Thrombosis Research 134 (2014) 976979

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Thrombosis Research
journal homepage: www.elsevier.com/locate/thromres

Regular Article

Red Blood Cell Distribution Width (RDW) and long-term survival in

patients with ST Elevation Myocardial Infarction
Yaron Arbel a,, Yacov Shacham a, Ariel Finkelstein a, Amir Halkin a, Assi Milwidsky b, Shlomo Berliner b,
Tomer Ziv-Baran c, Miri Revivo a, Itzhak Herz a, Gad Keren a, Shmuel Banai a
a
Department of Cardiology, Tel Aviv Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
b
Department of Internal Medicine D + E, Tel Aviv Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
c
Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: High RDW values are associated with adverse prognosis in many clinical conditions including short
Received 16 June 2014 and medium term outcome of patients with ST Elevation Myocardial Infarction (STEMI). The aim of the present
Received in revised form 12 August 2014 study was to evaluate the association between RDW and long term mortality in STEMI patients undergoing
Accepted 19 August 2014 primary angioplasty (PPCI).
Available online 29 August 2014
Material and methods: A cohort of 535 STEMI patients undergoing PPCI were divided into two groups (RDW N14%,
RDW 14%) using CHAID and CART methods. The association between RDW and 5-year all-cause mortality was
Keywords:
RDW
assessed using Coxs proportional hazards analysis.
Outcome Results: A total of 37 patients died during follow up of 5 years (mean: 1059, median: 1013, range 22130 days).
ST elevation myocardial infarction RDW N14% was associated with increased risk of all-cause mortality (HR = 5, CI 95% 2.7 9.9, p b 0.001). In
mortality multivariate analysis, RDW N 14 remained signicantly associated with increased risk for all-cause mortality
(HR = 3.8, CI 95% 1.8 7.99, p b 0.001). Patients with RDW above 14% did not have lower ejection fraction, higher
CPK or more conventional risk factors.
Conclusion: RDW value above 14 is independently associated with increased long term all-cause mortality in
patients with STEMI undergoing PPCI.
2014 Elsevier Ltd. All rights reserved.

Introduction
Red blood cell distribution width (RDW) is a numerical measure of
the variability in size of circulating erythrocytes. The normal RDW
range in human red blood cells is 1215%. Higher RDW values indicate
greater variation in size. High RDW has been shown to predict adverse
outcome in various clinical conditions [16]. In patients with ST eleva-
tion myocardial infarction (STEMI), elevated RDW has been associated
with adverse outcome at short and medium term follow up [7,8].
However RDW cutoffs used were outside the normal limit. In addition,
there are no studies evaluating RDW and its association with long
term survival. The mechanism underlying this phenomenon is not
entirely understood. It has been suggested that patients with elevated
RDW values have more bone marrow dysfunction and ineffective
erythropoiesis [5] and increased inammatory markers, such as soluble
tumor necrosis factor (TNF) receptors and C-reactive protein (CRP)
[911].
Corresponding author at: Interventional Cardiology, Tel Aviv Medical Center, 6
Weizman Street, Tel Aviv 64239, Israel. Tel.: +972 3 6973395; fax: +972 3 6962334.
E-mail address: yarona@tlvmc.gov.il (Y. Arbel).
The aim of the present study was to evaluate the signicance of RDW
in predicting long term all-cause mortality in cohort of STEMI patients
treated with primary angioplasty (PPCI). Our hypothesis was that
higher RDW values will be associated with increased long-term
mortality in STEMI patients.
Material and methods
Patients selection and care
Consecutive patients presenting with STEMI and treated with PPCI
were prospectively recruited to the study. Excluded were patients
who were treated either conservatively or with thrombolysis, and
patients whose nal diagnosis on discharge was other than STEMI
(e.g. myocarditis or Takotusubo cardiomyopathy). The data for this
study was collected as part of the Tel Aviv Prospective Angiographic
Survey (TAPAS) [1217]. TAPAS is a prospective, single-center registry
which enrolls all patients undergoing cardiac catheterization at the
Tel Aviv Medical Center (Tel Aviv, Israel). The study was approved by
the institutional ethics committee and all subjects signed a written
informed consent for participation.

http://dx.doi.org/10.1016/j.thromres.2014.08.016
0049-3848/ 2014 Elsevier Ltd. All rights reserved.
 Y. Arbel et al. / Thrombosis Research 134 (2014) 976979 977

Primary PCI was performed according to current guidelines. All pa- Table 1
tients were transferred to the Cardiac intensive care unit where they Baseline characteristics according to RDW values below and above 14%.

were treated according to the discretion of the senior attending physi- Variable RDW below RDW above p value
cian. The left ventricular ejection fraction was measured in all patients, 14% (n = 365) 14% (n = 170)
by bed side echocardiography, within the rst 48 hours of admission. Age (years) 59 12 64 14 b0.001
Patients records were also evaluated for hospital mortality and compli- Gender (Male) 308(82%) 124(73%) 0.007
cations occurring during the hospitalization. These included cardiogenic Diabetes mellitus 63(17%) 32 (11%) 0.33
Dyslipidemia 167(46%) 81 (48%) 0.48
shock or the need for intra aortic balloon counterpulsation (IABC), need
Hypertension 139(38%) 84 (49%) 0.04
for emergent coronary artery bypass graft (CABG) surgery, mechanical Current Smoker 161(44%) 77 (45%) 0.58
ventilation or heart failure episodes treated conservatively, clinically Family history of CAD 73(20%) 23 (14%) 0.13
signicant tachyarrhythmias (ventricular brillation, sustained ventric- Prior MI 2(0.5%) 0 (0%) 0.75
ular tachycardia, and atrial brillation) and bradyarrhythmias requiring 1 vessels 165(45%) 75 (44%) 0.86
2 vessels 117(32%) 53 (31%)
pacemaker, as well as major bleeding (requiring blood transfusion). 3 vessels 79(22%) 41 (24%)
Time to intervention was recorded from the time of entry to the Duration of hospitalization (days) 5.9 4.1 5.8 3 0.26
emergency room to the insertion of a wire in the culprit artery (time Peak CPK (Units/L) 1223 1377 997 1234 0.93
to balloon). Long term mortality was assessed over a period of 5 years Ultra sensitive troponin ng/dl 6.7 15.4 6.4 12.6 0.64
LV ejection fraction 48 8 47 8 0.17
(range 22,130 days) up to August 1, 2013. Assessment of survival
Door to balloon time (minutes) 43 65 41 13 0.8
following hospital discharge was determined from computerized Hs-CRP (mg/dl) 10.3 23 17 44 0.16
records of the ministry of health. WBC (n/ml3) 11.6 3.2 11 3.8 0.15
Hemoglobin (g/dl) 14.6 1.4 14.1 1.8 0.002
Platelets (1000*n/ml3) 263 76 254 83 0.17
Denition of risk factors MI: myocardial infarction; CPK: Creatine Phosphokinase; LV: left ventricle.

Diabetes mellitus (DM) was dened by the patients knowledge of

having been diagnosed as having it or he/she was receiving hypoglyce- Results
mic treatment (dietary, oral anti-diabetic agents or insulin). Hyperten-
sion (HTN) was dened by the patients knowledge of elevated blood A total of 535 consecutive patients undergoing primary coronary
pressure on at least two separate occasions or he/she was receiving angioplasty for STEMI were included in this study. The mean age was
anti-HTN medications. Dyslipidemia was likewise dened according to 61 13 (range 2796), 19% were women. RDW values ranged from
the patients medical history, or low-density lipoprotein (LDL) serum 11.7% to 34% (mean 13.8 1.4%, median 13.6%), and 11% of the patients
levels 160 mg/dl in the fasting state or the use of lipid-lowering had an RDW value N 15% which is the upper limit of normal range. The
medications. Smoking status was self-reported. cohort was divided into two groups according to RDW values using
CART and CHAID methods which gave the same threshold value
RDW analysis (14%). Group 1365 patients with RDW values 14%. Group 2170
patients with RDW values N14%. Patients with RDW N 14% had lower
Arterial blood was obtained from all participants via their arterial hemoglobin levels and were more likely to suffer from hypertension.
access puncture sites as a part of the coronary angiography procedure. However, they did not have lower ejection fractions, higher troponin
The complete blood count and RDW were measured by the Beckman or higher CPK. In addition, they had similar risk factors and the time
coulter (LH 750 model), and normal levels were set by the manufacturer needed for intervention was similar (Table 1).
at 12-15%. A total of 37 patients died during follow up of up to 5 years (median
follow up: 1013 days, range 22130 days). RDW was signicantly
associated with increased mortality when evaluated as a continuous
Statistical analysis variable in multivariate regression (HR = 1.17, CI 95% 1.025 1.34,
p = 0.02) for every 1% increase in RDW value. After dividing the cohort,
All data were summarized and displayed as mean ( standard RDW N 14% was associated with increased risk of all-cause mortality
deviation) or median (25-75%) for continuous variables and as number (HR = 6.4, CI 95% 2.7 15.5, p b 0.001) Fig. 1. In multivariate analysis,
(percentage) of patients in each group for categorical variables. Contin- RDW above 14% remained signicant risk factor for mortality (HR = 4.35,
uous variables were compared using the independent sample t test or CI 95% 2.06 9.17, p b 0.001) (Table 2). The addition of RDW to the re-
Mann Whitney test and categorical variables using chi square test or gression was signicant (2 = 15.8, p = 0 b 0.001). The discrimination
Fisher's exact test. We divided our cohort into groups according to
their RDW values and their outcome using CHAID and CART [18].
These methods choose the best cutoff of a continuous variable in order Table 2
to nd the best prognostic level using repeated automated CHI tests Multivariate COX regression for long term morality.
[19]. The inuence of RDW on the occurrence of all-cause mortality
Variable HR 95% CI p value
was evaluated using multivariate Cox regression. The RDW group was
added to the regression in additional block after including signicant Age 1.03 1.0011.06 0.039
Male gender 1.079 0.452.57 0.86
variables found in Univariate analysis (Tables 1 and 2), specically
LV Ejection fraction 0.933 0.890.98 0.005
age, gender, ejection fraction, cardiogenic shock, mechanical ventila- Cardiogenic Shock 5.1 1.3519.26 0.016
tion, family history, hs-crp, time of symptoms, hypertension, hemo- Mechanical Ventilation 0.944 0.184.88 0.95
globin and RDW. We evaluated the regression discrimination using Family History 1.06 0.234.8 0.94
Hs-CRP 1.01 1.0041.017 0.002
Harrell's C. We evaluated the contribution of RDW to the regression
Time to ER 1.00 0.991.00 0.06
using chi square ( 2 log likelihood change), Net Reclassication Hemoglobin 0.98 0.791.22 0.84
Improvement (NRI), integrated discrimination improvement (IDI) and HTN 1.02 0.442.4 0.96
the relative IDI (rIDI). A two-tailed p value of b 0.05 was considered RDW (above 14%) 4.35 2.069.17 b0.001
signicant for all analyses. All analyses were performed with the SPSS LV - left ventricle; hs-CRP-high sensitivity C reactive protein; ER- emergency room;
20.0 software (SPSS Inc., Chicago, IL). RDW- red blood cell distribution; HR Odds ratio.
978 Y. Arbel et al. / Thrombosis Research 134 (2014) 976979
of the regression before and after including the RDW was fair (Harrell's
C =0.753, 0.772, accordingly). Adding RDW to the regression improved
the classication of the model (IDI = 6%, p = 0.015, rIDI = 0.33, NRI =
0.61, p b 0.001). RDW was not related to in hospital complications
(Table 3).
Discussion
In the present study we show that RDW is an independent marker of
all-cause mortality up to 5 years following STEMI. We demonstrate that
elevated RDW which is an easily and routinely measured marker is not a
rare nding among these patients, and that it is not at all identied by
clinical characteristics. We chose to focus on a homogenous group of
patients (STEMI) in order to better evaluate the role of RDW in high
risk patients.
RDW which reects the variability in size of circulating red blood
cells and is used in the differential diagnosis of the cause of anemia, is
a strong predictor of prognosis in patients with cardiovascular diseases.
We recently demonstrated that elevated RDW is a good predictor of
adverse cardiovascular events among a heterogeneous population of
patients undergoing coronary angiography [5]. In the present study
we tested the prognostic value of elevated RDW in a selective patient
population suffering from STEMI, treated by the most updated
guideline-based therapies (primary angioplasty, ACEI, BB, high dose
statins, and dual anti-platelet therapy). In addition, we were able to
dene a specic high risk cut point (14%) that predicts adverse long
term outcome.
Previous reports demonstrated that elevated RDW is associated with
adverse outcomes in patients undergoing PCI [7,2022]. Poludsau et al.
[21] demonstrated that high RDW values was a strong and independent
predictor of long-term mortality in a large population of patients under-
going PCI who were not anemic at baseline. Similarly Tsuboi et al. [20]
showed that increased RDW was signicantly associated with increased
long-term all-cause mortality in diabetic patients after elective PCI. In
those studies however, none of the patients, had undergone primary
PCI for STEMI. Uyarel et al. [7] demonstrated that a high admission
RDW level in a large population of patients with STEMI undergoing
primary PCI was associated with increased risk for in-hospital and
medium-term (1.8 1.3 years) cardiovascular mortality. Karabulut
et al. [22] demonstrated that an admission elevated RDW level is associ-
ated with worse reperfusion in AMI treated with a primary coronary
intervention. In those trials however the cutoff in the elevated RDW
group was 14.8%, and the mean RDW in that group was 16.1 1.6%, a
much higher level compared with the cutoff levels used in our trial.
Sun et al. recently published a study showing that RDW was a signicant
marker of adverse outcome [23]. However, since they chose an arbitrary
cutoff (median), they did not show a strong association and in addition,
they controlled for clinical variables without controlling for biomarkers
thus weakening their results. Our study is novel by using a lower
specically chosen cutoff, longer follow up (up to 5 years) and it
identies patients that would otherwise not be identied.
Table 3
In hospital Complications according to RDW values below and above 14%.
Variable RDW below RDW above
14% (n = 365) 14% (n = 170)
Cardiogenic shock/Need for IABC 4(2%) 6 (3.5%)
In hospital CABG 1(0.5%) 2 (1.2%)
Mechanical ventilation 2(1%) 4 (2.4%)
Heart failure 0(0%) 1 (0.6%)
Severe bradycardia/cardiac pacemaker 0(0%) 0 (0%)
Ventricular brillation/tachycardia 0(0%) 26 (3%)
Atrial brillation 0(0%) 1 (0.6%)
Major bleeding/need for blood 0(0%) 1 (0.6%)
transfusion
IABC-Intra Aortic Balloon Counterpulsation; CABG- Coronary Artery Bypass Grafting.
The mechanism by which elevated RDW is association with adverse
outcome is not clear. The association between increased RDW and
mortality or major cardiac events is most commonly thought as a conse-
quence of mechanisms that involve inammatory stress and release of
cytokines that lead to dysfunctional bone marrow with ineffective pro-
duction of red blood cells and increased platelet activation, aggregation
and thrombus formation [5,24]. However, we did not nd any difference
in platelet or WBC counts in our cohort. We did nd lower hemoglobin
levels in the elevated RDW group.
RDW has been associated with inammatory markers such as
soluble tumor necrosis factor receptors and C-reactive protein, in the
setting of atherosclerosis and other chronic diseases [911]. Such
chronic inammatory conditions have been shown to relate with bone
marrow dysfunction, leading to impaired production or increased
destruction of red blood cells, reecting unfavorable physiologic condi-
tions that may lead to adverse clinical outcomes [5]. In the present
study, we did not nd hs-CRP to be elevated in patients with elevated
RDW. Others have suggested that elevated RDW values might be asso-
ciated with the presence of chronic renal failure or increased cholesterol
content in the membrane of erythrocytes [25]. Therefore, high RDW
values, might point to patients with aggressive atherosclerosis and
inammatory background disorders that might need closer and more
intense management and surveillance.
In our cohort, elevated RDW was associated with increased long term
risk of death and identies patients that were not marked as high risk by
other conventional measures such as: ejection fraction, conventional risk
factors and peak CPK. Since elevated RDW is shown to provide additive
prognostic information on top of conventional risk factors and biomarkers,
it might identify patients who should be more closely followed-up and
who potentially require a more intensive therapeutic management.
Study limitations
We had a relatively low event rate during follow up. We believe that
our long follow up period enabled us to correct for this potential bias. In
addition, only variables found to be signicant in univariate analysis
were used in the Cox regression. Another caveat of this study is that
we do not have data on the levels of folic acid, vitamin B12, and iron,
nor on the reticulocyte count, erythropoietin levels, measures of hemo-
lysis, or detailed liver function test results, all of which might affect
RDW values. Those variables had been investigated among our patients
only when there were clinical indications to do so. Therefore, the poten-
tial for subclinical deciencies in each of these variables cannot be ruled
out, although the mean corpuscular volume of our subjects was within
the normal range (85), making signicant deciencies unlikely.
Conclusions
RDW values above 14% in patients with STEMI are associated with
almost 5-fold increase in mortality risk at 5 years. RDW provides
additive prognostic data for patients with STEMI undergoing primary
PCI. Efforts should be made to better understand the underlying mech-
anisms leading to this strong association between RDW and long-term
outcome in patients with heart disease.
p value Conict of interest
0.6 None on the part of any author.
0.77
0.38 Financial disclosure
0.1
1
0.2 None.
0.1
0.1 Funding/support
This study was supported by Internal Departmental Resources.
 Y. Arbel et al. / Thrombosis Research 134 (2014) 976979
Fig. 1. Event rate in the entire cohort according to red blood cell distribution below and above 14%.
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