Gianni Turcato

Red blood cell distribution width independently predicts medium-term mortality and major adverse cardiac events after an acute coronary syndrome.

BACKGROUND The value of red blood cell distribution width (RDW), a simple and inexpensive measure of anisocytosis, has been associated with the outcome of many human chronic disorders. Therefore, this retrospective study was aimed to investigate whether RDW may be associated with medium-term mortality and major adverse cardiac events (MACE) after an acute coronary syndrome (ACS). METHODS A total number of 979 patients diagnosed with ACS were enrolled from June 2014 to November 2014, and followed-up until June 2015. RESULTS The RDW value in patients with 3-month MACE and in those who died was significantly higher than that of patients without 3-month MACE (13.3% vs. 14.0%; P<0.001) and those who were still alive at the end of follow-up (13.4% vs. 14.4%; P<0.001). In univariate analysis, RDW was found to be associated with 3-month MACE [odds ratio (OR), 1.70; 95% CI, 1.44-2.00, P<0.001]. In multivariate analysis, RDW remained independently associated with 3-month MACE (adjusted OR, 1.36; 95% CI, 1.19-1.55; P<0.001) and death (adjusted OR, 1.34; 95% CI, 1.05-1.71; P=0.020). The accuracy of RDW for predicting 3-month MACE was 0.67 (95% CI, 0.66-0.72; P<0.001). The most efficient discriminatory RDW value was 14.8%, which was associated with 3.8 (95% CI, 2.6-5.7; P<0.001) higher risk of 3-month MACE. Patients with RDW >14.8% exhibited a significantly short survival than those with RDW ≤14.8% (331 vs. 465 days; P<0.001). CONCLUSIONS The results of this study confirm that RDW may be a valuable, easy and inexpensive parameter for stratifying the medium-term risk in patients with ACS.

Red Blood Cell Distribution Width Is an Independent Predictor of Outcome in Patients Undergoing Thrombolysis for Ischemic Stroke

&NA; An appropriate and timely management, including early diagnosis and accurate prognostication, is the mainstay for managed care of patients with acute ischemic stroke. Since red blood cell distribution width (RDW) was found to be an independent predictor of clinical outcomes in patients with thrombotic disorders, we designed a retrospective observational study to investigate whether the RDW value may also retain predictive significance in stoke patients undergoing thrombolytic therapy. This retrospective study was based on all patients admitted to the Emergency Department (ED) of the University Hospital of Verona (Italy) with a diagnosis of ischemic stroke, who underwent systemic thrombolysis between January 2013 and June 2015. The RDW value along with basal clinical characteristics was recorded at ED admission. The final study population consisted of 316 patients. A significant association was found between stroke severity (NIHSS score) and RDW (r = 0.322; p < 0.001). The median RDW value in patients with clinical improvement after thrombolysis was significantly lower than in patients without (13.4 vs. 14.1%; p < 0.001). The diagnostic accuracy (area under the curve) of RDW for predicting the lack of neurological improvement was 0.667. In univariate analysis, RDW >14.5% was associated with increased rate of no neurological improvement (odds ratio [OR], 2.38; 95% confidence interval [CI], 1.37‐4.13), an association remaining significant also in multivariate analysis (OR, 1.85; 95% CI, 1.13‐3.32). Survivor curve analysis showed that patients with RDW values ≥14.5% had a higher risk of 1‐year mortality and shorter survival. These results suggest that RDW assessment at ED admission may provide valuable diagnostic and prognostic information in patients with acute ischemic stroke.

Early in-hospital variation of red blood cell distribution width predicts mortality in patients with acute heart failure

BACKGROUND Some studies showed that the value of red blood cell distribution width (RDW) at admission may predict clinical outcomes in patients with acutely decompensated heart failure (ADHF). Therefore, this study was planned to investigate whether in-hospital variations of RDW may also predict mortality in this condition. METHODS The final study population consisted of 588 patients admitted to the local Emergency Department (ED), who were hospitalized for ADHF. The RDW was measured at ED admission and after 48h and 96h of hospital stay. In-hospital variations from admission value, expressed as absolute variation (DeltaRDW) or percent variation (Delta%RDW), were then correlated with 30- and 60-day mortality. RESULTS Overall, 87 (14.8%) and 118 (20.1%) patients with ADHF died at 30 or 60days of follow-up. Delta%RDW after 96h of hospital stay independently predicted 30-day mortality (odds ratio, 1.12; 95% CI, 1.07-1.18). An increase >1% of Delta%RDW after 96h of hospital stay independently predicted both 30-day (odds ratio, 2.86; 95% CI, 1.67-4.97) and 60-day (odds ratio, 3.06; 95% CI, 1.89-4.96) mortality. A similar trend was observed for DeltaRDW, since an increase after 96h of hospital stay was associated with a nearly 4-fold higher 30-day mortality (odds ratio, 3.65; 95% CI, 2.02-6.15). CONCLUSION Despite it remains unclear whether RDW is a real risk factor or an epiphenomenon in ADHF, these results suggest that more aggressive management may be advisable in ADHF patients with increasing anisocytosis during the first days of hospitalization.

STARTING-SICH Nomogram to Predict Symptomatic Intracerebral Hemorrhage After Intravenous Thrombolysis for Stroke

Background and Purpose— Symptomatic intracerebral hemorrhage (sICH) is a rare but the most feared complication of intravenous thrombolysis for ischemic stroke. We aimed to develop and validate a nomogram for individualized prediction of sICH in intravenous thrombolysis–treated stroke patients included in the multicenter SITS-ISTR (Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register). Methods— All patients registered in the SITS-ISTR by 179 Italian centers between May 2001 and March 2016 were originally included. The main outcome measure was sICH per the European Cooperative Acute Stroke Study II definition (any type of intracerebral hemorrhage with increase of ≥4 National Institutes of Health Stroke Scale score points from baseline or death <7 days). On the basis of multivariate logistic model, the nomogram was generated. We assessed the discriminative performance by using the area under the receiver-operating characteristic curve and calibration of risk prediction model by using the Hosmer–Lemeshow test. Results— A total of 15 949 patients with complete data for generating the nomogram was randomly dichotomized into training (3/4; n=12 030) and test (1/4; n=3919) sets. After multivariate logistic regression, 10 variables remained independent predictors of sICH to compose the STARTING-SICH (systolic blood pressure, age, onset-to-treatment time for thrombolysis, National Institutes of Health Stroke Scale score, glucose, aspirin alone, aspirin plus clopidogrel, anticoagulant with INR ⩽1.7, current infarction sign, hyperdense artery sign) nomogram. The area under the receiver-operating characteristic curve of STARTING-SICH was 0.739. Calibration was good (P=0.327 for the Hosmer–Lemeshow test). Conclusions— The STARTING-SICH is the first nomogram developed and validated in a large SITS-ISTR cohort for individualized prediction of sICH in intravenous thrombolysis–treated stroke patients.

The START nomogram for individualized prediction of the probability of unfavorable outcome after intravenous thrombolysis for stroke

Background and purpose The nomogram is an important component of modern medical decision-making, which calculates the probability of an event entirely based on individual characteristics. We aimed to develop and validate a nomogram for individualized prediction of the probability of unfavorable outcome in intravenous thrombolysis-treated stroke patients included in the large multicenter Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register. Methods All patients registered in the Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register by 179 Italian centers between May 2001 and March 2016 were originally included. The main outcome measure was three-month unfavorable outcome (modified Rankin Scale 3–6). Four non-categorical predictors of unfavorable outcome (baseline National Institutes of Health (NIH) Stroke Scale score: 0–25, age ≥18 years, pre-stroke modified Rankin Scale score: 0–2, and onset-to-treatment time: 0–270 min) were identified a-priori by three neurologists with expertise in the management of stroke. To generate the NIHSS STroke Scale score, Age, pre-stroke mRS score, onset-to-treatment Time (START), the pre-established predictors were entered into a logistic regression model. The discriminative performance of the model was assessed using the area under the receiver operating characteristic curve. Results A total of 15,862 patients with complete data for generating the START was randomly dichotomized into training (2/3, n = 10,574) and test (1/3, n = 5288) sets. The area under the receiver operating characteristic curve of START was 0.800 (95% confidence interval: 0.792–0.809) in the training set and 0.815 (95% confidence interval: 0.804–0.822) in the test set. Conclusions By using a limited number of non-categorical predictors, the START is the first nomogram developed and validated in a large Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register cohort, which reliably calculates the probability of unfavorable outcome in intravenous thrombolysis-treated stroke patients.

Red blood cell distribution width in heart failure: A narrative review

The red blood cell distribution width (RDW) is a simple, rapid, inexpensive and straightforward hematological parameter, reflecting the degree of anisocytosis in vivo. The currently available scientific evidence suggests that RDW assessment not only predicts the risk of adverse outcomes (cardiovascular and all-cause mortality, hospitalization for acute decompensation or worsened left ventricular function) in patients with acute and chronic heart failure (HF), but is also a significant and independent predictor of developing HF in patients free of this condition. Regarding the biological interplay between impaired hematopoiesis and cardiac dysfunction, many of the different conditions associated with increased heterogeneity of erythrocyte volume (i.e., ageing, inflammation, oxidative stress, nutritional deficiencies and impaired renal function), may be concomitantly present in patients with HF, whilst anisocytosis may also directly contribute to the development and worsening of HF. In conclusion, the longitudinal assessment of RDW changes over time may be considered an efficient measure to help predicting the risk of both development and progression of HF.

A nomogram to predict the probability of mortality after first-ever acute manifestations of cerebral small vessel disease

BACKGROUND AND PURPOSE Symptomatic lacunar stroke (LS) and deep intracerebral hemorrhage (dICH) represent the acute manifestations of type 1 cerebral small vessel disease (cSVD). Recently, two studies showed that the risk factor profile of dICH differs from that associated with LS in subjects with biologically plausible cSVD; however, the prognostic predictors after acute manifestations are currently lacking. We aimed to develop a nomogram for individualized prediction of the mortality probability in a cohort of patients with a first-ever acute manifestation of biologically plausible cSVD. METHODS We conducted a retrospective analysis of data collected from consecutive patients with acute symptomatic non-embolic LS or primary dICH. The outcome measure was 3-month mortality. Based on multivariate logistic model, the nomogram was generated. RESULTS Of the 288 patients who entered into the study for biologically plausible cSVD, 131 (45%) experienced a LS and 157 (55%) a dICH. After multivariate logistic regression, 5 variables remained predictors of mortality to compose the nomogram: dICH (OR:11.36; p=0.001), severe presentation (OR:8.08; p<0.001), age (OR:1.08; p=0.001), glucose (OR:1.23; p=0.003) and creatinine (OR:1.01; p=0.024) at admission were predictors of mortality. The discriminative performance of nomogram assessed by using the area under the receiver operating characteristic curve (AUC-ROC) was 0.898. The model was internally validated by using bootstrap (1000 samples) with AUC-ROC of 0.895 and cross-validation (deleted-d method repeated 1000 times) with AUC-ROC of 0.895. CONCLUSIONS We developed the first nomogram for prediction of the mortality probability in a cohort of patients with a first-ever acute manifestation of biologically plausible cSVD.

Association between short- and medium-term air pollution exposure and risk of mortality after intravenous thrombolysis for stroke

The exposure to air pollutants may increase both incidence and mortality of stroke. We aimed to investigate the association of short- and medium-term exposure to particulate matter (PM) and nitrogen dioxide (NO2) with the outcome of intravenous thrombolysis (IVT) for stroke. We conducted a retrospective analysis based on data prospectively collected from 944 consecutive IVT-treated stroke patients. The main outcome measure was 3-month mortality. The secondary outcome measures were causes of neurological deterioration (≥ 1 NIHSS point from baseline or death < 7 days), including intracerebral hemorrhage, cerebral edema (CED), and persistence or new appearance of hyperdense cerebral artery sign. In the adjusted model, higher PM2.5 and PM10 values in the last 3 days and 4 weeks before stroke were independently associated with higher mortality rate [hazard ratio (HR) 1.014, 95% confidence intervals (CI) 1.005–1.024, p = 0.003; HR 1.079, 95% CI 1.055–1.103, p = 0.001; HR 1.019, 95% CI 1.005–1.032, p = 0.008; and HR 1.015, 95% CI 1.004–1.027, p = 0.007; respectively]. Higher PM2.5 and PM10 values in the last 4 weeks were associated with higher CED rate [odd ratio (OR) 1.023, 95% CI 1.007–1.040, p = 0.006; and OR 1.017, 95% CI 1.003–1.032, p = 0.021; respectively]. No significant association between PM or NO2 and other causes of neurological deterioration was observed. Higher exposure to PM in the last 3 days and 4 weeks before stroke may be independently associated with 3-month mortality after IVT. Higher exposure to PM in the last 4 weeks before stroke may also be independently associated with CED after IVT.

Association of Short- and Medium-Term Particulate Matter Exposure with Risk of Mortality after Spontaneous Intracerebral Hemorrhage

OBJECTIVE We investigated the association of short- and medium-term particulate matter (PM) exposure with risk of mortality in patients with spontaneous intracerebral hemorrhage (ICH) identified according to strict etiologic criteria. METHODS We conducted a retrospective analysis of prospectively collected data from consecutive patients with spontaneous ICH admitted to the emergency department of the University Hospital of Verona from March 2011 to December 2014. Outcome measures were mortality within 1 month after ICH and significant hematoma expansion (HE) defined as an absolute growth of more than 12.5 mL or a relative increase of more than 50% from baseline to follow-up computed tomography scan. RESULTS A final number of 308 patients were included. In the adjusted model, higher PM2.5 and PM10 values in the last 3 days (odds ratio [OR] 1.827, 95% confidence interval [CI] 1.057-3.159, P = .031 and OR 1.949, 95% CI 1.025-3.704, P = .042, respectively) and in the last 4 weeks (OR 4.975, 95% CI 2.174-11.381, P < .001 and OR 9.781, 95% CI 3.425-27.932, P < .001, respectively) before ICH were associated with higher mortality rate. No association was found between PM exposure and significant HE. CONCLUSIONS PM exposure in the short- and medium-term before spontaneous ICH was associated with risk of 1-month mortality, independent of predictors such as age, sex, stroke severity, intraventricular hemorrhage, ICH volume, ICH location, ICH etiologic subtype, significant HE, antithrombotic therapy, atrial fibrillation, and blood glucose levels.

Red Blood Cell Distribution Width Improves Reclassification of Patients Admitted to the Emergency Department with Acute Decompensated Heart Failure

Summary The usual history of chronic heart failure (HF) is characterized by frequent episodes of acute decompensation (ADHF), needing urgent management in the emergency department (ED). Since the diagnostic accuracy of routine laboratory tests remains quite limited for predicting short-term mortality in ADHF, this retrospective study investigated the potential significance of combining red blood cell distribution width (RDW) with other conventional tests for prognosticating ADHF upon ED admission. We conducted a retrospective study including visits for episodes of ADHF recorded in the ED of the Uni versity Hospital of Verona throughout a 4-year period. Demo - graphic and clinical features were recorded upon patient presentation. All patients were subjected to standard Chest X-ray, electrocardiogram (ECG) and laboratory testing in - cluding creatinine, blood urea nitrogen, B-type natriuretic peptide (BNP), complete blood cell count (CBC), sodium, chloride, potassium and RDW. The 30-day overall mortality after ED presentation was defined as primary endpoint. Results: The values of sodium, creatinine, BNP and RDW were higher in patients who died than in those who survived, whilst hypochloremia was more frequent in patients who died than in those who survived. The multivariate model, incorporating these parameters, displayed a modest efficiency for predicting 30-day mortality after ED admission (AUC, 0.701; 95% CI, 0.662-0.738; p=0.001). Notably, the inclusion of RDW in the model significantly enhanced prediction efficiency, with an AUC of 0.723 (95% CI, 0.693-0.763; p<0.001). These results were confirmed with net reclassification improvement (NRI) analysis, showing that combination of RDW with conventional laboratory tests resulted in a much better prediction performance (net reclassification index, 0.222; p=0.001). The results of our study show that prognostic assessment of ADHF patients in the ED can be significantly improved by combining RDW with other conventional laboratory tests.