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Relationship Between Hematologic Indices


and Global Registry of Acute Coronary Events
Risk Score in Patients With ST-Segment
Elevation Myocardial Infarction.

ARTICLE in CLINICAL AND APPLIED THROMBOSIS/HEMOSTASIS MAY 2014


Impact Factor: 1.58 DOI: 10.1177/1076029614533145 Source: PubMed

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Clinical and Applied Thrombosis/Hemostasis
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Relationship Between Hematologic Indices and Global Registry of Acute Coronary Events Risk Score
in Patients With ST-Segment Elevation Myocardial Infarction
Halit Acet, Faruk Ertas, Mehmet Ata Akil, Ferhat zyurtlu, Nihat Polat, Mehmet Zihni Bilik, Mesut Aydin, Mustafa
Oylumlu, Murat Yksel, Abdulkadir Yildiz, Hasan Kaya, Abdurrahman Akyz and Mehmet zbek
CLIN APPL THROMB HEMOST published online 8 May 2014
DOI: 10.1177/1076029614533145

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DOI: 10.1177/1076029614533145
Acute Coronary Events Risk Score cat.sagepub.com

in Patients With ST-Segment


Elevation Myocardial Infarction

Halit Acet, MD1, Faruk Ertas, MD1, Mehmet Ata Akl, MD1,
Ferhat Ozyurtlu, MD2, Nihat Polat, MD1, Mehmet Zihni Bilik, MD1,
Mesut Aydn, MD1, Mustafa Oylumlu, MD1, Murat Yuksel, MD1,
Abdulkadir Yldz, MD1, Hasan Kaya, MD1,
Abdurrahman Akyuz, MD1, and Mehmet Ozbek, MD1

Abstract
The aim of this study was to evaluate the relationship between hematologic indices and the Global Registry of Acute Coronary
Events (GRACE) score in patients with ST-segment elevation myocardial infarction (STEMI). A total of 800 patients who con-
secutively and retrospectively presented with STEMI within 12 hours of symptom onset. After accounting for exclusion criteria,
a total of 379 patients remained in the study. We enrolled 379 patients with STEMI (mean age 61.7 + 13.6 years; men 73%).
Neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), red cell distribution width (RDW), and monocyte
count were associated with increased worse GRACE risk score (P .008, P .012, P .005, P .022, respectively). In multi-
variate linear regression analysis, NLR, PLR, RDW, and monocyte count were found to be independent predictors of GRACE
risk score. We demonstrate for the first time that PLR, RDW, and monocyte were associated with the GRACE score in
patients with STEMI.

Keywords
GRACE risk score, hematologic indices, STEMI, platelet to lymphocyte ratio, neutrophil to lymphocyte ratio

Introduction novel prognostic marker in patients with cardiovascular dis-


ease.9 Platelets are activated to induce thrombosis and acute
Atherosclerosis is the major cause of cardiovascular disease
coronary events through several receptors situated on the pla-
that still accounts for most of the mortality worldwide.1,2
telet surface, between them and receptors for thromboxane,
Inflammation plays a significant role in initiating athero-
platelet activating factor, histamine, and high affinity and low
sclerosis and facilitating its progression.3 Inflammation char-
affinity immunoglobulin E receptors which are known as FCe
acterizes all phases of atherothrombosis, and the presence of
RI and FCe RII. The inflammatory mediators that activate the
inflammation at the site of the atherosclerotic lesion has a
above-mentioned specific receptors are released from eosino-
critical pathophysiological role in plaque formation and acute phils. That is why eosinophils are related to acute coronary
rupture.4,5 The rupture of a vulnerable atherosclerotic plaque
thrombotic events and should be always taken into account.
and consecutive thrombus formation leads to occlusion of the
However, eosinophils are pleiotropic multifunctional leukocytes
affected coronary artery followed by necrosis of the subtended
myocardial tissue. These events are clinically referred to as acute
coronary syndrome (ACS), which includes ST-segment elevated 1
Department of Cardiology, Dicle Universty Faculty of Medicine, Diyarbakr,
myocardial infarction (STEMI), non-STEMI, and unstable Turkey
angina pectoris (UAP).5 White blood cell count (WBC-c) and
2
Department of Cardiology, _Izmir Universty Faculty of Medicine _Izmir, Turkey
its subgroups have been investigated as potential inflamma-
Corresponding Author:
tory markers that predict cardiovascular outcomes in patients Halit Acet, Department of Cardiology, Dicle Universty Faculty of Medicine,
with coronary artery disease (CAD).6-8 The neutrophil to lym- Diyarbakr, Turkey.
phocyte ratio (NLR) is calculated from the WBC-c and is a Email: halitacet@gmail.com

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2 Clinical and Applied Thrombosis/Hemostasis

involved in initiation and propagation of inflammatory responses severe valvular disease, inflammatory or infectious diseases, and
and thus have important roles in the pathogenesis of inflamma- a history of bleeding diathesis. Patients on the following medica-
tory diseases.7,8 Platelet activation is one of the main contribu- tions were excluded from the study: corticosteroids, cytotoxic
tors to the development of ACSs.10 Platelets are a source of drugs, thrombolytic therapy, and glycoprotein IIb/IIIa inhibitors.
inflammatory mediators.11 Platelets have a major effect on the If during the study the patient was not treated with primary PCI,
formation of atherothrombosis and therefore play an impor- did not follow-up for blood work, and had poor echocardio-
tant role in the pathogenesis of ACS.12 Lymphocytes have graphic windows, then they were also eliminated from the inves-
been shown to modulate the immunologic response at all stages tigation. After accounting for all of these exclusion criteria, a
of the atherosclerotic process.13 The association between low total of 379 patients remained in the study sample.
lymphocyte count and major adverse cardiovascular outcomes Demographic data and variables that determine the in-hospital
was also shown in several studies.14,15 Recently, the platelet to death GRACE risk score points (that include age, creatinine,
lymphocyte ratio (PLR) has been proposed to be a novel, pro- heart rate, systolic blood pressure, Killip class, cardiac arrest
thrombotic and inflammatory marker.16,17 at admission, elevated cardiac markers, and ST-segment dev-
Red cell distribution width (RDW) is a measurement of iation) were recorded,23 and calculation of the GRACE risk
erythrocyte variability and size.18 Recent studies have identi- score was performed using a computer program (www.out
fied RDW as a predictor of cardiac mortality and systemic comes-umassmed.org/grace/acs_risk/acs_risk_content.html).
inflammation.19 The GRACE risk scores were stratified as low (<108 points),
Monocytes play an important role in inflammation and intermediate (108-140 points), and high (>140 points). For each
thrombosis, performing vital functions such as phagocytosis, patient, we estimated the risk of in-hospital mortality and coron-
cytokine production, and tissue repair.20 ary events according to GRACE risk score. All patients received a
The Global Registry of Acute Coronary Events (GRACE) complete physical examination, assessment of coronary risk fac-
risk scores have a high diagnostic performance for adverse tors, and medical histories. Presenting clinical symptoms were
outcomes in ACS and are the preferred scoring system that also recorded. Patients were evaluated for heart failure prognosis
current European Acute Coronary Syndrome guidelines rec- according to Killip clinical examination guidelines.24
ommend to apply on admission and at discharge in daily clin- Transthoracic 2-dimensional echocardiography was per-
ical practice.21 formed upon admission to determine left ventricular ejection
White blood cells and its subtype values are easily mea- fraction (LVEF; Vivid S6, GE Medical Systems, Horten, Nor-
sured during routine complete blood count analysis and may way). All patients underwent selective coronary angiography
be used as cost-effective predictors of inflammation and car- using the Judkin technique. Primary PCI was performed with the
diovascular complications. The relationship between NLR standard femoral approach using a 7F guiding catheter. Coron-
and STEMI has been shown in several studies, but there are ary vessel disease was defined as greater than 50% stenosis in
little data available about the association of NLR levels with one of the major coronary arteries. The Gensini scoring system
GRACE risk score. Moreover, there are no data available was used to determine the severity of CAD.25
about the association of PLR, RDW, and monocyte count with
GRACE score in STEMI. In this study, we aimed to investi-
gate the association of the concomitant hematological indices
Laboratory Analysis
such as NLR, PLR, RDW, and monocyte count with GRACE On admission, venous blood was obtained from all patients.
risk score in patients with STEMI who underwent primary Hematological indices were measured as part of the automated
percutaneous intervention (PCI). complete blood count before starting any medication. The NLR
was calculated as the ratio of the neutrophils and lymphocytes,
both obtained from the same automated blood sample at admis-
Methods sion. The PLR was measured by dividing the platelet count by
the lymphocyte count. Hematologic indices were measured by
Study Population and Definitions an automated hematology analyzer system (Abbott Cell-Dyn
A total of 800 patients who consecutively and retrospectively 3700; Abbott Laboratory, Abbott Park, Illinois, USA). Abso-
presented with STEMIs and underwent primary PCI within lute cell counts were utilized to perform subsequent analyses.
12 hours of symptom onset between January 2012 and January
2014 were included in the study. The STEMI was defined based
on the criteria created by the American College of Cardiology
Statistical Analysis
and the European Society of Cardiology22: an increase in tropo- Statistical analyses were performed using the SPSS software
nin I >1 ng/mL; a new ST-segment elevation as measured from version 18.0 (SPSS Inc, Chicago, Illinois). Categorical vari-
the J-point in 2 or more contiguous leads from leads V1, V2, and ables were summarized as percentages and compared with
V3 measuring at least 0.2 mV or at least 0.1 mV in the remaining Pearson chi-square test. Continuous variables were presented
leads during the first 12 hours after symptom onset. as mean + standard deviation and tested for normal distribu-
Exclusion criteria of the study were patients with severe liver tion by the Kolmogorov-Smirnov test. Comparison analyses
disease, autoimmune diseases, cancer, hematological disorders, between groups were made using Kruskal-Wallis test and

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Acet et al 3

Table 1. Demographic and Biochemical Characteristics of Patients in GRACE Risk Score Groups.

Variables Low GRACE Risk Score Intermediate GRACE Risk Score High GRACE Risk Score P Value

Age, years 43.13 + 8.10 51.84 + 8.03 69.25 + 10.41 .001a


Sex, male, n (%) 2 9(90.6) 93 (79.5) 154 (67.00) .003
Hypertension, n (%) 9 (28.1) 33 (28.2) 93 (40.4) .052
Diabetes mellitus, n (%) 9 (28.1) 23 (19.7) 63 (27.4) .267
Smoking, n (%) 12 (37.5) 33 (28.2) 31 (13.5) <.001
Hyperlipidemia, n (%) 3 (9.4) 7 (6.0) 9 (3.9) .351
Family history of CAD, n (%) 27 (84.) 77 (65.8) 109 (47.4) <.001
Cerebrovascular event, n (%) 1 (3.1) 1 (0.9) 17 (7.4) .027
Latency, hours 5.08 + 3.38 5.32 + 3.42 6.17 + 3.43 .042b
Admission LVEF, % 46.81 + 8.42 46.10 + 8.98 41.52 + 11.21 <.001b
White blood cell count, 103/mm3 14.91 + 4.06 13.15 + 4.85 13.65 + 5.87 .048a
Neutrophil count, 103/mm3 11.70 + 3.84 10.31 + 4.62 10.96 + 5.41 .307b
Lymphocyte count, 103/mm3 2.26 + 0.99 2.18 + 1.26 1.85 + 1.22 .001a
Neutrophil to lymphocyte ratio 6.25 + 3.57 6.19 + 4.06 7.96 + 6.05 .008b
Platelet count, 103/mm3 250.89 + 53.21 254.59 + 60.18 248.20 + 69.38 .692b
Platelet to lymphocyte ratio 128.41 + 50.72 153.45 + 95.15 176.54 + 111.99 .012a
Mean platelet volume 8.26 + 1.43 8.11 + 1.48 8.32 + 1.48 .478b
Red cell distribution width 15.64 + 1.20 15.66 + 1.23 16.18 + 1.66 .005b
Platelet distribution width 17.85 + 0.89 17.07 + 1.04 18.02 + 1.30 .063b
Monocyte count 0.79 + 0.28 0.68 + 0.34 0.66 + 0.32 .022a
Basophil count 0.09 + 0.04 0.08 + 0.06 0.07 + 0.05 .128b
Red blood cell count, M/mL 5.12 + 0.47 4.99 + 0.53 4.79 + 0.60 <.001a
Hemoglobin, g/dL 14.62 + 1.20 14.20 + 1.70 13.61 + 1.62 <.001a
Narrowed coronary vessels
1 vessel, n % 21 (67.7) 53 (46.5) 81 (37.2) .003
>1 vessel n, % 10 (32.3) 61 (53.5) 137 (62.8)
Gensini score 53.15 + 27.04 53.30 + 26.91 60.76 + 31.14 .001a
Abbreviations: ANOVA, analysis of variance; CAD, coronary artery disease; GRACE, Global Registry of Acute Coronary Events; LVEF, left ventricular ejection
fraction.
a
Kruskal Wallis test.
b
ANOVA test.

1-way analysis of variance test where appropriate. Spearman scores, and 229 (60.7%) patients had high GRACE risk
test was used for correlation analysis between hematologic scores.
indices and GRACE risk score, gender, LVEF, red blood cell, Demographic and biochemical characteristics of patients
hemoglobin, RDW, monocyte count, NLR, PLR, and WBC in GRACE risk score groups are shown in Table 1. Determi-
and GRACE point was analyzed using a multivariate linear nation of the GRACE risk score parameters is shown in
regression model. Multivariate linear regression analysis was Table 2. All patients of Killip class III-IV and who had car-
used to assess independent predictors of GRACE risk score diac arrest on admission are in the high GRACE risk score
and the results were expressed as the odds ratio (OR) with the patients group. Peak troponin, creatinine level, and age were the
corresponding 95% confidence interval (95% CI). A P value high GRACE risk score patients group.
lower than .05 was considered significant. Spearman correlation analysis revealed significant associa-
The study protocol was reviewed and approved by the Ethics tions between higher GRACE risk scores and NLR (r .172;
Committee in accordance with the Declaration of Helsinki. P < .001), PLR (r .110, P .033), and RDW (r .173,
P .001; Figure 1). Multivariate linear regression analysis
revealed that high measures of NLR and PLR were independent
predictors of the GRACE risk score. Higher NLR values
Results
were associated with GRACE risk score (b 1.200, 95%
The study population consisted of 379 consecutive patients CI 0.034-2.367, P < .001), higher PLR (b 0.073, 95%
with STEMI. In all, 72.8% of the patients were male, and CI 0.132-0.014, P .016), RDW (OR b 2.167; 95% CI
the mean age of patients was 61.67 + 13.59 years. In all, 0.170-4.164, P .034), WBC (b 0.989, 95% CI
135 (35.6%) patients had hypertension, 95 (25.1%) patients 0.277-1.702, P .007), and monocyte count (b
had diabetes, 19 (5.0%) patients had hyperlipidemia, and 10.722, 95% CI 20.678 to 0.766, p .035). A mul-
213 (56.2%) patients were smokers. According to the tivariate linear regression analysis for the relationship
GRACE risk score, 32 (8.4%) patients had low GRACE risk between GRACE score and other variables is shown in
scores, 117 (30.9%) patients had intermediate GRACE risk Table 3.

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4 Clinical and Applied Thrombosis/Hemostasis

Table 2. Determine of the GRACE Risk Score Parameters.

Variables Low GRACE Risk Score Intermediate GRACE Risk Score High GRACE Risk Score P Value

Age, years 43.13 + 8.10 51.84 + 8.03 69.25 + 10.41 <.001a


Creatinine, mg/dL 0.79 + 0.11 0.82 + 0.28 1.01 + 0.59 <.001a
SBP, mm Hg 144.21 + 24.58 129.01 + 20.30 124.56 + 24.74 <.001a
Killip class at admission, n (%)
I 32 (100) 11 (95.7) 145 (63.0) <.001
II 0 5 (4.3) 56 (24.3)
III 0 0 15 (6.5)
IV 0 0 14 (6.1)
Cardiac arrest at admission 0 0 28 (12.2) <.001
Peak troponin 52.25 + 34.61 51.32 + 37.76 59.37 + 37.74 <.001b
Abbreviations: ANOVA, analysis of variance; GRACE, Global Registry of Acute Coronary Events; SBP, systolic blood pressure.
a
Kruskal Wallis test.
b
ANOVA test.

Figure 1. A, Correlation between NLR and GRACE risk score. B, Correlation between PLR and GRACE risk score. C, Correlation between
RDW and GRACE risk score. NLR indicates neutrophil to lymphocyte ratio; PLR, platelet to lymphocyte ratio; RDW, red cell distribution width;
GRACE, Global Registry of Acute Coronary Events.

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Acet et al 5

Table 3. Independent Predictors for In-Hospital GRACE Death by Multivariate Linear Regression Analysis.

Standardized
Unstandardized Coefficients Coefficients 95% Confidence Interval for B

Model B Standard Error b t P value Lower Bound Upper Bound

(Constant) 85.459 25.437 3.360 .001 35.433 135.485


Age 1.759 0.117 .604 14.978 <.001 1.528 1.990
Gender 3.254 3.738 .036 0.871 .385 4.097 10.606
LVEF (%) 0.995 0.144 .263 6.907 <.001 1.279 0.712
RBC 4.695 3.730 .068 1.259 .209 12.031 2.641
Hemoglobin 0.858 1.429 .035 0.600 .549 3.667 1.952
RDW 2.167 1.016 .083 2.134 .034 0.170 4.164
Monocyte 10.722 5.063 .088 2.118 .035 20.678 0.766
NLR 1.200 0.593 .163 2.023 .044 0.034 2.367
PLR 0.073 0.030 .191 2.424 .016 0.132 0.014
WBC 0.989 0.362 .136 2.731 .007 0.277 1.702

Abbreviations: LVEF, left ventricular ejection fraction; RBC, red blood cell count; RDW, red cell distribution width; NLR, neutrophil to lymphocyte ratio; PLR, platelet
to lymphocyte ratio; WBC, white blood cell count; B, coefficient of regression; ANOVA, analysis of variance; GRACE, Global Registry of Acute Coronary Events.
R2 .540

Discussion we demonstrated that WBC, NLR, PLR, RDW, and monocytes


were independent predictors of worse GRACE risk score. Based
Coronary atherosclerosis is the main cause of STEMI. Multiple
on our knowledge, this is the first study to correlate concomitant
pathophysiological factors influence this atherosclerotic pro-
hematologic indices such as WBC, NLR, PLR, RDW, and
cess, and one of the most important factors is inflammation.4,26
monocytes with GRACE score in patients with STEMI.
The inflammatory process that underlines atherosclerosis has
a critical role in plaque destabilization and appearance of a
thrombus superimposed on the erosion of an atherosclerotic
plaque; this is the mechanism that can cause myocardial Platelet to Lymphocyte Ratio and GRACE Risk Score
infarction (MI).27 Platelets play a central role in the development of ACS,31
The GRACE risk scores include variables such as hemody- which is caused by complex interactions between leukocytes
namic status, Killip class, cardiac markers, and others but do and platelets causing the production of reactive oxygen species
not include inflammatory markers. The GRACE score has been contributing to ischemic endothelial damage.32 Proliferating
recognized as a validated predictor of adverse cardiovascular megakaryocytes and relative thrombocytosis are consequences
disease events in patients with cardiovascular disease (CVD).28 of an ongoing inflammatory response that contributes to a
Platelets are produced by megakaryocytopoiesis29 and play prothrombotic state in ACS. Prior studies have demonstrated
an important role in the pathogenesis of ACS.12 Platelet to lym- that a low lymphocyte count in patients with acute MIs
phocyte ratio has been proposed to be a novel, prothrombotic and chronic CAD gives information about worse prognosis.33
and inflammatory marker.16,17 Neutrophil to lymphocyte ratio Platelet to lymphocyte ratio is derived from the number of
is a novel prognostic inflammatory marker.9 A strong correla- platelets and lymphocytes and it is accepted as a new inflam-
tion between RDW with inflammatory markers, C-reactive matory marker.17,34,35 However, the advantage of PLR is that it
protein, and sedimentation rate has also been observed.19 reflects both coagulation and inflammatory pathways and may
Monocytes play important roles in cardiovascular disease, be superior to individual platelet or lymphocyte counts. More
and their actions can be both beneficial (angiogenesis or car- recent studies have stated that higher platelet and lower lym-
diovascular repair) and detrimental (excessive inflammatory phocyte counts may play a major role in adverse cardiovascu-
response). However, hematologic indices such as NLR, PLR, lar outcomes. Azab et al reported that higher PLR values were
RDW, and monocyte count are not included into the GRACE associated with increased long-term mortality in non-STEMI
scoring system. Correia et al30 demonstrated that assessment patients.34 Sunbul et al found that the PLR was a significant
of inflammation improves risk prediction and provides addi- predictor of nondipper status in patients with hypertension.36
tional prognostic information to the GRACE score. However, Gary et al revealed that increased PLR is significantly associ-
there have been no reports on the association between PLR, ated with patients at high for critical limb ischemia.37 Yildiz
RDW, monocyte, and GRACE risk score in patients with et al show that high preprocedural PLR and NLR levels are
STEMI. In the present study, we showed that hematologic significant and independent predictors of no reflow in patients
indices such as WBC-c, NLR, PLR, RDW, and monocytes undergoing primary PCI.38 Acar et al investigated the rela-
were significantly associated with GRACE risk score. Also, tionship between the PLR and the coronary collateral

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6 Clinical and Applied Thrombosis/Hemostasis

circulation (CCC) in 294 patients with stable angina pectoris GRACE risk score in patients with STEMI has not been inves-
and chronic total occlusion. They demonstrated that the PLR tigated before. Our results demonstrate for the first time that
values were higher in patients with poor CCC than in those the GRACE risk score and monocyte count are related. In this
with good CCC. Furthermore, it was found that PLR is an study, monocyte levels are decreased in patients with increased
independent predictor of poor CCC.39 In addition to the prog- GRACE risk score. Moreover, monocyte count was an indepen-
nostic significance, the PLR has also been demonstrated in dent negative predictor of GRACE risk score.
patients with various cancers.40 In a relatively recent study
in patients with small cell carcinoma of the esophagus, PLR Neutrophil to Lymphocyte Ratio and GRACE Risk Score
was proven to be superior to NLR in terms of relapse-free sur-
vival and overall survival.41 However, to the best of our White blood cell count and its subtypes may indicate inflam-
knowledge, the relationship between the PLR and the GRACE mation associated with CVD.51 In patients with ACS, neutro-
risk score in patients with STEMI undergoing primary PCI phils become functionally activated and mediate the
has not been investigated before. Our results demonstrate for destabilization of atherosclerotic plaques.52 Recent studies
the first time that the GRACE score and PLR at baseline are have shown that high neutrophil counts are associated with
significantly correlated. Moreover, PLR was determined to poorer angiographic outcomes, larger infarct sizes, and worse
be an independent predictor of worse GRACE risk score. prognosis in patients with STEMI.53-55 Several studies have
demonstrated that NLR is a marker of cardiovascular disease
prognosis.56,57 Previous studies focused on NLR and its associ-
Red Cell Distribution Width and GRACE Risk Score ation with adverse outcomes in patients with ACSs.58,59 Akpek
Red cell distribution width is a measurement of variability and et al demonstrated that preprocedural NLR is an independent
size of erythrocytes.18 Increased RDW has been reported to be predictor of no reflow in patients with STEMI.53 Nunez et al54
associated with negative clinical outcomes in patients with followed patients with STEMI and evaluated the predictive
heart failure, MI, and stable CAD, independent of hemoglobin value of NLR in long-term mortality and found that an increased
values.42-44 Uyarel et al45 demonstrated that higher admission NLR is associated with an increased risk of long-term mortality.
RDW levels in patients undergoing PCI for STEMI were asso- In both of these studies the NLR was measured at admission and
ciated with increased risk of in-hospital and long-term cardi- 3 to 4 days for follow-up. We measured the hematologic indices
ovascular mortality. Polat et al46 investigated the relationship at admission before starting any medication because WBC-c, its
between RDW and GRACE risk score in 193 small patients subtypes, and platelets could be affected by infectious disorders,
with UAP/non-STEMI. They demonstrated that high RDW anxiety, and medication. To our knowledge, only 1 study by
was an independent predictor of high GRACE score, and it Oncel et al has investigated the relationship between NLR and
is associated with in-hospital mortality in UAP/non-STEMI. GRACE risk score.60 They investigated the relationship between
However, the relation between the RDW and the GRACE NLR and GRACE score in 101 patients with STEMI. They
score in patients with STEMI has not been investigated. Our showed that NLR was a positive predictor of GRACE score.
results demonstrate for the first time in patients with STEMI In our study, we also found that high NLR was significantly
that the GRACE score and RDW at baseline are significantly increased with GRACE risk score. In sum, we showed that
correlated. Moreover, RDW was an independent positive pre- patients having STEMI with GRACE score had significantly
dictor of worse GRACE risk score in patients with STEMI. high NLR, PLR, RDW, and monocyte count. This suggests that
PLR, NLR, RDW, and monocytes may be indicators of GRACE
risk score in patients with STEMI.
Monocyte Count and GRACE Risk Score
Monocyte aggregation with platelets is accompanied by mono- Study Limitations
cyte activation, resulting in increased cytokine production,
The limitations of the present study were a retrospective design
expression of cell adhesion molecules, and the release of
and single-center experience. We could not compare NLR,
matrix metalloproteinases.47 Even in the absence of platelet
PLR, and RDW with other inflammatory markers, such as
interaction, monocytes play an important role in inflammation
C-reactive protein, fibrinogen, or myeloperoxidase because
and thrombosis, performing vital functions such as phagocy-
they were not routinely obtained in our study population.
tosis, cytokine production, and tissue repair20 as well as being
However, a major limitation of the study is that our results
a major source of blood tissue factor.48 Also, a recent study
do not give an idea about the relationship between hematolo-
demonstrated increased monocyte numbers in patients with
gic parameters and clinical outcome.
stable systolic heart failure.49 Wrigley et al showed that sig-
nificant upregulation of monocyteplatelet aggregates occurs
in patients with ischemic heart failure.50 Monocytes play
important roles in cardiovascular disease, and functional sta-
Conclusion
tus in cardiac disorders is still poorly understood. The specific The GRACE risk score is routinely used for stratification of
role of monocytes in hospital mortality is largely unknown. patients with ACS. Our study showed that hematological
Moreover, the relationship between monocyte count and indices such as NLR, PLR, RDW, and monocyte count may

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Acet et al 7

provide additional prognostic value in patients with STEMI. different platelet function tests. Thromb Haemost. 2009;102(4):
The determination of these hematologic indices for risk stra- 719-727.
tification of patients with STEMI during the hospitalization 13. Taleb S, Tedgui A, Mallat Z. Regulatory T-cell immunity and
period may be useful. We think that these significant findings its relevance to atherosclerosis. J Intern Med. 2008;263(5):
of our analysis can guide further clinical practice. 489-499.
14. Zouridakis EG, GarciaMoll X, Kaski JC. Usefulness of the blood
Declaration of Conflicting Interests lymphocyte count in predicting recurrent instability and death in
The author(s) declared no potential conflicts of interest with respect patients with unstable angina pectoris. Am J Cardiol. 2000;86(4):
to the research, authorship, and/or publication of this article. 449-451.
15. Ommen SR, Hammill SC, Gibbons RJ. The relative lympho-
Funding cyte count predicts death in patients receiving implantable car-
The author(s) received no financial support for the research, authorship, dioverter defibrillators. Pacing Clin Electrophysiol. 2002;
and/or publication of this article. 25(10):1424-1428.
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