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Neutrophil/lymphocyte ratio is associated with right ventricular dysfunction in patients with acute inferior ST-segment elevation myocardial infarction

BACKGROUND Acute inferior ST-segment elevation myocardial infarction (STEMI) is associated with increased in-hospital morbidity and mortality particularly among patients with coexisting right ventricular (RV) involvement. High neutrophil to lymphocyte ratio (NLR) is an independent predictor of major adverse cardiac events and mortality in patients with myocardial infarction. This study evaluated the relationship between the NLR and RV dysfunction (RVD) in patients with inferior STEMI who underwent primary percutaneous coronary intervention (PCI). METHODS A total of 213 subjects with inferior STEMI were divided into two groups according to the presence of RVD. The groups were compared according to NLR and receiver operating characteristic (ROC) analysis was performed to access the predictability of NLR on having RVD. RESULTS The NLR was significantly higher in the group with RVD compared to that without RVD (p < 0.001). In ROC analysis, NLR > 3.5 predicted RVD with sensitivity of 83% and specificity of 55%. In a multivariate regression analysis, NLR remained an independent predictor of RVD (OR 1.55, 95% CI 1.285-1.750, p < 0.001). CONCLUSIONS NLR was an independent predictor of RVD in patients with inferior STEMI undergoing primary PCI.

The effects of hyperoxaemia on tissue oxygenation in patients with a nadir haematocrit lower than 20% during cardiopulmonary bypass

Excessive haemodilution and the resulting anaemia during CPB is accompanied by a decrease in the total arterial oxygen content, which may impair tissue oxygen delivery. Hyperoxic ventilation has been proven to improve tissue oxygenation in different pathophysiological states of anaemic tissue hypoxia. The aim of this study was to examine the influence of arterial hyperoxaemia on tissue oxygenation during CPB. Records of patients undergoing isolated CABG with CPB were retrospectively reviewed. Patients with nadir haematocrit levels below 20% during CPB were included in the study. Tissue hypoxia was defined as hyperlactataemia (lactate >2.2 mmol/L) coupled with low ScVO2 (ScVO2 <70%) during CPB. One hundred patients with normoxaemia and 100 patients with hyperoxaemia were included in the study. Patients with hyperoxaemia had lower tissue hypoxia incidence than patients with normoxaemia (p<0.001). Compared with patients without tissue hypoxia, patients with tissue hypoxia had significantly lower PaO2 values (p<0.001) and nadir haematocrit levels (p<0.001). Nadir haematocrit levels <18% (OR: 5.3; 95% CI: 2.67–10.6; p<0.001) and hyperoxaemia (OR: 0.28; 95% CI: 0.14–0.56; p<0.001) were independently associated with tissue hypoxia. Conclusions: Hyperoxaemia during CPB may be protective against tissue hypoxia in patients with nadir haematocrit levels <20%.

The association between prolongation in QRS duration and presence of coronary collateral circulation in patients with acute myocardial infarction

Background It is known that QRS duration is related to prognosis in acute myocardial infarction. The relation between QRS duration and coronary collateral circulation is uncertain. In the present study, we aimed to determine the relation between QRS duration and coronary collateral circulation in patients admitted with acute myocardial infarction. Methods The present study was composed of 109 consecutive patients with acute myocardial infarction. All patients had total occlusion in the left anterior descending coronary artery. Electrocardiographic recordings on admission were obtained for the assessment of QRS duration. The Rentrop classification was used to define coronary collateral circulation on coronary angiography. Patients were divided into two groups as follows: Group 1 with poor coronary collateral circulation (Rentrop 0–1) and Group 2 with good coronary collateral circulation (Rentrop 2–3). Results Of all patients, 62 patients were included in group 1 and 47 patients in group 2, respectively. In the present study, patients in the group 1 had longer QRS duration than patients in the group 2 (p < 0.005). Additionally, we found that Rentrop grading had negative correlation with both QRS duration and white blood cell count (r: −0.28; p < 0.005 and r: −0.35; p < 0.001). Conclusion Our study showed that there was an inverse relationship between QRS duration on admission and presence of coronary collateral circulation in patients with acute myocardial infarction.

Response to the letter regarding the article "Neutrophil/lymphocyte ratio is associated with right ventricular dysfunction in patients with acute inferior ST-elevation myocardial infarction".

Thank you for the opportunity to reply to comments [1] related to our article “Neutrophil/ /lymphocyte ratio is associated with right ventricular dysfunction in patients with acute inferior ST-elevation myocardial infarction” [2]. We are very honored to gather feedback on our work. In acute phase, it was shown that the mortality was reduced following percutanous intervention or fibrinolytic therapy in patients with acute inferior ST elevation myocardial infarction (STEMI) involving right ventricle (RV) [3, 4]. However, deaths and right-sided heart failure due to RV myocardial infarction are very rare in long-term [5, 6]. Thus, we aimed to search short-term (in-hospital) effects of RV myocardial infarction on mortality via measuring neutrophil/lymphocyte ratio (NLR). Although there are several methods described to define RV dysfunction, such as catheterization, magnetic resonance imaging, echocardiography is the simplest and easiest to apply in acute setting. To define RV involvement, we preferred to use tricuspid annular plane systolic excursion (TAPSE) levels in accordance with the guidelines [7], since it is easily and quickly measured in acute inferior STEMI setting without significant interobserver difference. Additionally we confirmed RV involvement with RV fractional area change which is smaller in patients with RV dysfunction. Thus, considering TAPSE to define RV dysfunction is methodologically acceptable. It is known that NLR value and number of leukocyte subgroups can differ according to time and the type of the tubes used for blood sample. However, there was no significant time difference between the groups in respect to time of admission and timing of blood sample collection. Additionally, complete blood count parameters were measured by a hematology analyzer immediately after sampling. Thus, time effect on our results is not valid. Also, all blood samples were carried to hematology analyzer in identical standardized tubes. Exclusion criteria of our study included all clinical conditions which can possibly affect NLR, such as cancer, presence of active infection, chronic pulmonary disease, pulmonary hypertension, malignancy, end-stage liver disease, renal failure and past history of a systemic inflammatory process. Thus, the results can be attributed to acute myocardial infarction itself. It is known that dehydration can lead to a change in NLR but there is no clear-cut measure to show dehydration or overhydration. Still, inferior vena cava diameter can be used to reflect hydration status. In our study, all patients had inferior vena cava diameter of > 12 mm which is an indirect indicator for absence of dehydration [6]. Thus, we can conclude that our results are free of dehydration effect of NLR. Additionally, inferior vena cava plethora in patients with RV dysfunction was more pronounced than in patients without RV dysfunction and this finding also indirectly reflects the increased right atrial pressure due to RV dysfunction. Even though red cell distribution width (RDW) is an emerging parameter related to the inflammation, the clinical role of RDW in the evaluation of cardiovascular events has not been confirmed in randomized clinical trials. We didn not think that addition of RDW along with NLR would contribute to findings of our study, thus it was not included. According to our results, one can easily be aware of the fact that NLR values over 3.5 have significant clinical implication. This finding implied that RV involvement along with acute inferior STEMI induces higher level of inflammatory state including higher number of neutrophils and higher level of stress with more steroid production. Increased steroid level causes suppressed lymphocyte production in bone marrow. This pathophysiological mechanism implies that higher level RV involvement contributes to more significant NLR increase. In respect to other inflammatory markers, such as C-reactive protein, myeloperoxidase and CLINICAL CARDIOLOGY