Akut pulmoner emboli hastalarında nötrofil-lenfosit oranındaki dinamik değişimin prognostik etkisi

Year 2020, Volume: 9 Issue: 2, 101 - 108, 31.08.2020

Adil Gökuç Tuncay Kırış , Tarık Yıldırım , Eyüp Avcı

Abstract

Amaç: Nötrofil / lenfosit oranındaki (NLO) zamansal değişikliklerin akut pulmoner embolide (APE) toplam mortalite ile ilişkili olup olmadığı açık değildir. APE'li hastalarda prognoz için NLO'nun dinamik izlenmesinin değerini araştırdık.
Yöntemler: 214 ardışık APE hastasını geriye dönük olarak analiz ettik. Hastalar hayatta kalanlar veya hayatta kalmayanlar olarak iki gruba ayrıldı. Nötrofil sayısı, lenfosit sayısı ve NLO, başvuru sırasında ve 72. saatte elde edildi. İki ölçüm arasındaki fark NLR değişimi (ΔNLR) olarak kabul edildi. Çalışmanın sonlanım noktası, 30 günlük takipte toplam ölüm oranıydı.
Bulgular: Takip sırasında 30 ölüm (% 14) saptandı. ΔNLR, hayatta kalmayanlarda hayatta kalanlara göre daha yüksekti (5.22 [0.62-7.76] ve -0.71 [-2.28-0.76], P <0.001). Çok değişkenli analizde, ΔNLR'nin 30 günlük mortalitenin önemli bir prediktörü olduğu bulundu (OR: 1.059,% 95 CI: 1.021-1.098, p = 0.002). 30 günlük mortalite için basitleştirilmiş pulmoner emboli ciddiyet indeksi (sPESI) skorunun eğri altındaki alan (AUC) 0,719 (% 95 CI: 0,630-0,809, p <0,001) idi. ΔNLR, sPESI skoruna eklendiğinde, AUC 0.841 (% 95 CI: 0.769-0.913, fark p = 0.0008, Şekil 1) idi. Dahası, ΔNLR'nin sPESI skoruna eklenmesi, % 68.9 (p <0.001) olarak tahmin edilen önemli bir net yeniden sınıflandırma iyileşmesi ve 0.108'lik (p = 0.0046) bir entegre ayrımcılık gelişimi ile ilişkilendirildi.
Sonuç: Bulgularımız, başvuru sonrası NLO'daki artışın APE hastalarında total mortalite ile bağımsız olarak ilişkili olduğunu göstermektedir.

Keywords

nötrofil lenfosit oranı, inflamasyon, pulmoner emboli, mortalite

The prognostic impact of dynamic change in neutrophil to lymphocyte ratio in patients with acute pulmonary embolism

Abstract

Background: It is unclear whether temporal changes in neutrophil to lymphocyte ratio (NLR) are associated with total mortality in acute pulmonary embolism (APE). We investigated the value of dynamic monitoring of NLR for the prognosis in patients with APE.
Methods: We retrospectively analyzed 214 consecutive APE patients. The patients were divided into two groups: survivors or non-survivors. The neutrophil count, lymphocyte count and NLR were obtained at admission and 72 hours. The difference between the 2 measurements was considered as the NLR change (ΔNLR). The end point of the study was total mortality at 30-day follow-up.
Results: During follow-up, there were 30 deaths (14%). ΔNLR was higher in non-survivors than survivors survivors (5.22 [0.62-7.76] vs -0.71 [-2.28-0.76], P < .001). In multivariate analysis, the ΔNLR was found to be a significant predictor of 30-day mortality (OR: 1.059, 95% CI:1.021-1.098, p=0.002). For 30-day mortality, the area under the curve(AUC) of Simplified Pulmonary Embolism Severity Index ( sPESI) score was 0.719 ( 95% CI:0.630-0.809, p < 0.001). When ΔNLR was added to sPESI score, the AUC was 0.841 (95% CI: 0.769-0.913, difference p = 0.0008, Fig.1). Morever, the addition of ΔNLR to sPESI score was associated with a significant net reclassification improvement estimated at 68.9% (p < 0.001) and an integrated discrimination improvement of 0.108 ( p = 0.0046).
Conclusion: Our findings show that an increase in NLR after admission was independently associated with total mortality in patients with APE.

Keywords

neutrophil to lymphocyte ratio, inflammation, pulmonary embolism, mortality

References

• Aujesky, D., Obrosky, D. S., Stone, R. A., Auble, T. E., Perrier, A., Cornuz, J., Roy, P. M., & Fine, M. J. (2005). Derivation and validation of a prognostic model for pulmonary embolism. American Journal of Respiratory and Critical Care Medicine, 172(8), 1041–1046. doi: 10.1164/rccm.200506-862OC
• Bakirci, E. M., Topcu, S., Kalkan, K., Tanboga, I. H., Borekci, A., Sevimli, S., & Acikel, M. (2015). The Role of the Nonspecific Inflammatory Markers in Determining the Anatomic Extent of Venous Thromboembolism. Clinical and Applied Thrombosis/Hemostasis, 21(2), 181–185. doi: 10.1177/1076029613494469
• Başer, K., Duygu Baş, H., Attaluri, P., Rodrigues, T., Nichols, J., & Nugent, K. (2017). Changes in neutrophil-to-lymphocyte ratios in postcardiac arrest patients treated with targeted temperature management. Anatol J Cardiol, 18, 215–222. doi: 10.14744/AnatolJCardiol.2017.7716
• Becattini, C. (2008). Predictors of mortality from pulmonary embolism and their influence on clinical management. Thromb. Haemost, 100, 747–751.
• Becattini, Cecilia, Vedovati, M. C., & Agnelli, G. (2007). Prognostic Value of Troponins in Acute Pulmonary Embolism A Meta-Analysis. doi: 10.1161/CIRCULATIONAHA.106.680421
• Begieneman, M. P. V., Van De Goot, F. R. W., Van Der Bilt, I. A. C., Vonk Noordegraaf, A., Spreeuwenberg, M. D., Paulus, W. J., Van Hinsbergh, V. W. M., Visser, F. C., & Niessen, H. W. M. (2008). Pulmonary embolism causes endomyocarditis in the human heart. Heart, 94(4), 450–456. doi: 10.1136/hrt.2007.118638
• Binder, L., Pieske, B., Olschewski, M., Geibel, A., Klostermann, B., Reiner, C., & Konstantinides, S. (2005). N-terminal pro-brain natriuretic peptide or troponin testing followed by echocardiography for risk stratification of acute pulmonary embolism. Circulation, 112(11), 1573–1579. doi: 10.1161/CIRCULATIONAHA.105.552216
• Gallotta, G., Palmieri, V., Piedimonte, V., Rendina, D., De Bonis, S., Russo, V., Celentano, A., Di Minno, M. N. D., Postiglione, A., & Di Minno, G. (2008). Increased troponin I predicts in-hospital occurrence of hemodynamic instability in patients with sub-massive or non-massive pulmonary embolism independent to clinical, echocardiographic and laboratory information. International Journal of Cardiology, 124(3), 351–357. doi: 10.1016/j.ijcard.2006.03.096
• Goldhaber, S. Z., Visani, L., & De Rosa, M. (1999). Acute pulmonary embolism: Clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet, 353(9162), 1386–1389. doi: 10.1016/S0140-6736(98)07534-5
• Iwadate, K., Doi, M., Tanno, K., Katsumura, S., Ito, H., Sato, K., Yonemura, I., & Ito, Y. (2003). Right ventricular damage due to pulmonary embolism: Examination of the number of infiltrating macrophages. Forensic Science International, 134(2–3), 147–153. doi: 10.1016/S0379-0738(03)00138-5
• Iwadate, K., Tanno, K., Doi, M., Takatori, T., & Ito, Y. (2001). Two cases of right ventricular ischemic injury due to massive pulmonary embolism. Forensic Science International, 116(2–3), 189–195. doi: 10.1016/S0379-0738(00)00367-4
• Jae, K. O. H. et al. (2009). The Echo Manual 3th ed (3th ed.). Rochester: Lippincott-Williams Press.
• Jiménez Castro, D., Díaz, G., Molina, J., Martí, D., Del Rey, J., García-Rull, S., Escobar, C., Vidal, R., Sueiro, A., & Yusen, R. D. (2008). Troponin I and risk stratification of patients with acute nonmassive pulmonary embolism. European Respiratory Journal, 31(4), 847–853. doi: 10.1183/09031936.00113307
• Jiménez, D., Aujesky, D., Moores, L., Gómez, V., Lobo, J. L., Uresandi, F., Otero, R., Monreal, M., Muriel, A., & Yusen, R. D. (2010). Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Archives of Internal Medicine, 170(15), 1383–1389. doi: 10.1001/archinternmed.2010.199
• Kline, J. A., Zeitouni, R., Marchick, M. R., Hernandez-Nino, J., & Rose, G. A. (2008). Comparison of 8 biomarkers for prediction of right ventricular hypokinesis 6 months after submassive pulmonary embolism. American Heart Journal, 156(2), 308–314. doi: 10.1016/j.ahj.2008.03.026
• Klok, F. A., Mos, I. C. M., & Huisman, M. V. (2008). Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism: A systematic review and meta-analysis. American Journal of Respiratory and Critical Care Medicine, 178(4), 425–430. doi: 10.1164/rccm.200803-459OC
• Konstantinides, S. V., Torbicki, A., Agnelli, G., Danchin, N., Fitzmaurice, D., Galiè, N., Gibbs, J. S. R., Huisman, M. V., Humbert, M., Kucher, N., Lang, I., Lankeit, M., Lekakis, J., Maack, C., Mayer, E., Meneveau, N., Perrier, A., Pruszczyk, P., Rasmussen, L. H., … Pepke-Zaba, J. (2014). 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism. In European Heart Journal (Vol. 35, Issue 43, pp. 3033–3080). Oxford University Press. doi: 10.1093/eurheartj/ehu283
• Li, C., Zhang, F., Shen, Y., Xu, R., Chen, Z., Dai, Y., Lu, H., Chang, S., Qian, J., Wang, X., & Ge, J. (2017). Impact of Neutrophil to Lymphocyte Ratio (NLR) Index and Its Periprocedural Change (NLR▵) for Percutaneous Coronary Intervention in Patients with Chronic Total Occlusion. Angiology, 68(7), 640–646. doi: 10.1177/0003319716649112
• Mitchell, A. M., Nordenholz, K. E., & Kline, J. A. (2008). Tandem Measurement of D-dimer and Myeloperoxidase or C-reactive Protein to Effectively Screen for Pulmonary Embolism in the Emergency Department. Academic Emergency Medicine, 15(9), 800–805. doi: 10.1111/j.1553-2712.2008.00204.x
• Moya, A. et al. (2009). Guidelines for the diagnosis and management of syncope (version 2009). Task Force for the Diagnosis and Management of Syncope; European Society of Cardiology (ESC); European Heart Rhythm Association (EHRA); Heart Failure Association (HFA); Heart Rhythm So. Eur. Heart J, 30, 2631–2671. doi: 10.1093/eurheartj/ehp298
• Nordenholz, K. E., Mitchell, A. M., & Kline, J. A. (2008). Direct Comparison of the Diagnostic Accuracy of Fifty Protein Biological Markers of Pulmonary Embolism for Use in the Emergency Department. Academic Emergency Medicine, 15(9), 795–799. doi: 10.1111/j.1553-2712.2008.00203.x
• Park, J. J., Jang, H. J., Oh, I. Y., Yoon, C. H., Suh, J. W., Cho, Y. S., Youn, T. J., Cho, G. Y., Chae, I. H., & Choi, D. J. (2013). Prognostic value of neutrophil to lymphocyte ratio in patients presenting with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention. American Journal of Cardiology, 111(5), 636–642. doi: 10.1016/j.amjcard.2012.11.012
• Pencina, M. J., D’Agostino, R. B., & Steyerberg, E. W. (2011). Extensions of net reclassification improvement calculations to measure usefulness of new biomarkers. Statistics in Medicine, 30(1), 11–21. doi: 10.1002/sim.4085
• Raja, A. S., Greenberg, J. O., Qaseem, A., Denberg, T. D., Fitterman, N., & Schuur, J. D. (2015). Evaluation of Patients With Suspected Acute Pulmonary Embolism: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians. Annals of Internal Medicine, 163(9), 701. doi: 10.7326/M14-1772
• Sanchez, O., Trinquart, L., Colombet, I., Durieux, P., Huisman, M. V., Chatellier, G., & Meyer, G. (2008). Prognostic value of right ventricular dysfunction in patients with haemodynamically stable pulmonary embolism: A systematic review. European Heart Journal, 29(12), 1569–1577. doi: 10.1093/eurheartj/ehn208
• Scridon, T., Scridon, C., Skali, H., Alvarez, A., Goldhaber, S. Z., & Solomon, S. D. (2005). Prognostic significance of troponin elevation and right ventricular enlargement in acute pulmonary embolism. American Journal of Cardiology, 96(2), 303–305. doi: 10.1016/j.amjcard.2005.03.062
• Soylu, K., Gedikli, Ö., Ekşi, A., Avcıoğlu, Y., Soylu, A. İ., Yüksel, S., Aksan, G., Gülel, O., & Yılmaz, Ö. (2016). Clinical research Neutrophil-to-lymphocyte ratio for the assessment of hospital mortality in patients with acute pulmonary embolism. Arch Med Sci, 12, 95–100. doi: 10.5114/aoms.2016.57585
• Venetz, C., Labarère, J., Jiménez, D., & Aujesky, D. (2013). White blood cell count and mortality in patients with acute pulmonary embolism. American Journal of Hematology, 88(8), 677–681. doi: 10.1002/ajh.23484
• Watts, J. A., Gellar, M. A., Obraztsova, M., Kline, J. A., & Zagorski, J. (2008). Role of inflammation in right ventricular damage and repair following experimental pulmonary embolism in rats. International Journal of Experimental Pathology, 89(5), 389–399. doi: 10.1111/j.1365-2613.2008.00610.x
• Zahorec R. (2001). Ratio of neutrophil to lymphocyte counts-rapid and simple parameter of systemic inflammation and stress in critically ill. Bratısl Lek Lısty, 102(1), 5–14.