnerable carotid plaques. SII, type A plaque, plaque above carotid bifurcation, and severe carotid stenosis were independent risk factors for the presence of ulcerative plaque. The AUC value, the sensitivity, specificity, the best cutoff value of SII in predicting the presence of ulcerative plaque was 0.895, 93.3%, 89.2%, and 537.4 (109 /L), respectively.

CONCLUSION

SII at admission was found to be independently associated with the presence of AIS with vulnerable plaque, especially ulcerative plaques. Moreover, plaque ulceration was more likely to form when the area of higher plaque thickness was located in the upstream arterial wall of maximum plaque thickness (WTmax), plaque was above the carotid bifurcation and severe carotid stenosis.

Factors Associated With Hospital Mortality in Acute Myocardial Infarction

Aim    To determine clinical and laboratory parameters associated with in-hospital mortality in patients with acute myocardial infarction and to develop a multifactorial prognostic model of in-hospital mortality.Material and methods    This was a study based on the 2019-2020 Registry of acute coronary syndrome of the Tyumen Cardiology Research Center, a branch of the Tomsk National Research Medical Center. The study included 477 patients with ST-segment elevation acute myocardial infarction (AMI), 617 patients with non-ST segment elevation AMI, and 26 patients with unspecified AMI. In-hospital mortality was 6.0 % (n=67). Clinical and laboratory parameters were assessed on the day of admission. The separation power of indicators associated with in-hospital mortality was determined using a ROC analysis. The data array of each quantitative parameter was converted into a binary variable according to the obtained cut-off thresholds, followed by creation of a multifactorial model for predicting in-hospital mortality using a stepwise analysis with backward inclusion (Wald). The null hypothesis was rejected at p<0.05.Results    The multivariate model for prediction of in-hospital mortality included age (cut-off, 72 years), OR 3.0 (95 % CI: 1.5-5.6); modified shock index (cut-off threshold, 0.87), OR 1.5 (95 % CI: 1.1-2.0); creatine phosphokinase-MB (cut-off threshold, 32.8 U / L), OR 4.1 (95 % CI: 2.2-7.7); hemoglobin (121.5 g / l), OR 1.7 (95 % CI: 1.2-2.3); leukocytes (11.5×109 / l), OR 1.9 (95 % CI: 1.3-2.6); glomerular filtration rate (60.9 ml / min), OR 1.7 (95 % CI: 1.2-2.2); left ventricular ejection fraction (42.5 %), OR 4.1 (95 % CI: 2.0-8.3); and size of myocardial asynergy (32.5 %), OR 2.6 (95 % CI: 1.4-5.0).Conclusions    Independent predictors of in-hospital mortality in AMI are age, modified shock index, creatine phosphokinase-MB, peripheral blood leukocyte count, hemoglobin concentration, left ventricular ejection fraction, size of myocardial asynergy, and glomerular filtration rate. The in-hospital mortality model had a high predictive potential: AUC 0.930 (95 % CI: 0.905-0.954; p <0.001) with a cutoff threshold of 0.15; sensitivity 0.851, and specificity 0.850.

Systemic Coagulation Inflammation Index Associated With Bleeding in Acute Coronary Syndrome

AIM

Assessment of the inflammatory component of acute coronary syndrome (ACS) and the degree of activation of the coagulation cascade may provide prognostic information. The systemic coagulation-inflammation index (SCI) assesses both inflammation and the coagulation system, and it has also been found to be associated with clinical outcomes. We investigated the relationship between SCI and in-hospital clinical events (acute kidney injury, cardiogenic shock, life-threatening arrhythmia, bleeding) and mortality.

MATERIAL AND METHODS

The study included 396 patients aged ≥18 yrs who were hospitalized with a diagnosis of ACS. The SCI was calculated using the formula: platelet count (103 / µl) X fibrinogen (g / l) / white blood cell (WBC) count (103 / µl). Patients were divided into two groups according to whether their SCI score was >100 or <100, and the relationship between clinical and laboratory characteristics was analyzed accordingly.

RESULTS

The mean age of the patients was 61.4±12.2 years and 78.3 % (n=310) were male. The type of ACS was NSTEMI in 56.1 % (n=222). The responsible vessel was the left anterior descending artery (LAD) in 42.4 % of the patients (n=168). The mean SCI score was 97.5±47.1. WBC, neutrophil, and lymphocyte counts were higher in the SCI <100 group, whereas fibrinogen, C-reactive protein, and platelet count were higher in the SCI >100 group. Bleeding from any cause as an in-hospital complication was significantly higher in patients with SCI >100 (p<0.05). Other in-hospital events were not significantly associated with SCI (p>0.05).

CONCLUSIONS

Bleeding in ACS patients was significantly more common in the group with SCI >100. Thus, SCI may be a useful parameter for predicting in-hospital bleeding complications in ACS. On the other hand, SCI was not associated with mortality and other in-hospital clinical events.

Evaluation of frontal QRS-T angle values in electrocardiography in patients with chronic rhinosinusitis

BACKGROUND

Chronic Rhinosinusitis (CRS) refers to inflammation of the paranasal sinuses and nasal mucosa. Electrocardiographic indicators of ventricular repolarization have been shown to correlate with systemic inflammation parameters. Recently, the frontal QRS-T (fQRS-T) angle has been accepted as a new indicator of ventricular depolarization and repolarization heterogeneity. The (fQRS-T) angle is recommended in predicting the risk of malignant ventricular arrhythmia. In this study, we aimed to evaluate the ventricular arrhythmia potential in patients with chronic rhinosinusitis by examining the relationship between fQRS-T angle on ECG and inflammation markers.

METHODS

Inflammatory markers as well as electrocardiographc (ECG) f(QRS-T) angle, QRS duration, QT interval and corrected QT interval were examined in 54 patients with CRS versus 56 healthy control subjects.

RESULTS

The f(QRS-T) angle was significantly higher in CRS patients than in healthy controls (p < .001). The neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and monocyte-to-lymphocyte ratio (MLR) were significantly higher in CRS patients compared to healthy controls (p < .001, for all). Based on correlation analysis, NLR and f(QRS-T) angles were highly correlated (r = .845, p < .001), and according to the results of linear regression analysis, NLR was independently associated with the f(QRS-T) angle (t = 5.149, Beta = 0.595, p = < 0.001).

CONCLUSION

Both f(QRS-T) angle and NLR are significantly increased in CRS patients compared to healthy controls, with increases in NLR also independently associating with increases in f(QRS-T) angle. While the increases in f(QRS-T) angle did not result in clinically alarming absolute values for f(QRS-T), CRS patients might nonetheless be at relatively higher risk for malignant cardiac arrhythmias.

A Nomogram for Predicting In-Hospital Major Adverse Cardio- and Cerebro-Vascular Events in Patients Undergoing Major Noncardiac Surgery: A Large-Scale Nested Case-Control Study

Purpose

Few evidence-based predictive tools are available to evaluate major adverse cardio- and cerebro-vascular events (MACCEs) before major noncardiac surgery. We sought to develop a new simple but effective tool for estimating surgical risk.

Patients and Methods

Using a nested case-control study design, we recruited 105 patients who experienced MACCEs and 481 patients without MACCEs during hospitalization from 10,507 patients undergoing major noncardiac surgery in Beijing Chaoyang hospital. Least absolute shrinkage and selection operator (LASSO) regression and likelihood ratio were applied to screen 401 potential features for logistic regression. A nomogram was constructed using the selected variables.

Results

Chronic heart failure, valvular heart disease, preoperative serum creatinine >2.0 mg/dL, ASA class, neutrophil count and age were most associated with in-hospital MACCEs among all the factors. A new prediction model established based on these showed a good discriminatory ability (AUC, 0.758 [95% confidence interval (CI), 0.708–0.808] and a well-performed calibration curve (Hosmer–Lemeshow χ² = 7.549, p = 0.479), which upheld in the 10-fold cross-validation (AUC, 0.742 [95% CI, 0.718–0.767]. This model also demonstrated an improved performance in comparison to the modified Revised Cardiac Risk Index (RCRI) score (increase in AUC by 0.119 [95% CI, 0.056–0.180]; NRI, 0.445 [95% CI, 0.237–0.653]; IDI, 0.133 [95% CI, 0.087–0.178]. The decision curve analysis showed a positive net benefit of our new model.

Conclusion

Our nomogram, which relies upon simple clinical characteristics and laboratory tests, is able to predict MACCEs in patients undergoing major noncardiac surgery. This prediction shows better discrimination than the standardized modified RCRI score, laying a promising foundation for further large-scale validation.

The Leukocyte Subtype Counts and Ratios Can Effectively Predict the Risk of Arterial Stiffness Assessed by Cardio-Ankle Vascular Index: A Retrospective Study

Background: Arterial stiffness was the pathological basis and risk factor of cardiovascular diseases, with chronic inflammation as the core characteristic. We aimed to analyze the association between the arterial stiffness measured by cardio-ankle vascular index (CAVI) and indicators reflecting the inflammation degree, such as count of leukocyte subtypes, platelet, and monocyte-to-lymphocyte ratio (MLR), etc. Methods: The data of inpatients from November 2018 to November 2019 and from December 2019 to September 2020 were continuously collected as the training set (1,089 cases) and the validation set (700 cases), respectively. A retrospective analysis of gender subgroups was performed in the training set. The association between inflammatory indicators and CAVI or arterial stiffness by simple linear regression, multiple linear regression, and logistic regression was analyzed. The effectiveness of the inflammation indicators and the CAVI decision models to identify arterial stiffness by receiver operating curve (ROC) in the training and validation set was evaluated. Results: The effect weights of MLR affecting the CAVI were 12.87% in men. MLR was the highest risk factor for arterial stiffness, with the odds ratio (95% confidence interval) of 8.95 (5.04-184.79) in men after adjusting the covariates. A cutpoint MLR of 0.19 had 70% accuracy for identifying arterial stiffness in all participants. The areas under the ROC curve of the CAVI decision models for arterial stiffness were >0.80 in the training set and validation set. Conclusions: The MLR might be a high-risk factor for arterial stiffness and could be considered as a potential indicator to predict arterial stiffness.

Emergency department routine data and the diagnosis of acute ischemic heart disease in patients with atypical chest pain

Background

Due to an aging population and the increasing proportion of patients with various comorbidities, the number of patients with acute ischemic heart disease (AIHD) who present to the emergency department (ED) with atypical chest pain is increasing. The aim of this study was to develop and validate a prediction model for AIHD in patients with atypical chest pain.

Methods and results

A chest pain workup registry, ED administrative database, and clinical data warehouse database were analyzed and integrated by using nonidentifiable key factors to create a comprehensive clinical dataset in a single academic ED from 2014 to 2018. Demographic findings, vital signs, and routine laboratory test results were assessed for their ability to predict AIHD. An extreme gradient boosting (XGB) model was developed and evaluated, and its performance was compared to that of a single-variable model and logistic regression model. The area under the receiver operating characteristic curve (AUROC) was calculated to assess discrimination. A calibration plot and partial dependence plots were also used in the analyses. Overall, 4,978 patients were analyzed. Of the 3,833 patients in the training cohort, 453 (11.8%) had AIHD; of the 1,145 patients in the validation cohort, 166 (14.5%) had AIHD. XGB, troponin (single-variable), and logistic regression models showed similar discrimination power (AUROC [95% confidence interval]: XGB model, 0.75 [0.71–0.79]; troponin model, 0.73 [0.69–0.77]; logistic regression model, 0.73 [0.70–0.79]). Most patients were classified as non-AIHD; calibration was good in patients with a low predicted probability of AIHD in all prediction models. Unlike in the logistic regression model, a nonlinear relationship-like threshold and U-shaped relationship between variables and the probability of AIHD were revealed in the XGB model.

Conclusion

We developed and validated an AIHD prediction model for patients with atypical chest pain by using an XGB model.

Similar Clinical Course and Significance of Circulating Innate and Adaptive Immune Cell Counts in STEMI and COVID-19

This study aimed to assess the time course of circulating neutrophil and lymphocyte counts and their ratio (NLR) in ST-segment elevation myocardial infarction (STEMI) and coronavirus disease (COVID)-19 and explore their associations with clinical events and structural damage. Circulating neutrophil, lymphocyte and NLR were sequentially measured in 659 patients admitted for STEMI and in 103 COVID-19 patients. The dynamics detected in STEMI (within a few hours) were replicated in COVID-19 (within a few days). In both entities patients with events and with severe structural damage displayed higher neutrophil and lower lymphocyte counts. In both scenarios, higher maximum neutrophil and lower minimum lymphocyte counts were associated with more events and more severe organ damage. NLR was higher in STEMI and COVID-19 patients with the worst clinical and structural outcomes. A canonical deregulation of the immune response occurs in STEMI and COVID-19 patients. Boosted circulating innate (neutrophilia) and depressed circulating adaptive immunity (lymphopenia) is associated with more events and severe organ damage. A greater understanding of these critical illnesses is pivotal to explore novel alternative therapies.

Relationship between monocyte/lymphocyte ratio and non-culprit plaque vulnerability in patients with acute coronary syndrome: An optical coherence tomography study

The importance of monocyte/lymphocyte ratio (MLR) has been indicated in the initiation and progression of coronary artery disease. However, few previous researches demonstrated the relationship between MLR and plaque vulnerability. We aimed to investigate coronary non-culprit plaque vulnerability in patients with acute coronary syndrome (ACS) by optical coherence tomography (OCT).A total of 72 ACS patients who underwent coronary angiography and OCT test in Beijing Anzhen Hospital were included in this retrospective study. The plaque vulnerability and plaque morphology were assessed by OCT.The non-culprit plaque in high MLR group exhibited more vulnerable features, characterizing as thinner thickness of fibrous cap (P = .013), greater maximum lipid core angle (P = .010) and longer lipid plaque length (P = .041). A prominently negative liner relation was found between MLR and thickness of fibrous cap (R = -0.225, P = .005). Meanwhile, the proportion of OCT-detected thin cap fibro-atheroma (TCFA) (P = .014) and plaque rupture (P = .017) were higher in high MLR group. Most importantly, multivariable logistic regression analysis showed MLR level was identified as an independent contributor to the presence of TCFA (OR:3.316, 95%: 1.448-7.593, P = .005). MLR could differentiate TCFA with a sensitivity of 60.0% and a specificity of 85.1%.Circulating MLR level has potential value in identifying the presence of vulnerable plaque in patients with ACS. MLR, as a non- invasive biomarker of inflammation, may be valuable in revealing plaque vulnerability.

Relation of White Blood Cell Count to Bleeding and Ischemic Events in Patients With Acute Coronary Syndrome (from the ATLAS ACS 2-TIMI 51 Trial)

An elevated white blood cell (WBC) count is associated with an increased risk of ischemic events among acute coronary syndrome (ACS) patients, but the association between WBC count and bleeding in ACS patients is not well established. The aim of this analysis was to assess and compare the association between WBC count and the occurrence of short- and long-term bleeding and ischemic events. This was a post hoc analysis of the ATLAS ACS2-TIMI 51 trial. A subset of patients had a WBC count measurement at baseline (n = 14,231, 91.6%). Univariate and multivariable Cox proportional hazard models were constructed to determine if there is an association between WBC count at baseline and a composite outcome of Thrombolysis in Myocardial Infarction (TIMI) major and minor bleeds at 30 days and 1 year. Variables with a p <0.2 in the univariate analysis were included as potential parameters in the backward selection process A similar multivariable model was constructed to assess the association between WBC count and a composite ischemic endpoint of cardiovascular death, myocardial infarction and stroke. An increased risk of bleeding per a 1 × 10⁹/L increase in WBC at baseline was observed at 30 days (Adjusted hazard ratio [HR] 1.08 95% confidence interval [CI] 1.01 to 1.17, p = 0.019) but not at 1 year (Adjusted HR 1.02 95% CI 0.97 to 1.08, p = 0.409). Additionally, an increased risk of ischemia per a 1 × 10⁹/L increase in WBC at baseline was observed at 30 days (Adjusted HR 1.07, 95% CI: 1.03 to 1.12, p = 0.002) and at 1 year (Adjusted HR 1.05 95% CI 1.02 to 1.08, p = 0.001 at 1 year). In conclusion, a higher WBC count at baseline was associated with an increased risk of the composite bleeding endpoint by 30 days but not at 1 year. The association between WBC count and the risk of the composite ischemic endpoint was significant at 30 days and 1 year.

Association of lymphocyte to monocyte ratio and risk of in-hospital mortality in patients with acute type A aortic dissection

Aim: The aim of the study was to evaluate the relationship between lymphocyte to monocyte ratio (LMR) at admission and in-hospital mortality of patients with acute type A aortic dissection (AAAD). Patients & methods: We enrolled 536 patients with AAAD between June 2013 and December 2017. Patients were divided into two groups: the deceased group and the survival group. Results: In multivariable analysis, the association between LMR and in-hospital mortality was still significant. When the Q4 was set as the reference value, the odds ratios values of Q1, Q2 and Q3 were 4.4 (95% CI: 2.2-8.9; p < 0.001), 1.4 (95% CI: 1.1-3.4; p = 0.03) and 1.7 (95% CI: 0.8-2.9; p = 0.158). Conclusion: Lower LMR may be independently associated with in-hospital mortality in AAAD.

Hematologic disorders during essential hypertension

BACKGROUND

Besides the traditional risk factors, hematological changes may be involved in the development of arterial hypertension and in its pathogenesis.

METHODS

The study, conducted on a sample of 545 subjects, 215 with hypertension and 330 witnesses, were evaluated for peripheral blood parameters in western Algeria; Logistic regression analysis was used to predict hypertension with hematological parameters.

RESULTS

The characters studied related significantly; lower red blood cell levels have a three-and-a-half-fold risk of developing hypertension compared to those who have normal red blood cell counts (OR = 3.64, 95% CI = 1.37-9.65, p < 0.05). Subjects who have mean corpuscular volume rate below 80 fl are more exposed to hypertension (OR = 13.58, 95% CI = 4.68-39.41, p = 0.000). The mean corpuscular hemoglobin concentration reveals that subjects who have a lower than normal (<27 pg) are once less exposed to hypertension (OR = 0.04, 95% CI = 0.01-0.13, p = 0.000). Subjects who have lower platelet count than normal are twelve times more exposed to hypertension (OR = 12.13, 95% CI = 1.45-101.18, P = 0.021). Finally, the increase in sedimentation rate at one hour increases the risk of hypertension by 56.63 times compared to subjects with normal sedimentation rate (OR = 56.63, 95% CI = 3.37-597.33, P = 0.001).

CONCLUSIONS

Hematological profile associated with essential hypertension retained Red blood cells ratio, mean corpuscular volume, mean corpuscular hemoglobin concentration, platelet ratio, and sedimentation rate at one hour.

Relationship between monocyte-to-lymphocyte ratio and coronary plaque vulnerability in patients with stable angina

Aim: To investigate the relationship between monocyte-to-lymphocyte ratio (MLR) and plaque vulnerability assessed by virtual histology intravascular ultrasound in patients with stable angina. Methods: 133 patients with stable angina were enrolled. Results: MLR was found to be an independent risk factor of thin cap fibrous atheroma (OR: 2.61; p = 0.025). MLR could differentiate thin cap fibrous atheroma with a sensitivity of 73.7% and a specificity of 61.8%. MLR level was positively correlated with the percentage of necrotic core (NC) area at the sites of minimum lumen area and the largest NC area, and positively related to the percentage of NC volume. Conclusion: Circulating MLR level has potential in identifying the vulnerable plaques in the setting of stable angina.

Monocyte/lymphocyte ratio predicts the severity of coronary artery disease: a syntax score assessment

Background

We aimed to explore whether monocyte to lymphocyte ratio (MLR) provides predictive value of the lesion severity in patients with coronary artery disease (CAD).

Methods

Five hundred forty-three patients undergoing coronary angiography were analyzed in this retrospective study. Patients with coronary stenosis were divided into three groups on the basis of Syntax score. The control group consisted of patients with normal coronary arteries. MLR was calculated by dividing monocytes count by lymphocytes count obtained from routine blood examination. Multivariate logistic analysis was used to assess risk factors of CAD. Ordinal logistic regression analysis was used to assess the relationship between MLR and the lesion severity of coronary arteries.

Results

MLR was found to be an independent risk factor of the presence of CAD (OR: 3.94, 95% CI: 1.20–12.95) and a predictor of the lesion severity (OR: 2.05, 95% CI: 1.15–3.66). Besides, MLR was positively correlated with Syntax score(r = 0.437, p < 0.001). In the receiver-operating characteristic (ROC) curve analysis, MLR, with an optimal cut-off value of 0.25, predicted the severe coronary lesion with a sensitivity of 60.26% and specificity of 78.49%.

Conclusions

MLR was an independent risk factor of the presence of CAD, and a predictor of the lesion severity. Compared to neutrophil to lymphocyte ratio (NLR), MLR has better performance to reflect the severity of coronary lesion.

Association of peripheral differential leukocyte counts with dyslipidemia risk in Chinese patients with hypertension: insight from the China Stroke Primary Prevention Trial

The aim of the present study was to examine the association between peripheral differential leukocyte counts and dyslipidemia in a Chinese hypertensive population. A total of 10,866 patients with hypertension were enrolled for a comprehensive assessment of cardiovascular risk factors using data from the China Stroke Primary Prevention Trial. Plasma lipid levels and total leukocyte, neutrophil, and lymphocyte counts were determined according to standard methods. Peripheral differential leukocyte counts were consistently and positively associated with serum total cholesterol (TC), LDL cholesterol (LDL-C), and TG levels (all P < 0.001 for trend), while inversely associated with HDL cholesterol levels (P < 0.05 for trend). In subsequent analyses where serum lipids were dichotomized (dyslipidemia/normolipidemia), we found that patients in the highest quartile of total leukocyte count (≥7.6 × 10⁹ cells/l) had 1.64 times the risk of high TG [95% confidence interval (CI): 1.46, 1.85], 1.34 times the risk of high TC (95% CI: 1.20, 1.50), and 1.24 times the risk of high LDL-C (95% CI: 1.12, 1.39) compared with their counterparts in the lowest quartile of total leukocyte count. Similar patterns were also observed with neutrophils and lymphocytes. In summary, these findings indicate that elevated differential leukocyte counts are directly associated with serum lipid levels and increased odds of dyslipidemia.

[Blood count results from hypertensive patients seen in laboratory of CHU-HJRB Antananarivo in 2013]

INTRODUCTION

The blood count is a routine laboratory test prescribed to patients suffering from high blood pressure. This study aims to describe the results of blood count from hypertensive patients and to identify conditions associated.

METHODS

This retrospective and descriptive study concerns the period from the 1st of December 2012 to 31 th of December 2013 in the laboratory of University Hospital Center CHU-HJRB of Antananarivo. All records of results from hypertensive patients who requested blood count have been exploited.

RESULTS

Among 151 hypertensive patients, 91 (60.3%) had pathological blood counts. Of these, 64 (70.4%) showed one type of abnormality and 27 (29.6%) had multiple abnormalities. The anaemia (33.91%), the leukocytosis (33.04%), the polycythemia (10.43%) and the leukopenia (9.57%) are the most frequent. Among the multiple abnormalities, anaemia associated with leukocytosis is the most observed (29.6%). The microcytosis anaemia (41%) and the neutrophil polymorphonuclear leukocytosis are the most dominant (47.4%). Patients in nephrology (90%) and in endocrinology (81.3%) are the most concerned (p = 0,008). Hypertensive under 20 years old (100%) and women (61.5%) are the most affected (p > 0, 05). The seizures (100%), the edema of the lower limbs (100%) and diabetes (70%) are the signs and pathology most encountered.

CONCLUSION

The blood count should be prescribed for all hypertensive patients to identify the affections that will be treated simultaneously with the high blood pressure. Thus, hypertensive patients will have a good follow-up and their life expectancy will be improved.

Relation of Plasma Fibrinogen Level With the Presence, Severity, and Complexity of Coronary Artery Disease

BACKGROUND

Relation of plasma fibrinogen levels with extent, severity, and complexity of coronary artery disease (CAD) in patients with stable angina pectoris (SAP) has not been adequately investigated. The aim of this study was to evaluate whether plasma fibrinogen level is associated with coronary complexity, severity, and extent assessed by SYNTAX (Synergy between percutaneous coronary intervention with TAXUS and Cardiac Surgery) score (SS).

METHODS

We enrolled 134 consecutive patients with SAP who underwent coronary angiography. Baseline serum fibrinogen levels were measured, and SS was calculated from the study population. The patients were classified into 3 groups by tertiles of SS (SS, control group = 0; intermediate group < 22; and high group ≥ 22).

RESULTS

Plasma fibrinogen levels demonstrated a stepwise increase from control group to high SS group. There was a strong correlation between fibrinogen and the SS ( r = .535, P < .001). Area under the receivers operating characteristic curve of fibrinogen was 0.72 (95% confidence interval [CI] 0.61-0.82; < .001) for predicting a high SS. Fibrinogen value higher than 411 mg/dL has a sensitivity of 75% and a specificity of 64% in prediction of high SS. In multivariate analyses, plasma fibrinogen was observed to be an independent predictor for high SS in patients with stable CAD (odds ratio [OR] 1.01; 95% CI, 1.01-1.02; P < .001).

CONCLUSION

Plasma fibrinogen is a readily measurable systemic inflammatory marker and is independently associated coronary severity and complexity in patients with CAD.

Anxiety and adverse health outcomes among cardiac patients: a biobehavioral model

BACKGROUND

Anxiety is a common experience among patients with acute coronary syndrome (ACS) that can have a negative impact on health outcomes. Nonetheless, the negative role of anxiety remains underappreciated, as reflected by clinicians' underrecognition and undertreatment of anxious hospitalized and nonhospitalized patients with ACS. Underappreciation of the role of anxiety is possibly related to inadequate understanding of the mechanisms whereby anxiety may adversely affect health outcomes.

PURPOSE

The aim of this study was to synthesize the evidence about potential mechanisms by which anxiety and adverse health outcomes are related.

CONCLUSIONS

A biobehavioral model links anxiety to the development of thrombogenic and arrhythmic events in patients with ACS. Biologically, anxiety may interfere with the immune system, lipid profile, automatic nervous system balance, and the coagulation cascade, whereas behaviorally, anxiety may adversely affect adoption of healthy habits and cardiac risk-reducing behaviors. The biological and behavioral pathways complement each other in the production of poor outcomes.

CLINICAL IMPLICATIONS

Anxiety requires more attention from clinical cardiology. The adverse impact of anxiety on health outcomes could be avoided by efficient assessment and treatment of anxiety.

A streamlined approach for assessing the Allostatic Load Index in industrial employees

Work stress is common and can lead to various bodily dysfunctions. The Allostatic Load Index (ALI) is a tool to measure the wear and tear of the body caused by chronic stress. This cross-sectional study aimed to explore the association of work-related stress and ALI in German industrial employees. A short form ALI should be developed for practical use of company physicians. In this exploration of an industrial cohort (n = 3797; 79.3% male), work stress was measured by the effort-reward imbalance (ERI) questionnaire in 2009-2011. ALI was calculated using 15 variables including anthropometric data, heart rate variability, as well as blood and urine samples based on predefined subclinical cut-off values. Differences in ALI related to low (≤1) and high (>1) ERI categories were tested. Logistic regression models estimated odds ratios (ORs) and corresponding 95% confidence intervals (CIs) for the association between ALI and work stress controlling for multiple confounders. Employees exposed to high work stress showed higher ALI scores (p < 0.001) compared to those with low stress levels. In multivariable models, ALI was associated with work stress (OR 1.19 [95% CI: 1.00, 1.42]; p < 0.05) following adjustment for a range of potential confounders. By reducing ALI parameters to five variables this association increased modestly and remained statistically significant (OR 1.27 [95% CI: 1.05, 1.54]; p < 0.05). The results indicate that work stress is associated with ALI in German industrial employees. A short form index seems to be a promising approach for occupational health practitioners. The results should be validated in further longitudinal explorations defining a standard set of variables including gender-related thresholds.

Association of fibrinogen with severity of stable coronary artery disease in patients with type 2 diabetic mellitus

Background. Some studies have suggested a relation of plasma fibrinogen to the severity of coronary artery disease (CAD). However, whether plasma fibrinogen can predict the presence and severity of CAD in patients with diabetes mellitus has not been determined. Methods. A total of consecutive 373 diabetic patients with typical angina pectoris who received coronary angiography were enrolled and classified into three groups by tertiles of Gensini score (GS, low group <8; intermediate group 8~28; high group >28). The relationship between fibrinogen and GS was evaluated. Results. There were correlations of fibrinogen with hemoglobin A1c, C-reactive protein, and GS (r = 0.17, r = 0.52, and r = 0.21, resp.; all P < 0.001). Area under the receivers operating characteristic curve of fibrinogen was 0.62 (95% CI 0.56–0.68, P < 0.001) for predicting a high GS. Multivariate analysis suggested that plasma fibrinogen was an independent predictor of a high GS for diabetic patients (OR = 1.40, 95% CI 1.04–1.88, and P = 0.026) after adjusting for traditional risk factors of CAD. Conclusions. The present data indicated that plasma fibrinogen, a readily measurable systematic inflammatory marker, appeared to be an independent predictor for the severity of CAD in diabetic patients.

Relation of leukocytes and its subsets counts with the severity of stable coronary artery disease in patients with diabetic mellitus

BACKGROUND

Both coronary artery disease (CAD) and diabetes mellitus (DM) are associated with inflammation. However, whether and which leukocytes can predict the presence and extent of CAD in patients with DM has not been investigated. The aim of the present study was to examine the association of leukocyte and its subsets counts with the severity of CAD in patients with DM.

METHODS AND FINDINGS

Three hundred and seventy-three diabetic patients who were scheduled for coronary angiography due to typical stable angina pectoris were enrolled in this study. They were classified into the three groups according to tertiles of Gensini score (GS, low group <8, n=143; intermediate group 8~28, n=109; high group >28, n=121). The relationship between the leukocyte and its subsets counts with the severity of CAD were evaluated. The data indicated that there were significant correlations between leukocyte and neutrophil counts with GS (r=0.154 and 0.156, respectively, all P<0.003 for Pearson's correlation). Similarly, area under the receivers operating characteristic curve of leukocyte and neutrophil counts were 0.61 and 0.60 respectively (95%CI: 0.55-0.67, all P=0.001) for predicting high GS. Multivariate logistic regression analysis demonstrated that leukocyte count was an independent predictor for high GS patients with DM (OR=1.20, 95%CI 1.03-1.39, P=0.023) after adjusting for conventional risk factors of CAD.

CONCLUSIONS

Compared with its subsets, leukocyte count appeared to be an independent predictor for the severity of CAD and the optimal cut-off value for predicting high GS (>28 points) was 5.0 × 10(9) cells/L in diabetic patients.

Endogenous serum erythropoietin and no-reflow in patients with ST-elevation myocardial infarction

BACKGROUND

In models of acute ischaemia, erythropoietin (EPO) administration has been found to attenuate vascular injury largely through reduced apoptosis, suppressed inflammation and increased nitric oxide availability. We studied the association between circulating endogenous EPO and no-reflow in patients with first ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI).

METHODS

Blood sampling was performed before PPCI. Consecutive patients with (n = 24) or without (n = 24) evidence of angiographic no-reflow after PPCI were enrolled. Angiographic no-reflow was defined as Thrombolysis in Myocardial Infarction (TIMI) flow ≤ 2 or as TIMI flow = 3 but with myocardial blush grade < 2. We also assessed electrocardiographic (ECG) no-reflow as ≤ 50% resolution of maximal ST elevation 60 min after PPCI.

RESULTS

Baseline characteristics did not correlate significantly with EPO concentrations. In contrast, both angiographic and ECG no-reflow correlated with lower EPO levels at univariate analysis [median (interquartile): 4·2 (0·6-9·5) vs. 12·2 (5·2-20·3) mIU mL(-1), P = 0·001, and 4·0 (0·6-7·1) vs. 9·3 (1·0-12·6) mIU mL(-1), P = 0·01, respectively]. At multivariable analysis, decreasing EPO tertiles and left anterior descending as the infarct-related artery were the only factors that predicted both angiographic and ECG no-reflow (P = 0·017 and P = 0·02 for EPO; P < 0·005 and P > 0·05 for left anterior descending artery, respectively).

CONCLUSIONS

We found an independent, graded, inverse relation between endogenous EPO levels and angiographic and ECG no-reflow following PPCI. In animal models of ischaemia, EPO has been found to be protective. In humans, endogenous EPO may contribute to offset the mechanisms responsible for no-reflow.

White blood cell subsets are associated with carotid intima-media thickness and pulse wave velocity in an older Chinese population: the Guangzhou Biobank Cohort Study

Cross-sectional associations between white blood cell (WBC) count, lymphocyte and granulocyte numbers, and carotid intima-media thickness (IMT) and brachial-ankle pulse wave velocity (PWV) were examined in a novel older Chinese community sample. A total of 817 men and 760 women from a sub-study of the Guangzhou Biobank Cohort Study had a full blood count measured by an automated hematology analyzer, carotid IMT by B-mode ultrasonography and brachial-ankle PWV by a non-invasive automatic waveform analyzer. Following adjustment for confounders, WBC count (β=0.07, P<0.001) and granulocyte (β=0.07, P<0.001) number were significantly positively related to PWV, but not lymphocyte number. Similarly, WBC count (β=0.08, P=0.03), lymphocyte (β=0.08, P=0.002) and granulocyte (β=0.03, P=0.04) number were significantly positively associated with carotid IMT, but only the association with lymphocyte count survived correction for other cardiovascular risk factors. In conclusion, higher WBC, particularly lymphocyte and granulocyte, count could be used, respectively, as markers of cardiovascular disease risk, measured through indicators of atherosclerosis and arterial stiffness. The associations for WBC count previously observed by others were likely driven by higher granulocytes; an index of systemic inflammation.

Immune responses after acute ischemic stroke or myocardial infarction

BACKGROUND

We recently demonstrated an immediate immunodepressive state after acute ischemic stroke in humans.

METHODS

In the present study, we prospectively analyzed immune responses in patients with middle cerebral artery stroke (n=20), acute myocardial infarction (n=20) and healthy controls (n=20, also matched for age and gender).

RESULTS

Compared to controls, a rapid depression of monocytic HLA-DR expression and a defective lymphocytic IFN-γ production was obvious after ischemic stroke or myocardial infarction, while total counts of leukocytes and monocytes were significantly higher after myocardial infarction. A T cell-mediated lymphopenia was accentuated in patients with severe stroke, obviously predisposing these patients for nosocomial infections.

CONCLUSIONS

Our data reveal an immediate and to some extent differential suppression of cell-mediated immune responses after ischemic stroke or myocardial infarction respectively.

Post-reperfusion lymphopenia and microvascular obstruction in ST-segment elevation acute myocardial infarction

INTRODUCTION AND OBJECTIVES

The presence of microvascular obstruction after ST-segment elevation acute myocardial infarction is associated with a poor outcome. The pathophysiology of this process has not been fully defined. The aim of this study was to investigate the relationship between post-reperfusion lymphopenia and microvascular obstruction.

METHODS

This prospective study involved 212 patients with a first ST-segment elevation acute myocardial infarction who underwent reperfusion with thrombolytic agents or primary angioplasty and who had an open infarct-related artery. Serial measurements of lymphocyte, neutrophil and monocyte counts were taken. Cardiac magnetic resonance was used to detect microvascular obstruction during the first week after the infarction. Imaging was repeated 6 months after infarction.

RESULTS

Microvascular obstruction was observed in 67 patients (32%). A post-reperfusion lymphocyte count <1800 cells/ml was associated with a higher risk of microvascular obstruction (44% versus 20%; P< .001) as well as with a low left ventricular ejection fraction and large left ventricular volumes (P< .05). After adjustment for baseline characteristics, ECG findings, necrosis marker levels and angiographic variables, multivariate analysis showed that a post-reperfusion lymphocyte count <1800 cells/ml was independently associated with an increased risk of microvascular obstruction (odds ratio=3.2; 95% confidence interval 1.6-6.3; P< .001).

CONCLUSIONS

In ST-segment elevation myocardial infarction, post-reperfusion lymphopenia is an early and powerful predictor of the presence of microvascular obstruction. The pathophysiological and therapeutic implications of this association require further study.

Clinical implications of cytokines in the critical-care unit

To understand the role of different cytokines in the pathophysiology and management of different acute cardiovascular disorders in critically ill patients, we reviewed most of the pertinent articles published on Medline, Scopus and EBSCO host research databases from 1985 to January 2009. We used the indexing terms 'cytokines', 'cardiovascular', 'sepsis', 'critical care', 'myocardial dysfunction', 'shock', 'thromboembolism', 'inflammatory' and 'arrhythmias'. Myocardial dysfunction, dysrhythmic and thromboembolic disorders all appear associated with important fluctuations in cytokines. When and how to sample cytokine levels and the ways in which cytokines contribute to patient deterioration or improvement require further clinical studies. The measurement and interplay of several different cytokines may ultimately be of substantial clinical importance in the diagnosis, treatment and prognosis of patients with different acute cardiovascular disorders managed by critical-care physicians in intensive-care units. Although the role of cytokines in cardiovascular disorders is debatable, the clinical implication of cytokines in the critical-care unit is a new horizon that warrants more attention.

Relationship between low lymphocyte count and major cardiac events in patients with acute chest pain, a non-diagnostic electrocardiogram and normal troponin levels

OBJECTIVE

Risk stratification of patients with acute chest pain, non-diagnostic electrocardiogram and normal troponin (ACPneg) remains a challenge, partly because no standardized set of biomarkers with prognostic ability has been identified in this population. Lymphopenia has been associated with atherosclerosis progression and adverse outcomes in cardiovascular diseases; although its prognostic value in ACPneg is unknown. We sought to determine the relationship between the lymphocyte count obtained in the Emergency Department (ED) and the risk of the long-term all-cause mortality or myocardial infarction (MI) in patients with ACPneg.

METHODS

We analyzed 1030 consecutive patients admitted with ACPneg in our institution. Lymphocyte count was determined in the ED as a part of a routine diagnostic workup to rule out an acute coronary syndrome. Patients with inflammatory, infectious diseases, or active malignancy were excluded (final sample=975). The independent association between lymphocyte count and the composite endpoint (death/MI) was assessed by survival analysis for competing risk events (revascularization procedures).

RESULTS

During a median follow-up of 36 months, 139 (14.3%) patients achieved the combined endpoint, with rates increasing monotonically across lymphocyte quartiles (6.2%, 10%, 20.6% and 24.1% for Q4, Q3, Q2 and Q1 (p<0.001), respectively). In a multivariable analysis, patients in lymphocytes' Q1 and Q2 as compared with those in Q4 had an increased risk for the combined endpoint: HR=2.45 (CI 95% 1.25-4.79, p=0.008) and HR=2.56 (CI 95% 1.30-5.07, p=0.007), respectively.

CONCLUSION

In patients with ACPneg, low lymphocytes count was associated with an increased risk for developing the combined endpoint of death or MI.

Alterations in biomarkers of cardiovascular disease (CVD) in active acromegaly

OBJECTIVES

In acromegalic patients, cardiovascular and metabolic comorbidities contribute to enhance mortality. Available data on the lipoprotein profile of these patients are controversial. Our aim was to characterize the lipoprotein profile and emergent biomarkers of cardiovascular disease in active acromegalic patients in comparison with sex- and age-matched healthy controls.

PATIENTS

Eighteen patients with active acromegaly and 18 controls were studied.

MEASUREMENTS

Glucose levels, hormonal status, lipoprotein profile and C reactive protein (CRP) were evaluated by standardized methods. Cholesteryl ester transfer protein (CETP) and lipoprotein-associated phospholipase A(2 )(Lp-PLA(2)) were measured by radiometric techniques, endothelin-1 and vascular cell adhesion molecule (VCAM)-1 by enzyme-linked immunosorbent assay, and leucocytes CD18, CD49d and CD54 by flow cytometry.

RESULTS

After adjusting for body mass index (BMI), acromegalic patients presented a more atherogenic lipoprotein profile, consisting of higher levels of triglycerides and apolipoprotein B and alterations in the ratios which estimate insulin resistance and atherogenic risk. CETP activity was significantly increased in acromegalic patients as compared to controls (168 +/- 17 vs. 141 +/- 30% per ml h, respectively; P < 0.05). Endothelin-1 levels evidenced an increase in the patients' group (0.9 +/- 0.2 vs. 0.7 +/- 0.2 ng/l, respectively; P < 0.01) and showed positive and significant correlations with GH, IGF-1 and IGFBP-3 (r = 0.45, 0.42 and 0.44, respectively; P < 0.01 for all of them; with BMI as a fixed variable). Lymphocytes from acromegalic patients showed increased CD49d content (282 +/- 59 vs. 246 +/- 48 arbitrary units, respectively; P < 0.05).

CONCLUSIONS

Taken together, the alterations described seem to contribute to constituting a state of higher propensity for the development of atherosclerotic cardiovascular disease, which adds to the presence of specific cardiomyopathy.

Uncontrolled immune response in acute myocardial infarction: unraveling the thread

Recently, the theory that hyperinflammation is the body's primary response to potent stimulus has been challenged. Indeed, a deregulation of the immune system could be the cause of multiple organ failure. So far, clinicians have focused on the last steps of the inflammatory cascade. However, little attention has been paid to lymphocytes, which play an important role as strategists of the inflammatory response. Experimental evidence suggests a crucial role of T lymphocytes in the pathophysiology of atherosclerosis and acute myocardial infarction (AMI). In summary, from the bottom of an imaginary inverted pyramid, a few regulatory T-cells control the upper parts represented by the wide spectrum of the inflammatory cascade. In AMI, a loss of regulation of the inflammatory system occurs in patients with a decreased activity of regulatory T-cells. As a consequence, aggressive T-cells boost and anti-inflammatory T-cells drop. A pleiotropic proinflammatory imbalance with damaging effects in terms of left ventricular performance and patient outcome is the result of this uncontrolled immune response. It is needed to unravel the thread of the inflammatory cells to better understand the pathophysiology as well as to open innovative therapeutic options in AMI.