Association between RDW and stent thrombosis in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention

Is Red Cell Distribution Width a Reliable Marker for Cardiovascular Diseases? A Narrative Review

Red cell distribution width (RDW) is an easy-to-access marker which is routinely measured in complete blood count (CBC) test. Besides the classic use of RDW as a marker for discriminating different types of anemia, recent studies had indicated the relationship between high RDW and cardiovascular diseases. High RDW is not only useful in the diagnosis and prognostication of various cardiovascular conditions but also could be used as a valuable tool for predicting the incidence of cardiovascular diseases. population-based studies have indicated that higher RDW could effectively predict the incidence of heart failure (HF), atherosclerotic diseases, and atrial fibrillation (AF). It has been also demonstrated that higher RDW is associated with worse outcomes in these diseases. Recent studies have shown that high RDW is also associated with other cardiovascular conditions including cardiomyopathies, and pulmonary hypertension. The predictive role of RDW in endovascular interventions has also been demonstrated by many recent studies. Here in this review, we attempt to compile the most recent findings with older reports regarding the relation between high RDW and HF, cardiomyopathies, pulmonary hypertension, AF, atherosclerotic disorders, primary hypertension, and the outcomes of endovascular interventions. we also discussed the role of RDW in the prognostication of different cardiovascular conditions when combined with classic classification criteria.

Factors associated with early, late, and very late stent thrombosis among patients with acute coronary syndrome undergoing coronary stent placement: analysis from the ATLAS ACS 2-TIMI 51 trial

Background

Stent thrombosis (ST) is an uncommon but serious complication of stent implantation. This study aimed to explore factors associated with early, late, and very late ST to help guide risk assessment and clinical decision-making on ST.

Methods

The analysis included patients who received stent placement for the index acute coronary syndrome (ACS). Cumulative incidence of ST was assessed at 30 days (early ST), 31-360 days (late ST), 361-720 days (very late ST), and up to 720 days. Cox proportional hazards models were used to assess associations between ST and various factors, including patient characteristics [i.e., age, sex, ACS presentation, history of hypertension, smoking, diabetes, prior myocardial infarction (MI), heart failure, prior ischemic stroke, and cancer], laboratory tests [i.e., positive cardiac biomarker, hemoglobin, platelet count, white blood cell (WBC) count], and treatment [i.e., drug-eluting stent (DES) vs. bare-metal stent (BMS) and anticoagulant with rivaroxaban vs. placebo].

Results

Among the 8,741 stented patients, 155 ST events (2.25%) occurred by Day 720. The cumulative incidences of early, late, and very late ST were 0.80%, 0.81%, and 0.77%, respectively. After multivariable adjustment, age ≥ 75 [hazard ratio (HR) = 2.13 (95% confidence interval, CI: 1.26-3.60)], a history of prior MI [HR = 1.81 (95% CI: 1.22-2.68)], low hemoglobin level [HR = 2.34 (95% CI: 1.59-3.44)], and high WBC count [HR = 1.58 (95% CI: 1.02-2.46)] were associated with a greater risk of overall ST, whereas DES [HR = 0.56 (95% CI: 0.38-0.83)] and rivaroxaban therapy [HR = 0.63 (95% CI: 0.44-0.88)] were associated with a lower risk of overall ST up to 720 days. Low hemoglobin level and high WBC count were associated with early ST (low hemoglobin: HR = 2.35 [95% CI: 1.34-4.12]; high WBC count: HR = 2.11 [95% CI: 1.17-3.81]). Low hemoglobin level and prior MI were associated with a greater risk of late ST (low hemoglobin: HR = 2.32 [95% CI: 1.26-4.27]; prior MI: HR = 2.98 [95% CI: 1.67-5.31]), whereas DES was associated with a lower risk of late ST [HR = 0.33 (95% CI: 0.16-0.67)]. Age ≥75 years was associated with very late ST.

Conclusion

The study identified positive and negative associations with early, late, and very late ST. These variables may be useful in constructing risk assessment models for ST.

Clinical Trial Registration

http://www.clinicaltrials.gov, identifier NCT00809965.

An in vivo investigation on the effects of stent implantation on hematological and hemorheological parameters

BACKGROUND

Even though cardiovascular stenting is widely used for the treatment of coronary artery disease, information on how it can affect the hematological and hemorheological profile is scarce in the literature. Most of the work on this issue is based on theoretical or computational fluid dynamics models, lacking in-depth in vitro and in vivo experimental verification.

OBJECTIVE

This work investigates, in an in vivo setting, the effects of stenting and the implantation time-course on hematological and hemorheological parameters that could potentially compromise the device's functionality and longevity.

METHODS

Custom-made self-expanding nitinol stents were implanted in the common carotid artery of male CD1 mice. Whole blood samples were collected from control (non-stented) and stented animals at 5 and 10 weeks post-implantation. Hematological measurements and blood viscosity, red blood cell aggregation, and deformability were performed using standard techniques.

RESULTS

Implant-induced changes were observed in some of the hematological and hemorheological indices. Blood viscosity seems to have been negatively affected by an increased hematocrit and reduced RBC deformability, at 10 weeks post-implantation, despite a slight decrease in RBC aggregation.

CONCLUSIONS

Although the alterations observed may be the result of the peri-implant inflammatory response, the physiological consequences due to hemorheological changes need to be further investigated.

Identification of predictors for the comprehensive clinical risk and severity of coronary lesions of acute coronary syndrome

Background

Acute coronary syndrome (ACS) is the most common cause of death in patients with coronary artery disease. The aim of the study was to identify the predictors of both comprehensive clinical risk and severity of coronary lesions by comprehensive use of GRACE and SYNTAX scores in patients with ACS.

Methods

Clinical data of 225 ACS patients who underwent coronary angiography between 2015 and 2016 were collected. Multiple logistic regression analysis (stepwise) was used to identify the predictors. The predictive ability of predictors and the model were determined using receiver operating characteristics analyses.

Results

Multivariable logistic regression analyses showed that high aspartate aminotransferase (AST) predicted the comprehensive clinical risk with odds ratios (ORs) and 95% confidence intervals (CIs) of 1.011 (1.002–1.021). High total cholesterol (TC) and red blood cell distribution width (RDW) predicted the severity of coronary lesions with ORs and 95% CIs of 1.517 (1.148–2.004) and 1.556 (1.195–2.028), respectively. Low prealbumin predicted both severity of coronary lesions and comprehensive clinical risk of ACS patients with ORs and 95% CIs of 0.743 (0.672–0.821) and 0.836 (0.769–0.909), respectively. The model with a combination of prealbumin and AST had the highest predictive efficacy for comprehensive clinical risk, and the combination of prealbumin, TC, and RDW had the highest predictive efficacy for the severity of coronary lesions. The sensitivity and specificity, and the optimal cut-off values of these four indexes were determined.

Conclusions

Four predictors for the comprehensive clinical risk and severity of coronary lesions of ACS were identified, which provided important information for the early diagnosis and appropriate treatment of ACS.

Red Blood Cell Distribution Width: A Risk Factor for Prognosis in Patients with Ischemic Cardiomyopathy after Percutaneous Coronary Intervention

BACKGROUND

It has been demonstrated in previous studies that red blood cell distribution width (RDW) is correlated with the severity and prognosis of cardiovascular disease. The target of our study was to assess the relationship between RDW and the prognosis of ischemic cardiomyopathy (ICM) patients undergoing percutaneous coronary intervention (PCI).

METHODS

The study retrospectively enrolled 1986 ICM patients undergoing PCI. The patients were divided into three groups by RDW tertiles. The primary endpoint was major adverse cardiovascular events (MACE) and the secondary endpoints were each of the components of MACE (all-cause mortality, nonfatal myocardial infarction (MI) and any revascularization). Kaplan-Meier survival analyses were conducted to show the association between RDW and the incidence of adverse outcomes. The independent effect of RDW on adverse outcomes was determined by multivariate Cox proportional hazard regression analysis. In addition, the nonlinear relationship between RDW values and MACE was explored using restricted cubic spline (RCS) analysis. The relationship between RDW and MACE in different subgroups was determined using subgroup analysis.

RESULTS

As RDW tertiles increased, the incidences of MACE (Tertile 3 vs. Tertile 1: 42.6 vs. 23.7, p < 0.001), all-cause death (Tertile 3 vs. Tertile 1: 19.3 vs. 11.4, p < 0.001) and any revascularization (Tertile 3 vs. Tertile 1: 20.1 vs. 14.1, p < 0.001) increased significantly. The K-M curves showed that higher RDW tertiles were related to increased incidences of MACE (log-rank, p < 0.001), all-cause death (log-rank, p < 0.001) and any revascularization (log-rank, p < 0.001). After adjusting for confounding variables, RDW was proved to be independently associated with increased risks of MACE (Tertile 3 vs. Tertile 1: HR, 95% CI: 1.75, 1.43-2.15; p for trend < 0.001), all-cause mortality (Tertile 3 vs. Tertile 1: HR, 95% CI: 1.58, 1.17-2.13; p for trend < 0.001) and any revascularization (Tertile 3 vs. Tertile 1: HR, 95% CI: 2.10, 1.54-2.88; p for trend < 0.001). In addition, the RCS analysis suggested nonlinear association between RDW values and MACE. The subgroup analysis revealed that elderly patients or patients with angiotensin receptor blockers (ARBs) had a higher risk of MACE with higher RDW. Patients with hypercholesterolemia or without anemia also had a higher risk of MACE.

CONCLUSIONS

RDW was significantly related to the increased risk of MACE among ICM patients undergoing PCI.

Predictive Value for Increased Red Blood Cell Distribution Width in Unprovoked Acute Venous Thromboembolism at the Emergency Department

Acute venous thromboembolism (VTE) is a common worldwide disease admitted to emergency departments (ED), usually presenting as pulmonary embolism or lower limb deep vein thrombosis (DVT). Due to the lack of typical clinical and biomarker diagnostic features of unprovoked VTE, early identification is challenging and has direct consequences on correct treatment delay. Longitudinal, prospective, observational study. Patients admitted to ED with a suspicion of unprovoked acute VTE between October 2020 and January 2021 were included. Clinical and laboratorial variables were compared between VTE positive and negative diagnoses. Red cell distribution width (RDW) cut point was determinate through a receiver operating characteristic analysis. RDW accuracy, sensitivity, and specificity were calculated. Fifty-eight patients were analyzed. And 82.8% of suspected patients with VTE were diagnosed with an acute thrombotic event confirmed by imaging examination. In patients with VTE, RDW at admission in ED was higher than with other diagnosis, respectively, 14.3% (13.2-15.1) and 13.5% (13.0-13.8). Platelet count was the only additional characteristic that revealed difference between the 2 groups (264×109/L for VTE and 209×109/L for non-VTE). Logistic regression models showed good discriminatory values for RDW≥14%, with an area under the curve (AUC) = 0.685 (95% confidence interval, 0.535-0.834). These findings were more pronounced in isolated DVT, with a sensitivity of 76.9%, specificity 100%, and accuracy 85.7%. Our study demonstrated a significant association between an early high RDW and the diagnosis of acute unprovoked DVT. RDW ≥ 14% has an independent predictor of unprovoked VTE in adult patients.

Nomogram for Predicting Postoperative Portal Venous Systemic Thrombosis in Patients with Cirrhosis Undergoing Splenectomy and Esophagogastric Devascularization

OBJECTIVES

The aim of the study is to develop a nomogram for predicting postoperative portal venous systemic thrombosis (PVST) in patients with cirrhosis undergoing splenectomy and esophagogastric devascularization.

METHODS

In total, 195 eligible patients were included. Demographic characteristics were collected, and the results of perioperative routine laboratory investigations and ultrasound examinations were also recorded. Blood cell morphological traits, including the red cell volume distribution width (RDW), mean platelet volume, and platelet distribution width, were identified. Univariate and multivariate logistic regressions were implemented for risk factor filtration, and an integrated nomogram was generated and then validated using the bootstrap method.

RESULTS

A color Doppler abdominal ultrasound examination on a postoperative day (POD) 7 (38.97%) revealed that 76 patients had PVST. The results of the multivariate logistic regression suggested that a higher RDW on POD3 (RDW3) (odds ratio (OR): 1.188, 95% confidence interval (CI): 1.073-1.326), wider portal vein diameter (OR: 1.387, 95% CI: 1.203-1.642), history of variceal hemorrhage (OR: 3.407, 95% CI: 1.670-7.220), and longer spleen length (OR: 1.015, 95% CI: 1.001-1.029) were independent risk parameters for postoperative PVST. Moreover, the nomogram integrating these four parameters exhibited considerable capability in PVST forecasting. The nomogram's receiver operating characteristic curve reached 0.83 and achieved a sensitivity and specificity of 0.711 and 0.848, respectively, at its cutoff. The nomogram's calibration curve demonstrated that it was well calibrated.

CONCLUSION

The nomogram exhibited excellent performance in PVST prediction and might assist surgeons in identifying vulnerable patients and administering timely prophylaxis.

Value of Hematological and Coagulation Parameters as Prognostic Factors in Acute Coronary Syndromes

The values of hematological and coagulation biomarkers were evaluated as predictors of in hospital mortality and complications, in patients with acute coronary syndromes (ACS). This retrospective observational study enrolled 936 ACS subjects admitted to the Clinical Emergency Hospital of Oradea, Romania, between January-December 2019. Hematological and coagulation parameters were obtained at admission. During hospitalization, the following adverse events were recorded: death, ventricular rhythm disturbances, atrial fibrillation, heart failure, re-infarction, and stroke. Accuracy of hematological and coagulation parameters as predictors of adverse outcome were also evaluated. The diagnosis was unstable angina in 442 patients (47.22%), non-ST-elevation myocardial infarction (NSTEMI) in 113 patients (12.1%) and ST-elevation myocardial infarction (STEMI) in 381 patients (40.70%); 87 patients (9.29%) died during hospitalization and 193 (20.7%) developed complications. Predictors for in hospital mortality were as follows: red cell distribution width (RDW) (AUC 0.691, p < 0.0001), white blood cells (WBC) (AUC 0.684, p < 0.0001), neutrophils (NEU) (AUC 0.684, p < 0.0001), and prothrombin time (PT) (AUC 0.765, p < 0.0001). WBC (AUC 0.659, p < 0.0001), NEU (AUC 0.664, p < 0.0001), RDW (AUC 0.669, p < 0.0001), and PT (AUC 0.669, 95% CI 0.622-0.714, p < 0.0001) also had accuracy for complications prediction. RDW had a good ability to predict heart failure in NSTEMI patients (AUC 0.832, p < 0.0001). An acceptable ability to predict ventricular rhythm disturbances occurrence had WBC (AUC 0.758, p < 0.0001) and NEU (AUC 0.772, p < 0.0001). Hematological and coagulation parameters can help in risk stratification of ACS patients. RDW, WBC, NEU, and PT were able to predict mortality and in-hospital complications in ACS patients. RDW has a good accuracy in predicting complications and heart failure in NSTEMI patients. WBC and NEU are good predictors for ventricular rhythm disturbances.

Blood Cell Count Biomarkers, Risk, and Outcomes of Ischemia-Related Lower Limb Amputations: Systematic Review

Lower limb amputations due to ischemia represent an important health care and social issue. However, there are currently no specific biomarkers able to predict the risk of amputation and postamputation complications and prognosis. We conducted a systematic review of studies investigating whether blood cell count indexes of systemic inflammation are linked to the risk and the outcome of lower limb amputations due to ischemia. Overall, in 22 studies involving 8832 patients selected for review, several blood cell count indexes, particularly the neutrophil lymphocyte ratio, showed some promise in terms of predicting amputations and general outcomes of conservative and surgical treatments, as well as postamputation complications and prognosis. However, largely due to methodological limitations, further prospective studies are required to establish the clinical utility and applicability of blood cell indexes in the routine management of patients with ischemia-related lower limb amputations.

Red Cell Distribution Width as a Novel Prognostic Marker in Multiple Clinical Studies

Red cell distribution width (RDW), which is a quantitative method applied for the measurement of anisocytosis, is the most reliable and inexpensive method for differentiation of iron deficiency anemia and thalassemia trait. An increase in its rate reflects a great heterogeneity in the size of red blood cells (RBCs). Recent studies have shown a significant relationship between RDW and the risk of morbidity and mortality in patients with multiple diseases. A strong association is established between changes in RDW and the risk of adverse outcome in patients with heart failure in multiple studies. In this review, we try to focus on the association and correlation between the increase in RDW and different outcomes of common diseases that may be related to RDW and based on the results of various studies, we are trying to introduce RDW as a diagnostic indicator for these diseases.

The role of red blood cell distribution width (RDW) in cardiovascular risk assessment: useful or hype?

Red blood cell distribution width (RDW) reflects erythrocyte size distribution, thus representing a reliable index of anisocytosis, widely used for the differential diagnosis of micro- and normocytic anaemias. Along with the large use in diagnostic hematology, RDW has been associated with presence and complications of a vast array of human pathologies during the last decades, including cardiovascular (CV) diseases. This article is hence aimed to provide an overview of important studies and systematic reviews with meta-analysis, in which RDW has been associated with CV events and mortality, in the attempt of establishing whether enough evidence exists for supporting its routine use in clinical practice. According to available data it seems reasonable to conclude that although the diagnostic specificity is low, and this measure is still plagued by important lack of standardization, RDW can be regarded as an index of enhanced patient fragility and higher vulnerability to adverse outcomes. Abnormal RDW values shall hence persuade physicians to broaden the diagnostic reasoning over anaemias, especially those due to malnutrition or malabsorption, encompassing a comprehensive assessment of traditional and non-traditional CV risk factors.

Red blood cell distribution width (RDW) is an independent predictor of post-implantation syndrome in patients undergoing endovascular aortic repair for abdominal aortic aneurysm

Background

This observational, retrospective study aims establishing the role of red blood cell distribution width (RDW) for identifying abdominal aortic aneurism (AAA) patients at risk of developing post-implantation syndrome (PiS) after endovascular aneurysm repair (EVAR).

Methods

The study population consisted of all patients undergoing EVAR for AAA at the University Hospital of Verona (Italy), between June 1, 2016 and May 31, 2018. Blood samples for measuring hemoglobin, mean corpuscular volume (MCV) and RDW were collected at hospital admission and the day after EVAR. The primary endpoint was PiS development. Delta variations were calculated as the ratio between values measured after and before EVAR.

Results

The final study population consisted of 124 patients (10 women and 114 men; median age, 75 years), 55 of whom developed PiS. In patients with or without PiS hemoglobin significantly decreased after EVAR, whilst RDW significantly increased in patients with PiS and decreased in those without. Age, sex, hypertension, diabetes and renal failure were similar in patients who developed PiS or not, whilst a positive history of coronary artery disease was more frequent in PiS patients. Although hemoglobin and MCV changes after EVAR did not differ in patients with or without PiS, delta RDW was higher in those with PiS. The rate of patients with delta RDW >1 was significantly higher in patients with PiS that in those without (61.8% vs. 34.8%; P=0.002). In multivariate analysis, delta RDW remained independently associated with PiS (β coefficient, 2.023; P=0.001). A delta RDW >1 after EVAR was associated with ~3-fold enhanced risk of PiS (odds ratio, 3.04; P=0.003) and exhibited a good prognostic performance (area under the curve, 0.69; P<0.001).

Conclusions

Calculation of delta RDW after EVAR seems an efficient prognostic tool for stratifying the risk of developing PiS, especially in the early postoperative period.

Diagnostic and Prognostic Relevance of Red Blood Cell Distribution Width for Vascular Aging and Cardiovascular Diseases

Evidence suggests association of red blood cell distribution width (RDW) with cardiovascular diseases (CVDs). On the contrary, we underline that the sole RDW values cannot represent a valid CVD biomarker. High RDW values are expression of biological effects of a lot of both endogenous and exogenous factors (i.e., age, sex, genetic background, inflammation, hormones, drugs, diet, exercise, hematological analyzers, and ranges of values), modulating the biology and physiology of erythrocytes. Thus, the singular monitoring of RDW cannot be used to predict cardiovascular disorders. Accordingly, we have reviewed the evidence for potential relationship of RDW values with alterations in the cardiovascular system (i.e., regenerative capacity, endothelial turnover, and senescence of cardiovascular cells), associated with vascular aging and disease. In addition, we highlight the inevitable impact of biases in clinical application of RDW related to CVDs. Based on our thorough review of literature, we suggest a combined evaluation of RDW with other emerging biomarkers related to vascular aging and the diagnosis and prognosis of CVDs, including telomere length of leukocytes, circulating nucleated red blood cells (nRBCs) and endothelial progenitor cells (EPCs) in future large scale studies.

High red cell distribution width at the time of ST segment elevation myocardial infarction is better at predicting diastolic than systolic left ventricular dysfunction: A single-center prospective cohort study

Multiple studies have demonstrated the association of red cell distribution width (RDW) with the ultrasound parameters of both systolic and diastolic heart dysfunction. We aimed to further investigate the clinical associations of RDW in the setting of ST-elevation myocardial infarction (STEMI) and to comparatively evaluate its predictive properties regarding systolic and diastolic dysfunction.A total of 89 patients with STEMI were prospectively analyzed. RDW was obtained at the time of STEMI and compared to the parameters of systolic and diastolic dysfunction obtained by transthoracic heart ultrasound on the 5th through 7th day post-STEMI.The median RDW was 13.9%, and among other factors, RDW was significantly associated with older age (P < .001), arterial hypertension (P = .017), hyperlipoproteinemia 2, nonsmoking (P = .027), increased thrombolysis in myocardial infarction score (P = .004), and multivessel disease (P = .007). A higher RDW was observed in patients with parameters that indicated systolic and diastolic dysfunction (ejection fraction of the left ventricle < 50% [P = .009], early/late diastolic filling wave ratio [E/A] < 1 [P = .001], ratio of peak early transmitral velocity and early diastolic annular velocity [E/E'] >10 [P < .001], and combined E/A < 1 and E/E' > 10 [P < .001]). The best discriminatory properties were observed for combined E/A < 1 and E/E' > 10. RDW remained significantly associated with the aforementioned parameters in a series of multivariate regression models.Elevated RDW is significantly associated with the parameters of systolic and diastolic dysfunction even after adjusting for several confounding factors in the setting of STEMI and subsequent percutaneous coronary intervention. RDW seems to be better at discriminating patients with diastolic rather than systolic dysfunction.

Role of RDW in Prediction of Burn after Caustic Substance Ingestion

A quantifiable, quick, inexpensive and reproducible predictor is needed to decide if caustic substance ingestion results in burn regardless of the symptoms. A multicenter cohort study was conducted to investigate the predictive value of red cell distribution width (RDW) in detecting the esophageal burns. The data of 174 patients were retrospectively analyzed. Eleven patients were excluded due to inability to define the substance ingested. Complete blood count (CBC) was taken at admission, and an esophagogastroduodenoscopy was performed within the first 12–24 h in all patients, regardless of their symptoms. The age and gender of the patients, the types of substances ingested, the parameters in the CBC and the severity of the esophageal injury were correlated. Esophageal burns were diagnosed in 38 of 163 patients (23.3%). The risk of esophageal burn with RDW values below 12.20 was significantly lower. Multivariate analysis showed that RDW was the most significant predictor of esophageal burn (p = 0.000, odds ratio (OR) 7.74 (95% confidence interval (CI), 3.02–19.9)). Receiver operating characteristic (ROC) curve analysis demonstrated 84.2% sensitivity at a cut-off value of 12.20 for RDW. The results showed that CBC parameters could avoid unnecessary esophagogastroduodenoscopy. The RDW values regardless of the symptomatology is a good predictor of esophageal burns, and an RDW value over 12.20 shows the increased risk of esophageal burn.

Red Blood Cell Distribution Width: A Novel Predictive Indicator for Cardiovascular and Cerebrovascular Diseases

The red blood cell distribution width (RDW) obtained from a standard complete blood count (CBC) is a convenient and inexpensive biochemical parameter representing the variability in size of circulating erythrocytes. Over the past few decades, RDW with mean corpuscular volume (MCV) has been used to identify quite a few hematological system diseases including iron-deficiency anemia and bone marrow dysfunction. In recent years, many clinical studies have proved that the alterations of RDW levels may be associated with the incidence and prognosis in many cardiovascular and cerebrovascular diseases (CVDs). Therefore, early detection and intervention in time of these vascular diseases is critical for delaying their progression. RDW as a new predictive marker and an independent risk factor plays a significant role in assessing the severity and progression of CVDs. However, the mechanisms of the association between RDW and the prognosis of CVDs remain unclear. In this review, we will provide an overview of the representative literatures concerning hypothetical and potential epidemiological associations between RDW and CVDs and discuss the underlying mechanisms.