Effect of peripheral edema on oscillometric blood pressure measurement

To Evaluate Platelet Indices, Platelet to Lymphocyte Ratio and Neutrophil to Lymphocyte Ratio as Prognostic and Risk Factors in Patients with Coronary Artery Disease

To evaluate platelet indices, platelet to lymphocyte ratio and neutrophil to lymphocyte ratio as prognostic and risk factors in patients with coronary artery disease Introduction: cardiovascular diseases have 12 million deaths annually which is one of the commonest causes of death globally. Platelet parameters like Mean platelet volume (MPV), platelet distribution width (PDW) and WBC parameters like Neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio(PLR) have recently been emerging as a new prognostic marker in number of coronary artery disease (CAD) with limited studies to explore their utility.

AIMS AND OBJECTIVES

this study aimed to evaluate MPV, P-LCR, PDW, PLR, NLR and GRACE risk score in CAD patients.

MATERIAL AND METHODS

this descriptive cross-sectional study was done in 330 cases of CAD and 200 healthy controls were studied.MPV, platelet-large cell ratio (P-LCR), PLR, NLR and PDW of patients were analyzed.

RESULTS

In our study, 245 were males and 85 were females. Mean PDW, MPV, Mean PLCR, Mean NLR was significantly higher in CAD cases as compared to controls (p value < 0.05). Mean PLR was not significantly different in CAD cases and controls. MPV was more associated risk predictor of CAD (8.98 times) followed by NLR (2.79 times), PDW (1.53 times) and PLCR (1.02 times).

DISCUSSION AND CONCLUSION

platelet indices, NLR and PLR are simple cost effective parameters and in future these might be useful adjuvant tests in conjunction with conventional biochemical cardiac markers in early prediction of risk of CAD in patients admitted to hospital and can guide clinicians in assessing the prognosis on short and long term follow up of these patients in terms of morbidity and mortality.

Evaluation of Intermountain Risk Score for Short- and Long-Term Mortality in ST Elevation Myocardial Infarction Patients

The aim of this study was to examine the Intermountain Risk Score (IMRS) for short- and long-term mortality in ST elevation myocardial infarction (STEMI) patients and compare it with the well-known risk scores, such as the Thrombolysis in Myocardial Infarction (TIMI) and the Global Registry of Acute Coronary Events (GRACE). In this retrospective and cross-sectional study, 1057 consecutive patients with STEMI were evaluated. The end-points of the study were short- and long-term mortality. The overall mortality rate was 16% (n = 170 patients). The IMRS was significantly higher in STEMI patients who did not survive compared with those who survived. According to multivariable COX proportional regression analysis, the IMRS was independently related to both short- (HR: 1.482, 95% CI: 1.325-1.675, p < .001) and long-term mortality (HR: 1.915, 95% CI: 1.711-2.180, p < .001). The comparison of receiver operating characteristic curves revealed that the IMRS had non-inferior predictive capability for short- and long-term mortality than the TIMI and GRACE risk scores. To the best of our knowledge, this is the first study to show that the IMRS can predict short- and long-term prognosis of patients with STEMI. Further, the IMRS' predictive value for overall mortality was non-inferior compared with TIMI and GRACE scores.

Comparison of Blood Pressure Measurements by Currently Available Multiparameter Monitors and Mercury Column Sphygmomanometer in Patients Admitted in Pediatric Intensive Care Unit

Background

The multiparameter monitor (MPM) is replacing mercury column sphygmomanometers (MCS) in acute care settings. However, data on the former's accuracy in critically ill children are scarce and mostly extrapolated from adults. We compared non-invasive blood pressure (NIBP) measurements by MPMs with MCS in pediatric intensive care unit (PICU).

Patients

Adequately sedated and hemodynamically stabilized children (age, 1-144 months) were prospectively enrolled.

Materials and methods

Three NIBP measurements were obtained from MCS (Diamond®, India) and MPM (Intellivue MX800® or Ultraview SL®) in rapid succession in the upper limb resting in supine position. Respective three measurements were averaged to obtain a paired set of NIBP readings, one each from MCS and MPM. Such readings were obtained thrice a day. NIBP readings were then compared, and agreement was assessed.

Results

From 39 children [median age (IQR), 30 (10-72) months], 1,690 sets of NIBP readings were obtained. A-third of readings were from infants and children >96 months, while 383 (22.6%) readings were from patients on inotropes. Multiparameter monitors gave significantly higher NIBP readings compared to MCS [median systolic blood pressure (SBP), 6.5 (6.4-6.7 mm Hg); diastolic blood pressure (DBP), 4.5 (4.3-4.6 mm Hg); mean arterial pressure (MAP), 5.3 (5.1-5.4 mm Hg); p < 0.05]. It was consistent across age, gender, and critical care characteristics. Multiparameter monitors overestimated SBP in 80% of readings beyond the maximal clinically acceptable difference (MCAD).

Conclusions

Non-invasive blood pressure readings from MCS and MPMs are not interchangeable; SBP was 6-7 mm Hg higher with the latter. Overestimation beyond MCAD was overwhelming. Caution is required while classifying systolic hypotension with MPMs. Confirmation with auscultatory methods is advisable. More studies are required to evaluate currently available MPMs in different pediatric age groups.

How to cite this article

Khan AA, Gupta PK, Baranwal AK, Jayashree M, Sahoo T. Comparison of Blood Pressure Measurements by Currently Available Multiparameter Monitors and Mercury Column Sphygmomanometer in Patients Admitted in Pediatric Intensive Care Unit. Indian J Crit Care Med 2023;27(3):212-221.

Assessment of Admission Time Cell Blood Count (CBC) Parameters in Predicting Post-primary Percutaneous Coronary Intervention TIMI Frame Count in Patients with ST-segment Elevation Myocardial Infarction

OBJECTIVES

In this study, we aimed to assess the value of admission time CBC parameters in predicting post-primary PCI corrected TIMI frame count.

BACKGROUND

Recent years have witnessed a large series of studies evaluating different laboratory variables to predict no-reflow phenomenon following primary PCI (PPCI) in patients with STEMI. However, a general agreement about the most reliable predictor of the no-reflow phenomenon is challenging and also intriguing.

METHODS

The current study concluded 208 consecutive patients who underwent primary PCI for ST-Elevation Myocardial Infarction (STEMI) from January 2014 to February 2016. Blood samples were obtained after taking ECG. Complete blood samples were collected and analyzed within 5 minutes from sampling. Post-PCI corrected Thrombolysis in Myocardial Infarction (TIMI) frame count was determined by one interventional cardiologist blinded to patients' clinical data. The correlation between admission time blood parameters and post-primary PCI corrected TIMI frame count in patients with STEMI were assessed.

RESULTS

Corrected TIMI frame count was positively correlated with WBC count (R: 0.18, P-value: <0.01), neutrophil count (R: 0.34, P-value: <0.01), and platelet count (R: 0.23, P-value: <0.01) and negatively correlated with lymphocyte count (R: -0.2, P-value: <0.01). Multiple linear regression results demonstrated that corrected TIMI frame count was positively correlated with neutrophil count (P < 0·001) and platelet count (P < 0·001) and negatively correlated with lymphocyte count (p=0.004).

CONCLUSION

High counts of WBC, neutrophil, and platelet and low count of lymphocyte may be predictors of no-reflow in STEMI patients undergoing PPCI. The clinical significance of such predictive parameters becomes clear as we consider the treatment approach in STEMI patients. Appropriate risk stratification leads to better treatment planning and allocation of resources.

Neutrophil-Mediated Cardiac Damage After Acute Myocardial Infarction: Significance of Defining a New Target Cell Type for Developing Cardioprotective Drugs

Significance: Acute myocardial infarction (AMI) is a leading cause of death worldwide. Post-AMI survival rates have increased with the introduction of angioplasty as a primary coronary intervention. However, reperfusion after angioplasty represents a clinical paradox, restoring blood flow to the ischemic myocardium while simultaneously inducing ion and metabolic imbalances that stimulate immune cell recruitment and activation, mitochondrial dysfunction and damaging oxidant production. Recent Advances: Preclinical data indicate that these metabolic imbalances contribute to subsequent heart failure through sustaining local recruitment of inflammatory leukocytes and oxidative stress, cardiomyocyte death, and coronary microvascular disturbances, which enhance adverse cardiac remodeling. Both left ventricular dysfunction and heart failure are strongly linked to inflammation and immune cell recruitment to the damaged myocardium. Critical Issues: Overall, therapeutic anti-inflammatory and antioxidant agents identified in preclinical trials have failed in clinical trials. Future Directions: The versatile neutrophil-derived heme enzyme, myeloperoxidase (MPO), is gaining attention as an important oxidative mediator of reperfusion injury, vascular dysfunction, adverse ventricular remodeling, and atrial fibrillation. Accordingly, there is interest in therapeutically targeting neutrophils and MPO activity in the setting of heart failure. Herein, we discuss the role of post-AMI inflammation linked to myocardial damage and heart failure, describe previous trials targeting inflammation and oxidative stress post-AMI, highlight the potential adverse impact of neutrophil and MPO, and detail therapeutic options available to target MPO clinically in AMI patients.

Neutrophil-lymphocyte ratio is a marker of survival and cardiac complications rather than patency following revascularization of lower extremities

The neutrophil-lymphocyte ratio (NLR), as a marker of inflammation, is associated with the severity of peripheral artery disease (PAD). The role of the NLR on predicting future complications after elective revascularization for patients with PAD remains unknown. We aimed to examine the role of the NLR in the development of major adverse limb events (MALE) and the long-term mortality of these patients. We evaluated 1708 revascularization procedures from May 2001 to December 2015 at the Veterans Affairs Western New York Healthcare System from a prospectively maintained vascular database that included demographics, comorbidities and pre-procedural medications. Peri-procedural laboratory findings including complete blood cell count and metabolic panel were further retrieved from the electronic health record. The NLR was calculated, and the patients were categorized into tertiles according to NLR cut-off points. Multivariate Cox regression analysis was performed to determine MALE and 10-year mortality. The primary endpoint of the study was MALE, and the secondary endpoint included 10-year mortality. A total of 1228 patients were included for final analyses. Patients in the third NLR tertile were more likely to experience MALE during the follow-up period ( p<0.001). In addition, fewer patients in tertile 3 survived over the follow-up period compared to tertiles 1 and 2 ( p<0.0001). Patients in tertile 3 tended to be older with a higher frequency of hypertension, diabetes, chronic kidney disease, coronary artery disease and congestive heart failure. Our multivariate analysis demonstrated that the NLR was independently associated with higher rates of MALE in the affected vessels following revascularization procedures. Similarly, the NLR was revealed to be an independent predictor of higher long-term mortality in these patients.

Hemographic indices are associated with mortality in acute heart failure

Hemographic indices have been associated with clinical outcomes in patients with chronic heart failure. We therefore investigated the prognostic values of hemographic indices in patients hospitalized for acute heart failure (AHF). Patients hospitalized primarily for AHF were drawn from an intramural registry. Hemographic indices, including white blood cell counts, neutrophil counts, neutrophil-to-lymphocyte ratio, reciprocal of lymphocyte (RL) and platelet-to-lymphocyte ratio were recorded. Among a total of 1923 participants (mean age 76 ± 12 years, 68% men), 875 patients died during a mean follow-up of 28.6 ± 20.7 months. Except for white blood cell counts, all the other hemographic indices were related to mortality, independently. In a forward stepwise Cox regression analysis among hemographic indices, RL was the strongest predictor (HR and 95% CI per-1SD:1.166,1.097-1.240) for mortality, after accounting for confounders. However, conditioned on the survivals, the hemographic indices were independently related to mortality within 3 years of follow-up, rather than beyond. Hemographic indices were independent risk factors of mortality in patients hospitalized for AHF, especially in patients with impaired left ventricular systolic function. As an acute presentation of inflammation, hemographic indices might be useful to identify subjects at risk of mortality soon after the index hospitalization.

Interaction of 12/15-lipoxygenase with fatty acids alters the leukocyte kinetics leading to improved postmyocardial infarction healing

The metabolic transformation of fatty acids to form oxylipids using 12/15-lipoxygenase (LOX) can promote either resolving or nonresolving inflammation. However, the mechanism of how 12/15-LOX interacts with polyunsaturated fatty acids (PUFA) in postmyocardial infarction (post-MI) healing is unclear. Here, we reported the role of 12/15-LOX in post-MI cardiac remodeling in a PUFA [10% (wt/wt), 22 kcal]-enriched environment. Wild-type (WT; C57BL/6J) and 12/15-LOX-null (12/15-LOX^-/-) male mice of 8-12 wk of age were fed a PUFA-enriched diet for 1 mo and subjected to permanent coronary artery ligation. Post-MI mice were monitored for day 1 or until day 5 along with standard diet-fed MI controls. No-MI surgery mice served as naïve controls. PUFA-fed WT and 12/15-LOX^-/- mice improved ejection fraction and reduced lung edema greater than WT mice at day 5 post-MI (P < 0.05). Post-MI, neutrophil density was decreased in PUFA-fed WT and 12/15-LOX^-/- mice at day 1 (P < 0.05). Deletion of 12/15-LOX in mice led to increased cytochrome P-450-derived bioactive lipid mediator epoxyeicosatrienoic acids (EETs), i.e., 11,12-EpETrE and 14,15-EpETrE, which were further enhanced by acute PUFA intake post-MI. Macrophage density was decreased in WT + PUFA and 12/15-LOX^-/- mice compared with their respective standard diet-fed WT controls at day 5 post-MI. 12/15-LOX^-/- + PUFA mice displayed an increased expression of chemokine (C-C motif) ligand 2 and reparative macrophages markers (Ym-1, Mrc-1, and Arg-1, all P < 0.05) in the infarcted area. Furthermore, 12/15-LOX^-/- mice, with or without PUFA, showed reduced collagen deposition at day 5 post-MI compared with WT mice. In conclusion, deletion of 12/15-LOX and short-term exposure of PUFA promoted leukocyte clearance, thereby limiting cardiac remodeling and promoting an effective resolution of inflammation.NEW & NOTEWORTHY This study determined that 1) deletion of 12/15-lipoxygenase (LOX) promotes the generation of epoxyeicosatrienoic acids, the cytochrome P-450-derived metabolites in postmyocardial infarction (post-MI) healing; 2) acute exposure of fatty acids to 12/15-LOX^-/- mice drives leukocyte (neutrophils and macrophages) clearance post-MI; and 3) metabolic transformation of fats is the significant contributor in leukocyte clearance to drive either resolving or nonresolving inflammation post-MI.

The prognostic and risk-stratified value of neutrophil–lymphocyte count ratio in Chinese patients with community-acquired pneumonia

Community-acquired pneumonia is a common disease associated with high mortality. This retrospective study examined whether the neutrophil–lymphocyte count ratio (NLR), already widely used as an index of inflammation, can be used to predict in-hospital mortality of adults with community-acquired pneumonia. Clinical characteristics, CURB-65 and pneumonia severity index score of pneumonia severity, NLR, serum levels of C-reactive protein and procalcitonin, and in-hospital mortality were analyzed for 318 consecutive adults with community-acquired pneumonia admitted to West China Hospital between July 2012 and December 2013. The ability of NLR and other parameters to predict in-hospital mortality was assessed using receiver operating characteristic (ROC) curves. Results showed that NLR increased with increasing CURB-65 ( P < 0.05) and pneumonia severity index ( P < 0.05), and NLR correlated positively with serum levels of C-reactive protein (r = 0.239, P < 0.05) and procalcitonin (r = 0.211, P < 0.05). The median value of NLR was significantly higher among patients who died in hospital (11.96) than among those who were alive at the end of hospitalization (4.19, P < 0.05). Based on a cut-off NLR of 7.12, this index predicted in-hospital mortality with a sensitivity of 82.61% and specificity of 72.20% (area under ROC curve, 0.799). Predictive power was greater for the combination of NLR and serum levels of C-reactive protein and procalcitonin. These results suggest that NLR may be useful for predicting prognosis in Chinese adults with community-acquired pneumonia, and it may work better in combination with traditional markers.

Natural history and risk stratification of patients undergoing non-invasive ventilation in a non-ICU setting for severe COPD exacerbations

Non-invasive ventilation (NIV) delivered in an intensive care unit (ICU) has become the cornerstone in the treatment of patients with severe chronic obstructive pulmonary disease (COPD) exacerbations. A trend towards managing these patients in non-ICU setting has emerged in recent years, although out-of-hospital survival by this approach and how to prognosticate it is unknown. We aimed to investigate these issues. We consecutively recruited 100 patients (49 males; median age 82 years) who received NIV treatment for acute respiratory failure due to COPD exacerbation in non-ICU medical wards of our hospital, between November 2008 and July 2012. We assessed survival (both in-hospital and out-of-hospital) of all these patients, and analyzed baseline parameters in a Cox proportional hazards model to develop a prognostic score. The median survival in the study population was 383 days (240-980). Overall survival rates were 71.0, 65.3, and 52.7 % at 1, 3, and 12 months, respectively. Age >85 years, a history of heart disorders and a neutrophil count ≥10 × 10(9) were associated with higher mortality at Cox's analysis (χ (2) = 35.766, p = 0.0001), and were used to build a prognostic score (NC85). The presence of two or more factors determined the deepest drop in survival (when NC85 ≥2, mortality at 1, 3, and 12 was 60.7, 70.4, and 77.2 %, respectively, while when NC85 = 0 were 4.0, 4.0, and 14.0 %). A simple model, based on three variables (age, neutrophil count and history of heart disease), accurately predicts survival of COPD patients receiving NIV in a non-ICU setting.

Goal-directed Fluid Therapy May Improve Hemodynamic Stability of Parturient with Hypertensive Disorders of Pregnancy Under Combined Spinal Epidural Anesthesia for Cesarean Delivery and the Well-being of Newborns

Background:

Hypotension induced by combined spinal epidural anesthesia in parturient with hypertensive disorders of pregnancy (HDP) can easily compromise blood supply to vital organs including uteroplacental perfusion and result in fetal distress. The aim of this study was to investigate whether the goal-directed fluid therapy (GDFT) with LiDCO_rapid system can improve well-being of both HDP parturient and their babies.

Methods:

Fifty-two stable HDP parturient scheduled for elective cesarean delivery were recruited. After loading with 10 ml/kg lactated Ringer's solution (LR), parturient were randomized to the GDFT and control group. In the GDFT group, individualized fluid therapy was guided by increase in stroke volume (ΔSV) provided via LiDCO_rapid system. The control group received the routine fluid therapy. The primary endpoints included maternal hypotension and the doses of vasopressors administered prior to fetal delivery. The secondary endpoints included umbilical blood gas abnormalities and neonatal adverse events.

Results:

The severity of HDP was similar between two groups. The total LR infusion (P < 0.01) and urine output (P < 0.05) were higher in the GDFT group than in the control group. Following twice fluid challenge tests, the systolic blood pressure, mean blood pressure, cardiac output and SV in the GDFT group were significantly higher, and the heart rate was lower than in the control group. The incidence of maternal hypotension and doses of phenylephrine used prior to fetal delivery were significantly higher in the control group than in the GDFT group (P < 0.01). There were no differences in the Apgar scores between two groups. In the control group, the mean values of pH in umbilical artery/vein were remarkably decreased (P < 0.05), and the incidences of neonatal hypercapnia and hypoxemia were statistically increased (P < 0.05) than in the GDFT group.

Conclusions:

Dynamic responsiveness guided fluid therapy with the LiDCO_rapid system may provide potential benefits to stable HDP parturient and their babies.

Is there a link between the neutrophil-to-lymphocyte ratio and venous thromboembolic events after knee arthroplasty? A pilot study

Background

This study aimed to identify (1) if the postoperative increase in the neutrophil-to-lymphocyte ratio (NLR) is different between contrasting knee arthroplasty procedures, and (2) if the NLR predicts venous thromboembolism (VTE) after total knee arthroplasty (TKA).

Materials and methods

To address the first objective, we retrospectively studied patients who underwent primary unilateral TKA (n = 111) or unicompartmental knee arthroplasty (UKA; n = 74) between 2009 and 2012. Patients who required a blood transfusion, underwent autologous blood salvage, experienced any postoperative complication (such as VTE), or were re-admitted >90 days were excluded from analysis. For the second objective, we retrospectively identified patients (cases, n = 10) who underwent primary unilateral TKA between 2010 and 2012 and developed postoperative VTE (deep venous thrombosis, pulmonary embolism, or both) during inpatient care (postoperative day 1 or day 2). Cases were matched to surgeon, gender, body mass index, age, and date of surgery controls (n = 20) who underwent primary unilateral TKA without developing VTE before patient discharge. The NLR was calculated from the neutrophil and lymphocyte counts extracted from pre- and postoperative (day 1 and day 2) blood chemistry records.

Results

On postoperative day 1, the NLR increase was exacerbated (p = 0.02) following TKA compared to UKA and predicted (p = 0.02) the occurrence of VTE in TKA patients prior to hospital discharge.

Conclusion

We conclude that the NLR increase is greater following TKA compared to UKA and could serve as a matrix to predict or identify a patient susceptible of sustaining VTE after TKA.

Level of evidence

3.

Relationship between white blood cells and hypertension in Chinese adults: the Cardiometabolic Risk in Chinese (CRC) study

Increased blood pressure was associated with increased white blood cell count (adjusted p < 0.001) in a community-based health examination survey of adults in China (n = 39 282; aged 18-93 years). Adjusted odds ratios (95% confidence intervals) for hypertension across white blood cell count quintiles were 1.00, 0.99 (0.89-1.09), 1.11 (1.01-1.22), 1.09 (0.99-1.20), and 1.19 (1.08-1.31) (p for trend < 0.001). Body mass index and white blood cell count had an additive effect on systolic blood pressure (p for interaction = 0.047). Therefore, white blood cell count could independently predict hypertension in Chinese adults.

Association between HbA1c levels with severity of coronary artery disease and short-term outcomes of acute ST-elevation myocardial infarction in nondiabetic patients

BACKGROUND

The severity of coronary artery disease (CAD) is directly related to the quality of glucose control in diabetic patients. Additionally, mortality after an acute coronary syndrome is higher in patients with diabetes and it correlates to the level of glucose control. However, the role of higher gluconated hemoglobin in the process of coronary atherosclerosis and clinical outcome of acute myocardial infarction is unknown.

OBJECTIVES

To evaluate the association of HbA1c level and severity of CAD and short-term outcomes of acute ST-elevation myocardial infarction (STEMI) in nondiabetics.

METHODS

A total of 290 nondiabetic patients with STEMI were prospectively enrolled following their admission. Patients were stratified into 2 groups based on the median percent of HbA1c (⩽5.8% 'Low' and >5.8% 'High'). The severity of CAD based on the Califf scoring system, in-hospital mortality and morbidities of STEMI were compared between groups. Patients were followed for 1 year after discharge to assess readmission and mortality rate.

RESULTS

The severity score for CAD was significantly higher in the 'High' versus 'Low' HbA1c group (7.7 ± 2.7 and 5.5 ± 2.6, p = 0.001). A total of 15 patients died in both groups during the follow-up period. While in-hospital mortality was similar between the two groups, 12-month mortality was significantly higher in the 'High' group (7.7% versus 2.7%, p = 0.043). In addition, the rehospitalization rate within 1 year was 8.8% in the 'Low' group, which was significantly lower than 19.0% in the 'High' group (p = 0.016).

CONCLUSION

Among nondiabetic patients presenting with STEMI, the severity of CAD was higher in those with HbA1c level >5.8%; 1-year mortality and hospital readmission rates were also higher in this group of patients.