Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2021 | Month : August | Volume : 15 | Issue : 8 | Page : OC67 - OC70 Full Version

Predictive Value of Neutrophil Lymphocyte Ratio and Platelet Lymphocyte Ratio in Immediate Outcomes of ST-elevation Myocardial Infarction: A Cross-sectional Study


Published: August 1, 2021 | DOI: https://doi.org/10.7860/JCDR/2021/49214.15312
Sneha Barkur Sadashiva, KS Chenthil

1. Junior Resident, Department of Internal Medicine, Mahatma Gandhi Medical College and Research Institute, Puducherry, India. 2. Professor, Department of Internal Medicine, Mahatma Gandhi Medical College and Research Institute, Puducherry, India.

Correspondence Address :
Dr. KS Chenthil,
Professor, Department of Internal Medicine, Mahatma Gandhi Medical College and
Research Institute, Pilliyarkuppam-607403, Puducherry, India.
E-mail: chenthil21 @gmail.com

Abstract

Introduction: There have been various inflammatory markers implicated in the pathogenesis of Acute Coronary Syndromes (ACS). However, the role of the Neutrophil Lymphocyte Ratio (NLR) and Platelet Lymphocyte Ratio (PLR) as prognostic markers in ST-elevation Myocardial Infarction (STEMI) remains poorly researched.

Aim: To determine the prognostic value of NLR and PLR to predict the immediate outcomes in patients with acute STEMI, and if any association exists between NLR/PLR and Thrombolysis in Myocardial Infarction (TIMI) risk score.

Materials and Methods: This was a cross-sectional study conducted at a tertiary care centre, Puducherry, India, where 190 patients who presented to casualty with STEMI were enrolled. The patient co-morbidities, personal and family history were obtained. The routine laboratory parameters including platelets, lymphocytes, neutrophils and their corresponding ratios were calculated. Patients were grouped into low and high NLR/PLR groups and were assessed for occurrence of in-hospital mortality or Major Adverse Cardiovascular Events (MACE). Analysis was made to see if there is an association between NLR/PLR and MACE. Chi-square test and one-way ANOVA test was used for statistical significance.

Results: Among 190 subjects, 157 male and 33 female with mean age of 55.72±11.24 years were included. A total of 8.94% patients 8.94% had MACE. NLR was positively associated with MACE (p-value=0.0006), whereas PLR was not associated with MACE. Patients with high NLR had 1.45 times higher odds of having MACE. NLR was significantly associated with TIMI risk score. Both NLR (F ratio=6.341) and PLR (F ratio=4.600) showed significant association with Killip classification, however NLR showed higher association (p-value <0.001).

Conclusion: NLR can be used as a powerful prognostic marker for predicting immediate MACE and death in STEMI patients. In addition, NLR showed positive correlation with Killip classification and TIMI risk score.

Keywords

Acute coronary syndrome, Inflammatory markers, Killip classification, Major adverse cardiovascular events, Prognostic markers

Acute STEMI is one of the most common emergencies seen worldwide. The underlying pathophysiological mechanism is atherosclerotic plaque rupture and thrombus formation. Inflammation has been found to be the basis of many cardiovascular diseases, especially those that involve atherosclerosis, a mechanism seen in Coronary Artery Disease (CAD) (1),(2),(3). The body responds to inflammation by producing white blood cells, especially neutrophils from the bone marrow. Lymphocytes and monocytes play a key role in the early stages of plaque formation (4).

One of the most selective markers to detect myocardial damage is troponin. There is ambiguity in the use of troponin in emergency setting, as there can be a prolonged elevation in serum troponin levels and there is a need to measure it at successive intervals to see the increasing trend. Although, the fundamental flaw against it is an increase in its serum level 3-4 hours after the onset of symptoms. Thus, in most centers, these markers should be reviewed in consecutive times. And in this case, its application in rapid triage of patients with Myocardial Infarction (MI) is faced with ambiguity (5). Hence, there is a need to find novel biomarkers. D-dimer level is expected to increase in acute ischemic events faster than other cardiac markers (6). CD40 ligand is known to regulate the thrombotic potential of human atherosclerotic lesion by inducing the expression of tissue factor (7).

Therefore, there is increasing need to find prognostic markers capable of accelerating diagnostic and decision making processes for STEMI patients (8). NLR and PLR are the two indices which have attracted attention as inflammatory markers capable of predicting poor prognosis and MACE (9),(10). There are many advantages of NLR such as being cost effective and high speed of testing, hence, saves a lot of time in the decision process and planning for a referral to a higher ICU centre if worse prognosis is predicted (11). Moreover, there is inadequate research regarding the prognostic value of NLR and PLR when compared to the standard Thrombolysis in Myocardial Infarction (TIMI) scoring, which is a well established tool that analyses the 30 days mortality of patients with STEMI. The effect of NLR on cardiovascular diseases is still unclear and prognostic significance of NLR in patients with STEMI is not established.

Hence, this study aimed to determine the prognostic value of NLR and PLR to predict the immediate outcomes (one week) in patients with acute STEMI.

Material and Methods

It was a prospective cross-sectional study, conducted at a tertiary care centre, Puducherry, India from January 2019 to June 2020 after approval from Institutional Ethical Committee Board (Reg no. ECR/451/inst/PO/2013/RR-16, project number- 02/2019/16). Informed consent was obtained in local language from the participants.

Sample size calculation: Sample size was calculated using the statistical formula for estimating a proportion with 5% absolute precision and 5% level of significance. The study included a total sample size of 190 participants.

Inclusion criteria: Study participants, aged more than 18 years who presented to casualty with STEMI. The STEMI was diagnosed based on the criteria laid by the American Heart Association as a new ST-elevation measured from the J point in two or more contiguous leads with a cut-off point of 0.1 mV in all leads except V2,V3, whereas a cut-off >2 mm >40 years of age, >2.5 mm <40 years of age, >1.5 mm in leads V2, V3 in a woman irrespective of age, during the first 12 hours after the onset of symptoms were included in the study. (12).

Exclusion criteria: Patients with unstable angina, non-STEMI, severe liver disease, autoimmune disease, haematological disorders, inflammatory and infectious disease, pre-existing valvular disease and whose laboratory blood investigations were not available were excluded from the study.

Study Procedure

The basic demographics of patients like age, sex, co-morbidities (diabetes mellitus, hypertension, dyslipidaemia), personal history (smoking and alcohol consumption) and family history of CAD were obtained. Two mL of venous blood sample was drawn at the time of admission in casualty and sent for estimation of complete blood counts. NLR and PLR were calculated. Patients were grouped into low and high NLR groups based on a cut-off of 3.53, whereas the cut-off for PLR was 172 (13).

All patients were assessed for occurrence of MACE which includes arrythmias, cardiogenic shock, cardiac rupture, re-infarction and in hospital mortality. Data was analysed to find out if there is an association between NLR/PLR and MACE and the correlation between NLR/PLR and TIMI risk score.

TIMI risk score is a well researched score that analyses the 30 day mortality and 1 year mortality of patients with STEMI-ACS. The total is 7 points, and each variable is assigned 1 point. Variables includes age over 65 years, the presence of three or more CAD risk factors, previous coronary artery stenosis more than 50%, changes in ECG ST segment elevation, angina attacks greater than or equal to 2 in the past 24 hours, ingestion of aspirin and raised cardiac enzymes in the past 7 days (14). Patients were also grouped into clinical severity based on Killip classification and data was analysed. Killip class I- no clinical signs of failure; Killip class II- rales/crackles in the lung; Killip class III- pulmonary oedema; Killip class IV- cardiogenic shock (15).

Statistical Analysis

Descriptive analysis was carried out by calculating mean and standard deviation for quantitative variables, frequency and proportion for categorical variables. Chi-square test and one-way ANOVA test was used for statistical significance. Statistical Package for the Social Sciences (SPSS) version 25.0 was used for statistical analysis.

Results

There were 157 males and 33 females; their co-morbidities, risk factors and haematological parameters are shown in (Table/Fig 1). Logistic regression analysis was carried out to find out the association of the NLR and PLR with MACE (Table/Fig 2). This analysis found that both NLR and PLR were associated with the MACE as an outcome. However, the NLR showed a higher association than PLR. It was again proved by the odds ratio. Patients with high NLR had 1.45 times higher odds of having MACE, whereas patients with high PLR had 0.9917 times higher odds of having MACE. Based on this analysis, it was concluded that the percentage of cases correctly classified by NLR was 92.63% (Table/Fig 3). NLR was observed as a high value in MACE positive than negative group which was statistically significant (p-value=0.0042).

The one-way ANOVA was conducted to confirm the above results. The ANOVA showed that NLR had a close association with MACE while PLR was not associated with MACE (Table/Fig 4). In the total population, NLR has shown a prognostic value to identify the cardiovascular outcomes appropriately

Both NLR and PLR showed significant association with Killip Classification (Table/Fig 4). However, NLR showed higher association with Killip (p-value <0.001).

The NLR has shown significant differences and associations with the TIMI risk score. The one-way ANOVA showed that the NLR has significantly differed among the three groups of TIMI risk Score (p-value=0.039). The PLR did not show any significant difference (p-value=0.525) (Table/Fig 4).

Discussion

Even though various studies showed NLR as a good prognostic marker in STEMI, there was lack of evidence of comparison between NLR and established TIMI mortality risk score (16),(17),(18),(19),(20). NLR combines two subtypes of leukocytes, which have opposite effects on inflammation. Therefore, the ratio is more predictive than using any one parameter alone. The aim of this study was to determine the predictive value of NLR and PLR with the in-hospital mortality and MACE in patients with acute STEMI and also to evaluate the association between TIMI risk score with NLR and PLR in patients with STEMI. The results showed that higher NLR was significantly associated with MACE, KILLIP classification and TIMI risk score in STEMI.

A study among patients with ACS found that NLR at admission was an independent predictor of hospitalisation and six month mortality (21),(22). Similar to this study results, other studies also have shown that the NLR is a prognostic marker in patients with CAD (23). In addition, the maximum NLR can effectively predict the subsequent mortality of STEMI hospitalised patients, and has a high discriminative ability (24).

Platelets have a significant role in production of inflammatory mediators (25). However, platelets are known to be an important factor in the formation of a thrombus, thus play a key role in the pathogenesis of ACS (26). The association between low lymphocyte count and MACE has also been shown in several studies (27),(28). Subsequently, PLR has been proposed to be a useful prothrombotic and inflammatory marker (29),(30). It has been reported that higher platelet and lower lymphocyte counts are associated with poor cardiovascular prognosis (31).

The present study found a significant association between Total Leukocyte Count (TLC) and NLR, which was concordant with results of previous study (32),(33). Several studies have found that TLC provides independent predictive value for short-term mortality in patients with acute myocardial infarction (33),(34). This can be explained by mechanisms such as leukocyte mediated hypercoagulability and indirect cardiotoxicity mediated by proinflammatory cytokines (35),(36).

The prognostic significance of different WBC subtypes varies in patients with acute myocardial infarction (37),(38),(39),(40),(41),(42). High neutrophil count was associated with a larger infarction size, worse angiographic outcomes and poor short-term prognosis in patients with acute STEMI (37). Neutrophils produce certain inflammatory mediators like elastase, myeloperoxidase, and acid phosphatase that cause acute myocardial injury or further tissue damage after STEMI (42). In addition, lymphopenia is associated with a high risk of adverse consequences and mechanical complications after acute myocardial infarction (28).

In a study, a comparison was made between NLR and complexity of CAD, it was found that complex CAD had a NLR of 2.3, which was higher than others which had NLR of 1.6 (43). Another study proved that the severity of CAD increased with increasing NLR (44).

There was no statistically significant correlation between the age and NLR which was also manifested in a previous study, whereas in few previous studies, it was observed that patients who had higher NLR were older than those with lower NLR (21),(45). Hence, based on the risk stratification, the association of age with NLR could vary.

A non significant association was seen in patients, between NLR and diabetes mellitus in previous studies which is similar to our results (32),(45). Also, we found no significant association between Hypertension (HTN) and NLR, similar to previous studies (32),(45).

A meta-analysis study explored the impact of NLR on clinically important outcomes in ACS. It was found high NLR measured at admission, was associated with a higher mortality rate and with major clinical adverse outcomes. Overall, the risk of in-hospital and long-term mortality increased in patients with higher NLR (46).

Many ACS studies now support the use of NLR as a biomarker of admission, which can be used to determine prognosis (21),(22),(23). NLR can be easily calculated at the time of care, thereby helping STEMI patients with short-term and long-term risk prediction, even before revascularisation occurs. In patients with high NLR, early identification of MACE can be achieved by strict surveillance which can help in making treatment decisions, preventing complications and reducing hospital stay (46).

Limitation(s)

Although NLR, a combined surrogate marker for both acute inflammatory reactions and activated neurohormonal system, might be more potent than these other surrogate markers, there is lack of comparison studies with these markers and NLR. Also, it was a cross-sectional study, not a cohort study. Therefore, the derived cut-off value of the study could not be applied to the general population.

Conclusion

NLR is used as a good prognostic indicator for predicting short-term MACE and death in STEMI patients, whereas PLR did not show a positive association with MACE. In addition, NLR showed positive correlation with Killip classification and TIMI risk score, which can predict prognosis in STEMI patients. It is a widely used, easy to calculate, inexpensive, immediately available and effective blood index, hence it can be used as a reliable admission biomarker to determine prognosis in acute STEMI patients.

References

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Yayan J. Emerging families of biomarkers for coronary artery disease: Inflammatory mediators. Vasc Health Risk Manag. 2013;9:435-56. [crossref] [PubMed]
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Wu AHB, Smith A, Christenson RH, Murakami MM, Apple FS. Evaluation of a point-of-care assay for cardiac markers for patients suspected of acute myocardial infarction. Clin Chim Acta. 2004;346(2):211-19. [crossref] [PubMed]
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DOI and Others

10.7860/JCDR/2021/49214.15312

Date of Submission: Mar 03, 2021
Date of Peer Review: Apr 26, 2021
Date of Acceptance: Jun 11, 2021
Date of Publishing: Aug 01, 2021

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Mar 04, 2021
• Manual Googling: Jun 10, 2021
• iThenticate Software: Jul 22, 2021 (25%)

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