ORIGINAL ARTICLE
The Clinical Respiratory Journal
Endothelial dysfunction in patients with pulmonary thromboembolism: neutrophil to lymphocyte ratio and platelet to lymphocyte ratio Ercan Kurtipek1, Zafer Büyükterzi2, Meral Büyükterzi3, Mehmet Sertaç Alpaydın2 and Said Sami Erdem4 1 Department 2 Department 3 Department 4 Department
of of of of
Chest Diseases, Konya Training and Research Hospital, Konya, Turkey Cardiology, Konya Training and Research Hospital, Konya, Turkey Radiology, Konya Training and Research Hospital, Konya, Turkey Biochemistry, Konya Training and Research Hospital, Konya, Turkey
Abstract Background and Aims: Pulmonary thromboembolism (PTE) is a common cardiovascular emergency. Activated leukocytes may produce free oxygen radicals and endothelial damage, and, thereby, increased inflammation and thrombogenesis. In this study, we aimed to investigate endothelial dysfunction in patients with PTE. Methods: Between May 2012 and July 2013, a total of 71 patients with acute PTE (32 males, 39 females; mean age: 64.94 ± 15.27 years; range: 33 to 87 years) who were admitted to the Emergency and Thoracic Diseases Departments and 56 healthy controls (44 males, 12 females; mean age: 62.52 ± 9.80 years; range: 46 to 79 years) were included. Brachial artery flow-mediated dilation (BFMD) was performed. Neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) were calculated. Results: Significantly higher BFMD values were observed in patients with PTE (P < 0.05). Patients with PTE also had significantly higher NLR and PLR values, compared with the healthy control group (P < 0.05). Conclusion: The results of our study suggest that using non-invasive method such as ultrasonography combined with NLR and PLR in endothelial dysfunction diagnosis in PTE patients are both effective and inexpensive. We believe in PTE patients endothelial dysfunction may play a role in the development of probable cardiovascular events in future. Please cite this paper as: Kurtipek E, Büyükterzi Z, Büyükterzi M, Alpaydın MS and Erdem SS. Endothelial dysfunction in patients with pulmonary thromboembolism: neutrophil to lymphocyte ratio and platelet to lymphocyte ratio. Clin Respir J 2015; ••: ••–••. DOI: 10.1111/crj.12308.
Key words brachial artery flow-mediated dilation – endothelial dysfunction – neutrophil to lymphocyte ratio – platelet to lymphocyte ratio Correspondence Ercan Kurtipek, MD, Orgeneral Tural Mah, Yeni Meram Cad, Yeni Yol Konakları H1, 8 Meram, Konya, Turkey. Tel: (+) 90 332 3236709 3110 Fax: (+) 90 332 3236723 email: [email protected] Received: 18 December 2014 Revision requested: 13 March 2015 Accepted: 21 April 2015 DOI:10.1111/crj.12308 Authorship and contributorship Büyükterzi Z, Büyükterzi M, Alpaydın MS and Erdem SS have contributed in performance of work and in data analysis. All authors contributed to the drafting of article and/or critical revision and final approval of the manuscript. Ethics The study protocol was approved by the Ethics Committee of Selcuk University Medicine Faculty, Konya, Turkey. Conflict of interest The authors have stated explicitly that there are no conflicts of interest in connection with this article.
Introduction Pulmonary thromboembolism (PTE), which affects nearly one to five patients per 1000 patients, is often
The Clinical Respiratory Journal (2015) • ISSN 1752-6981 © 2015 John Wiley & Sons Ltd
overlooked in the absence of clinical suspicion with a challenging diagnosis and high mortality rate if not treated appropriately (1). Despite contemporary diagnostic and therapeutic modalities in recent years,
1
Early endothelial dysfunction in thromboembolism
Kurtipek et al.
3-month mortality rate is still nearly 15% (2). Because of the presence of misleading clinical signs, diagnostic tests need to be performed. Early diagnosis and effective treatment are of utmost importance for reduced mortality rates and prevention of death events. PTE may present a broad of range of manifestations including from asymptomatic embolism to massive embolism leading to cardiogenic shock. As clinical manifestations are non-specific, late diagnosis can be caused with increased mortality rates. Increased neutrophil to lymphocyte ratio (NLR) has been shown to play a role in predicting mortality in patients with PTE (3). Recently, hemogram parameters such as NLR and platelet to lymphocyte ratio (PLR) have been investigated in several diseases as a novel expression of inflammatory markers (4). These parameters have been also investigated in vascular diseases, as they have a role in inflammatory processes (5). In recent years, brachial artery flow-mediated dilation (BFMD) measurement has been widely used in identifying endothelial dysfunction in the early physiological stage of atherosclerosis (6–8). Because it is a non-invasive ultrasonographic examination, it has been widely adopted. In this study, we aimed to investigate endothelial dysfunction in patients with PTE and to determine the possible role of NLR and PLR values.
gesics, lipid lowering drugs, anti-hypertensives, anticoagulants, nitrates, caffeine, aspirin (acetylsalicylic acid) and non-steroidal anti-inflammatory drugs were discontinued 8 h before the exam. High-resolution B-mode ultrasound with 12.5 mHz linear array transducer was performed (GE LOGIQ 7 6; GE Healthcare, Milwaukee, WI, USA). Endothelial function was assessed by a single ultrasonographer. At a room temperature of 22°C, BFMD was measured in supine position. The cuff was placed 2–6 cm above the right elbow. The brachial artery was viewed above the antecubital fossa in the longitudinal plane. Internal diameter of the brachial artery was measured in end-diastole. The mean value of three consecutive measurements was calculated. Baseline measurements of brachial artery diameter were recorded (P0 = brachial artery diameter at baseline). The cuff was inflated to 200 mmHg or 50 mmHg in systolic blood pressure. Ischemia was induced in the forearm for 5 min and the cuff pressure was deflated. Arterial diameter was measured at 60 s (P1 = post-reactive hyperemia diameter: brachial artery diameter after cuff deflation). The difference (% BFMD) [%BFMD = 100 × (P1 − P0)/P0] in diameter between reactive hyperemia and baseline measurements was calculated (9).
Patients and methods
NLR and PLR
Study design
Complete blood count was performed during hospitalization. Blood samples were drawn from antecubital vein to the vacuum tubes including Ethylenediaminetetraacetic acid (EDTA) (15% K3 EDTA 0.054 mL / 4.5 mL) for automatic blood analysis for 1 h. Blood analysis was performed using a fully automated blood count analyzer [ADVIA 2120 Hematology System, Siemens Healthcare Diagnostic Systems, Tarrytown, NY, USA]. The NLR and PLR values were calculated based on neutrophil, platelet and lymphocyte counts.
A total of 127 subjects (71 PTE, 32 males, 39 females; mean age: 64.94 ± 15.27 years; range: 33 to 87 years) and 56 healthy controls consisting of visitors of the chest disease clinic of the Meram Training and Research Hospital (44 males, 12 females; mean age: 62.52 ± 9.80 years; range: 46 to 79 years) were included. This cross-sectional case–control study was conducted between May 2012 and July 2013. Computed tomography pulmonary angiography is a multidetector used to confirm the presence of thrombus in the main pulmonary artery and its branches. A total of 71 patients with acute PTE and 56 healthy controls were included in the study. The patients were hospitalized with preliminary diagnosis and BFMD values were measured 10 days after hospitalization and definitive diagnosis.
Brachial artery vasoreactivity – BFMD The patients were prepared with an 8-h fasting. All the drugs which may affect vasoreactivity including anal-
2
Statistical analysis Statistical analysis was performed using SPSS v20.0 software (SPSS Inc., Chicago, IL, USA). The mean baseline BFMD, BFMD and BFMD% values were calculated. Data were expressed in mean ± standard deviation and number (percentage). The chi-squared test, Fisher exact test, Student t-test, Kruskal–Wallis test and univariate analysis were performed to compare the groups. A P value of less than 0.05 was
The Clinical Respiratory Journal (2015) • ISSN 1752-6981 © 2015 John Wiley & Sons Ltd
Kurtipek et al.
Early endothelial dysfunction in thromboembolism
Table 1. Demographic and biochemical parameters of study subjects Age (years) (mean ± SD) Male [n (%)] Female [n (%)] Neutrophil [n (%)] Platelet [n (%)] Lymphocyte [n (%)] RDW
Patients (n = 71)
Controls (n = 56)
P value
64.94 ± 15.27 32 (% 45.07) 39 (%54.03) 10.12 ± 10.15 273.54 ± 106.79 2.35 ± 4.37 15.12 ± 2.02
62.52 ± 9.80 44 (%78.57) 12 (%21.43) 4.44 ± 1.68 252.60 ± 62.94 2.24 ± 0.68 14.38 ± 1.43
0.3
0.001 0.19 0.86 0.02
P < 0.05 was considered statistically significant. RDW, red cell distribution width.
considered statistically significant. Written informed consents were obtained from all the subjects.
Results The demographic characteristics of the study population are summarized in Table 1. The mean age was similar between the groups. Moreover, the red cell distribution width (RDW) comparison between the groups was statistically significant. RDW of the PTE group was 15.12 ± 2.02 and of the control group 14.38 ± 1.43 (P = 0.02). Baseline BFMD values significantly increased in patients with PTE, compared with healthy controls (4.46 ± 0.65, 3.44 ± 0.24, respectively; P = 0.0001). The BFMD values significantly increased in the patient group (4.78 ± 0.68, 3.80 ± 0.25, respectively; P = 0.0001). In addition, a significantly higher value of BFMD% was found in the patient group compared with the controls (8.92 ± 5.20, 10.56 ± 3.56, respectively; P = 0.03) (Table 2). There was a significantly increased NLR values in patients with PTE compared with the controls (4.26 ± 4.90, 1.89 ± 1.46, respectively; P = 0.0001). Also, PLR increased in the patient group compared with the controls (140.64 ± 126.68, 112.45 ± 57.62, respectively; P = 0.003) (Table 3).
Discussion The major finding of the present study was significantly impaired BFMD values at an early stage in patients with Table 2. Brachial artery flow-mediated dilation values among patients with pulmonary thromboembolism and healthy controls
Baseline FMD FMD FMD %
Patients (n = 71)
Controls (n = 56)
P value
4.46 ± 0.65 4.78 ± 0.68 8.92 ± 5.20
3.44 ± 0.24 3.80 ± 0.25 10.56 ± 3.56
0.0001 0.0001 0.03
P < 0.05 was considered statistically significant. FMD, flow-mediated dilation.
The Clinical Respiratory Journal (2015) • ISSN 1752-6981 © 2015 John Wiley & Sons Ltd
PTE. PTE, by definition, is caused by the thrombus located in systemic veins which blocks the part of the arterial tree of the lung with clinical variations ranging from asymptomatic submassive embolism to massive embolism resulting in circulatory collapse and death (10, 11). Clinical manifestations may vary depending on the location, number (single/multiple), size of embolism (massive/submassive), recurrence, the presence of infarction and cardiac reserve (12, 13). BFMD, a non-invasive ultrasonographic method, obtains endothelial dysfunction (14). It also gives functional changes of the arterial wall. Previous studies showed that impaired BFMD was associated with an increased risk for cardiovascular events (15). Currently, according to our best knowledge, there is no study about endothelial dysfunction in pulmonary emboli patients and related secondary conditions. In our study, we also evaluated NLR and PLR values in predicting cardiovascular events at an early stage as well as the prognostic value of BFMD measurements. Similarly, NLR has been shown to be a potential marker in detecting inflammation in cardiac and noncardiac events (16). Our study, therefore, investigated BFMD as well as NLR and PLR in predicting the risk of cardiovascular diseases among the patients with PTE. The major finding of the present study was significantly impaired BFMD values in patients with PTE. To the best of our knowledge, this is the first study comparing these parameters in PTE. In a study using BFMD values in predicting atherosclerosis in postmenopausal women, Gatto et al. (17). reported that
Table 3. NLR and PLR values among patients with pulmonary thromboembolism and healthy controls
NLR PLR
Patients (n = 71)
Controls (n = 56)
P value
4.26 ± 4.90 140.64 ± 126.68
1.89 ± 1.46 112.45 ± 57.62
0.0001 0.003
P < 0.05 was considered statistically significant. NLR, neutrophil to lymphocyte ratio; PLR, platelet to lymphocyte ratio.
3
Early endothelial dysfunction in thromboembolism
anatomical and physiological BFMD values were associated with coronary artery disease. Similarly, we also observed endothelial dysfunction in the patients with PTE. In another study conducted in Turkey among patients with rheumatoid arthritis, the authors reported an increased epicardial adipose tissue thickness which was associated with endothelial dysfunction assessed by BFMD measurement (18). Based on these results, endothelial dysfunction has been shown to play a role in the development of cardiac diseases and NLR and PLR values have been widely used as a contributing factor to inflammation in recent years (19, 20). Another study carried out in Turkey showed that carotid-intima media thickness (CIMT), NLR and PLR values were feasible parameters in identifying subclinical atherosclerosis among the patients with psoriasis (21). The authors reported that NLR was a potential unrecognized predictor in subclinical atherosclerosis. In another study investigating the predictive value of NLR in acute pulmonary embolism related mortality in Turkey, NLR appeared to be beneficial (3). Depending on varying results, NLR has been recently used as a potential marker in identifying inflammation in cardiac and non-cardiac diseases (22). The calculation of NLR value is an easy and inexpensive method compared with other inflammatory cytokines such as interleukin 6 and tumor necrosis factor alpha (23). Recently, NLR has been shown to be an inflammatory indicator in end-stage renal disease (24). In addition, NLR has been adopted in predicting mortality in patients with percutaneous coronary intervention (25). Similarly, NLR was demonstrated to be an independent predictor for expected mortality in patients with acute heart failure (26). The present study also suggests that early inflammation might induce endothelial dysfunction in patients with PTE. On the other hand, our study has some limitations. First, our sample size was small. Second, further studies are required to assess CIMT in identifying subclinical atherosclerosis in the long-term. In conclusion, using a non-invasive method such as ultrasonography combined with NLR and PLR in detecting endothelial dysfunction is both easy and inexpensive. We believe in PTE patients endothelial dysfunction may play a role in the development of probable cardiovascular events in future.
Acknowledgement We, as the authors of the present study, gratefully acknowledge the support and generosity of Turkish Respiratory Society in translation of the manuscript into English.
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References 1. Nielsen HK. Pathophysiology of venous thromboembolism. Semin Thromb Hemost. 1991;17(3): 250–3. 2. Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet. 1999;353: 1386–9. 3. Yes¸ildag˘ M, Keskin S, Güler I˙, Keskin Z. Correlation of computerized tomography angiographic pulmonary artery obstruction score with hematologic outcome and mortality in patients with acute pulmonary embolism. Türkiye Klinikleri J Med Sci. 2013;33(4): 952–7. 4. Bhat T, Teli S, Rijal J, Bhat H, Raza M, Khoueiry G, Meghani M, Akhtar M, Constantino T. Neutrophil to lymphocyte ratio and cardiovascular diseases: a review. Expert Rev Cardiovasc Ther. 2013;11: 55–9. 5. Gary T, Pichler M, Belaj K, et al. Platelet-to-lymphocyte ratio: a novel marker for critical limb ischemia in peripheral arterial occlusive disease patients. PLoS ONE. 2013;8(7): e67688. doi: 10.1371/journal.pone.0067688. 6. Núñez J, Núñez E, Bodí V, et al. Usefulness of the neutrophil to lymphocyte ratio in predicting long term mortality in ST segment elevation myocardial infarction. Am J Cardiol. 2008;101(6): 747–52. 7. Dibble CT, Shimbo D, Barr RG, Bagiella E, Chahal H, Ventetuolo CE, Herrington DM, Lima JA, Bluemke DA, Kawut SM. Brachial artery diameter and the right ventricle: the multi-ethnic study of atherosclerosis-right ventricle study. Chest. 2012;142(6): 1399–405. 8. Hu R, Wang WQ, Lau CP, Tse HF. Gender differences on brachial flow-mediated dilation and carotid intima-media thickness for prediction of spontaneous cardiovascular events. Clin Cardiol. 2008;31(11): 525–31. 9. Korkmaz H, Akbulut M, Ozbay Y, Koç M. The relation of intima-media thickness with endothelial function and left ventricular mass index. Anadolu Kardiyol Derg. 2010;10(3): 220–5. 10. Bach AG, Nansalmaa B, Kranz J, et al. CT pulmonary angiography findings that predict 30-day mortality in patients with acute pulmonary embolism. Eur J Radiol. 2015;84(2): 332–7. 11. Tapson VF, Witty LA. Massive pulmonary embolism. Diagnostic and therapeutic strategies. Clin Chest Med. 1995;16: 329–40. 12. Uresandia F, Blanquer J, Conget F, et al. Guidelines for the diagnosis, treatment, and follow up of pulmonary embolism. Arch Bronconeumol. 2004;40: 580–94. 13. Goldhaber SZ. Pulmonary embolism. In: Braunwald E, editor. Heart Diseases, 5th edn. Philadelphia, WB Saunders, 1997: 1582–603. 14. Sankatsing RR, de Groot E, Jukema JW, et al. Surrogate markers for atherosclerotic disease. Curr Opin Lipidol. 2005;16: 434–41. 15. Shimbo D, Grahame-Clarke C, Miyake Y, et al. The association between endothelial dysfunction and
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cardiovascular outcomes in a population-based multi-ethnic cohort. Atherosclerosis. 2007;192: 197–203. Tamhane UU, Aneja S, Montgomery D, Rogers EK, Eagle KA, Gurm HS. Association between admission neutrophil to lymphocyte ratio and outcomes in patients with acute coronary syndrome. Am J Cardiol. 2008;102(6): 653–7. Gatto NM, Hodis HN, Liu CR, Liu CH, Mack WJ. Brachial artery vasoreactivity is associated with cross-sectional and longitudinal anatomical measures of atherosclerosis in postmenopausal women with coronary artery disease. Atherosclerosis. 2008;196(2): 674–81. Temiz A, Gökmen F, Gazi E, Akbal A, Barutçu A, Bekler A, Altun B, Tan YZ, Günes¸ F, Sen H. Epicardial adipose tissue thickness, flow-mediated dilatation of the brachial artery, and carotid intima–media thickness. Associations in rheumatoid arthritis patients. Herz. 2015;40(3): 217–24. Akbas EM, Demirtas L, Ozcicek A, Timuroglu A, Bakirci EM, Hamur H, Ozcicek F, Turkmen K. Association of epicardial adipose tissue, neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio with diabetic nephropathy. Int J Clin Exp Med. 2014;7(7): 1794–801. Abakay O, Abakay A, Sen HS, Tanrikulu AC. The relationship between inflammatory marker levels and pulmonary tuberculosis severity. Inflammation. 2015;38(2): 691–6.
The Clinical Respiratory Journal (2015) • ISSN 1752-6981 © 2015 John Wiley & Sons Ltd
Early endothelial dysfunction in thromboembolism
21. Yurtdas¸ M, Yaylali YT, Kaya Y, Ozdemir M, Ozkan I, Aladag˘ N. Neutrophil-to-lymphocyte ratio may predict subclinical atherosclerosis in patients with psoriasis. Echocardiography. 2014;31(9): 1095–104. 22. Walsh SR, Cook EJ, Goulder F, Justin TA, Keeling NJ. Neutrophil-lymphocyte ratio as a prognostic factor in colorectal cancer. J Surg Oncol. 2005;91(3): 181–4. 23. Okyay GU, Inal S, Oneç K, Er RE, Pas¸aog˘lu O, Pas¸aog˘lu H, Derici U, Erten Y. Neutrophil to lymphocyte ratio in evaluation of inflammation in patients with chronic kidney disease. Ren Fail. 2013;35(1): 29–36. doi: 10.3109/0886022X.2012.734429. 24. Turkmen K, Guney I, Yerlikaya FH, Tonbul HZ. The relationship between neutrophil-to-lymphocyte ratio and inflammation in end-stage renal disease patients. Ren Fail. 2012;34(2): 155–9. doi: 10.3109/0886022X.2011.641514. 25. Duffy BK, Gurm HS, Rajagopal V, Gupta R, Ellis SG, Bhatt DL. Usefulness of an elevated neutrophil to lymphocyte ratio in predicting long-term mortality after percutaneous coronary intervention. Am J Cardiol. 2006;97(7): 993–6. 26. Arruda-Olson AM, Reeder GS, Bell MR, Weston SA, Roger VL. Neutrophilia predicts death and heart failure after myocardial infarction: a community-based study. Circ Cardiovasc Qual Outcomes. 2009;2(6): 656–62.
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The Clinical Respiratory Journal
Endothelial dysfunction in patients with pulmonary thromboembolism: neutrophil to lymphocyte ratio and platelet to lymphocyte ratio Ercan Kurtipek1, Zafer Büyükterzi2, Meral Büyükterzi3, Mehmet Sertaç Alpaydın2 and Said Sami Erdem4 1 Department 2 Department 3 Department 4 Department
of of of of
Chest Diseases, Konya Training and Research Hospital, Konya, Turkey Cardiology, Konya Training and Research Hospital, Konya, Turkey Radiology, Konya Training and Research Hospital, Konya, Turkey Biochemistry, Konya Training and Research Hospital, Konya, Turkey
Abstract Background and Aims: Pulmonary thromboembolism (PTE) is a common cardiovascular emergency. Activated leukocytes may produce free oxygen radicals and endothelial damage, and, thereby, increased inflammation and thrombogenesis. In this study, we aimed to investigate endothelial dysfunction in patients with PTE. Methods: Between May 2012 and July 2013, a total of 71 patients with acute PTE (32 males, 39 females; mean age: 64.94 ± 15.27 years; range: 33 to 87 years) who were admitted to the Emergency and Thoracic Diseases Departments and 56 healthy controls (44 males, 12 females; mean age: 62.52 ± 9.80 years; range: 46 to 79 years) were included. Brachial artery flow-mediated dilation (BFMD) was performed. Neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) were calculated. Results: Significantly higher BFMD values were observed in patients with PTE (P < 0.05). Patients with PTE also had significantly higher NLR and PLR values, compared with the healthy control group (P < 0.05). Conclusion: The results of our study suggest that using non-invasive method such as ultrasonography combined with NLR and PLR in endothelial dysfunction diagnosis in PTE patients are both effective and inexpensive. We believe in PTE patients endothelial dysfunction may play a role in the development of probable cardiovascular events in future. Please cite this paper as: Kurtipek E, Büyükterzi Z, Büyükterzi M, Alpaydın MS and Erdem SS. Endothelial dysfunction in patients with pulmonary thromboembolism: neutrophil to lymphocyte ratio and platelet to lymphocyte ratio. Clin Respir J 2015; ••: ••–••. DOI: 10.1111/crj.12308.
Key words brachial artery flow-mediated dilation – endothelial dysfunction – neutrophil to lymphocyte ratio – platelet to lymphocyte ratio Correspondence Ercan Kurtipek, MD, Orgeneral Tural Mah, Yeni Meram Cad, Yeni Yol Konakları H1, 8 Meram, Konya, Turkey. Tel: (+) 90 332 3236709 3110 Fax: (+) 90 332 3236723 email: [email protected] Received: 18 December 2014 Revision requested: 13 March 2015 Accepted: 21 April 2015 DOI:10.1111/crj.12308 Authorship and contributorship Büyükterzi Z, Büyükterzi M, Alpaydın MS and Erdem SS have contributed in performance of work and in data analysis. All authors contributed to the drafting of article and/or critical revision and final approval of the manuscript. Ethics The study protocol was approved by the Ethics Committee of Selcuk University Medicine Faculty, Konya, Turkey. Conflict of interest The authors have stated explicitly that there are no conflicts of interest in connection with this article.
Introduction Pulmonary thromboembolism (PTE), which affects nearly one to five patients per 1000 patients, is often
The Clinical Respiratory Journal (2015) • ISSN 1752-6981 © 2015 John Wiley & Sons Ltd
overlooked in the absence of clinical suspicion with a challenging diagnosis and high mortality rate if not treated appropriately (1). Despite contemporary diagnostic and therapeutic modalities in recent years,
1
Early endothelial dysfunction in thromboembolism
Kurtipek et al.
3-month mortality rate is still nearly 15% (2). Because of the presence of misleading clinical signs, diagnostic tests need to be performed. Early diagnosis and effective treatment are of utmost importance for reduced mortality rates and prevention of death events. PTE may present a broad of range of manifestations including from asymptomatic embolism to massive embolism leading to cardiogenic shock. As clinical manifestations are non-specific, late diagnosis can be caused with increased mortality rates. Increased neutrophil to lymphocyte ratio (NLR) has been shown to play a role in predicting mortality in patients with PTE (3). Recently, hemogram parameters such as NLR and platelet to lymphocyte ratio (PLR) have been investigated in several diseases as a novel expression of inflammatory markers (4). These parameters have been also investigated in vascular diseases, as they have a role in inflammatory processes (5). In recent years, brachial artery flow-mediated dilation (BFMD) measurement has been widely used in identifying endothelial dysfunction in the early physiological stage of atherosclerosis (6–8). Because it is a non-invasive ultrasonographic examination, it has been widely adopted. In this study, we aimed to investigate endothelial dysfunction in patients with PTE and to determine the possible role of NLR and PLR values.
gesics, lipid lowering drugs, anti-hypertensives, anticoagulants, nitrates, caffeine, aspirin (acetylsalicylic acid) and non-steroidal anti-inflammatory drugs were discontinued 8 h before the exam. High-resolution B-mode ultrasound with 12.5 mHz linear array transducer was performed (GE LOGIQ 7 6; GE Healthcare, Milwaukee, WI, USA). Endothelial function was assessed by a single ultrasonographer. At a room temperature of 22°C, BFMD was measured in supine position. The cuff was placed 2–6 cm above the right elbow. The brachial artery was viewed above the antecubital fossa in the longitudinal plane. Internal diameter of the brachial artery was measured in end-diastole. The mean value of three consecutive measurements was calculated. Baseline measurements of brachial artery diameter were recorded (P0 = brachial artery diameter at baseline). The cuff was inflated to 200 mmHg or 50 mmHg in systolic blood pressure. Ischemia was induced in the forearm for 5 min and the cuff pressure was deflated. Arterial diameter was measured at 60 s (P1 = post-reactive hyperemia diameter: brachial artery diameter after cuff deflation). The difference (% BFMD) [%BFMD = 100 × (P1 − P0)/P0] in diameter between reactive hyperemia and baseline measurements was calculated (9).
Patients and methods
NLR and PLR
Study design
Complete blood count was performed during hospitalization. Blood samples were drawn from antecubital vein to the vacuum tubes including Ethylenediaminetetraacetic acid (EDTA) (15% K3 EDTA 0.054 mL / 4.5 mL) for automatic blood analysis for 1 h. Blood analysis was performed using a fully automated blood count analyzer [ADVIA 2120 Hematology System, Siemens Healthcare Diagnostic Systems, Tarrytown, NY, USA]. The NLR and PLR values were calculated based on neutrophil, platelet and lymphocyte counts.
A total of 127 subjects (71 PTE, 32 males, 39 females; mean age: 64.94 ± 15.27 years; range: 33 to 87 years) and 56 healthy controls consisting of visitors of the chest disease clinic of the Meram Training and Research Hospital (44 males, 12 females; mean age: 62.52 ± 9.80 years; range: 46 to 79 years) were included. This cross-sectional case–control study was conducted between May 2012 and July 2013. Computed tomography pulmonary angiography is a multidetector used to confirm the presence of thrombus in the main pulmonary artery and its branches. A total of 71 patients with acute PTE and 56 healthy controls were included in the study. The patients were hospitalized with preliminary diagnosis and BFMD values were measured 10 days after hospitalization and definitive diagnosis.
Brachial artery vasoreactivity – BFMD The patients were prepared with an 8-h fasting. All the drugs which may affect vasoreactivity including anal-
2
Statistical analysis Statistical analysis was performed using SPSS v20.0 software (SPSS Inc., Chicago, IL, USA). The mean baseline BFMD, BFMD and BFMD% values were calculated. Data were expressed in mean ± standard deviation and number (percentage). The chi-squared test, Fisher exact test, Student t-test, Kruskal–Wallis test and univariate analysis were performed to compare the groups. A P value of less than 0.05 was
The Clinical Respiratory Journal (2015) • ISSN 1752-6981 © 2015 John Wiley & Sons Ltd
Kurtipek et al.
Early endothelial dysfunction in thromboembolism
Table 1. Demographic and biochemical parameters of study subjects Age (years) (mean ± SD) Male [n (%)] Female [n (%)] Neutrophil [n (%)] Platelet [n (%)] Lymphocyte [n (%)] RDW
Patients (n = 71)
Controls (n = 56)
P value
64.94 ± 15.27 32 (% 45.07) 39 (%54.03) 10.12 ± 10.15 273.54 ± 106.79 2.35 ± 4.37 15.12 ± 2.02
62.52 ± 9.80 44 (%78.57) 12 (%21.43) 4.44 ± 1.68 252.60 ± 62.94 2.24 ± 0.68 14.38 ± 1.43
0.3
0.001 0.19 0.86 0.02
P < 0.05 was considered statistically significant. RDW, red cell distribution width.
considered statistically significant. Written informed consents were obtained from all the subjects.
Results The demographic characteristics of the study population are summarized in Table 1. The mean age was similar between the groups. Moreover, the red cell distribution width (RDW) comparison between the groups was statistically significant. RDW of the PTE group was 15.12 ± 2.02 and of the control group 14.38 ± 1.43 (P = 0.02). Baseline BFMD values significantly increased in patients with PTE, compared with healthy controls (4.46 ± 0.65, 3.44 ± 0.24, respectively; P = 0.0001). The BFMD values significantly increased in the patient group (4.78 ± 0.68, 3.80 ± 0.25, respectively; P = 0.0001). In addition, a significantly higher value of BFMD% was found in the patient group compared with the controls (8.92 ± 5.20, 10.56 ± 3.56, respectively; P = 0.03) (Table 2). There was a significantly increased NLR values in patients with PTE compared with the controls (4.26 ± 4.90, 1.89 ± 1.46, respectively; P = 0.0001). Also, PLR increased in the patient group compared with the controls (140.64 ± 126.68, 112.45 ± 57.62, respectively; P = 0.003) (Table 3).
Discussion The major finding of the present study was significantly impaired BFMD values at an early stage in patients with Table 2. Brachial artery flow-mediated dilation values among patients with pulmonary thromboembolism and healthy controls
Baseline FMD FMD FMD %
Patients (n = 71)
Controls (n = 56)
P value
4.46 ± 0.65 4.78 ± 0.68 8.92 ± 5.20
3.44 ± 0.24 3.80 ± 0.25 10.56 ± 3.56
0.0001 0.0001 0.03
P < 0.05 was considered statistically significant. FMD, flow-mediated dilation.
The Clinical Respiratory Journal (2015) • ISSN 1752-6981 © 2015 John Wiley & Sons Ltd
PTE. PTE, by definition, is caused by the thrombus located in systemic veins which blocks the part of the arterial tree of the lung with clinical variations ranging from asymptomatic submassive embolism to massive embolism resulting in circulatory collapse and death (10, 11). Clinical manifestations may vary depending on the location, number (single/multiple), size of embolism (massive/submassive), recurrence, the presence of infarction and cardiac reserve (12, 13). BFMD, a non-invasive ultrasonographic method, obtains endothelial dysfunction (14). It also gives functional changes of the arterial wall. Previous studies showed that impaired BFMD was associated with an increased risk for cardiovascular events (15). Currently, according to our best knowledge, there is no study about endothelial dysfunction in pulmonary emboli patients and related secondary conditions. In our study, we also evaluated NLR and PLR values in predicting cardiovascular events at an early stage as well as the prognostic value of BFMD measurements. Similarly, NLR has been shown to be a potential marker in detecting inflammation in cardiac and noncardiac events (16). Our study, therefore, investigated BFMD as well as NLR and PLR in predicting the risk of cardiovascular diseases among the patients with PTE. The major finding of the present study was significantly impaired BFMD values in patients with PTE. To the best of our knowledge, this is the first study comparing these parameters in PTE. In a study using BFMD values in predicting atherosclerosis in postmenopausal women, Gatto et al. (17). reported that
Table 3. NLR and PLR values among patients with pulmonary thromboembolism and healthy controls
NLR PLR
Patients (n = 71)
Controls (n = 56)
P value
4.26 ± 4.90 140.64 ± 126.68
1.89 ± 1.46 112.45 ± 57.62
0.0001 0.003
P < 0.05 was considered statistically significant. NLR, neutrophil to lymphocyte ratio; PLR, platelet to lymphocyte ratio.
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Early endothelial dysfunction in thromboembolism
anatomical and physiological BFMD values were associated with coronary artery disease. Similarly, we also observed endothelial dysfunction in the patients with PTE. In another study conducted in Turkey among patients with rheumatoid arthritis, the authors reported an increased epicardial adipose tissue thickness which was associated with endothelial dysfunction assessed by BFMD measurement (18). Based on these results, endothelial dysfunction has been shown to play a role in the development of cardiac diseases and NLR and PLR values have been widely used as a contributing factor to inflammation in recent years (19, 20). Another study carried out in Turkey showed that carotid-intima media thickness (CIMT), NLR and PLR values were feasible parameters in identifying subclinical atherosclerosis among the patients with psoriasis (21). The authors reported that NLR was a potential unrecognized predictor in subclinical atherosclerosis. In another study investigating the predictive value of NLR in acute pulmonary embolism related mortality in Turkey, NLR appeared to be beneficial (3). Depending on varying results, NLR has been recently used as a potential marker in identifying inflammation in cardiac and non-cardiac diseases (22). The calculation of NLR value is an easy and inexpensive method compared with other inflammatory cytokines such as interleukin 6 and tumor necrosis factor alpha (23). Recently, NLR has been shown to be an inflammatory indicator in end-stage renal disease (24). In addition, NLR has been adopted in predicting mortality in patients with percutaneous coronary intervention (25). Similarly, NLR was demonstrated to be an independent predictor for expected mortality in patients with acute heart failure (26). The present study also suggests that early inflammation might induce endothelial dysfunction in patients with PTE. On the other hand, our study has some limitations. First, our sample size was small. Second, further studies are required to assess CIMT in identifying subclinical atherosclerosis in the long-term. In conclusion, using a non-invasive method such as ultrasonography combined with NLR and PLR in detecting endothelial dysfunction is both easy and inexpensive. We believe in PTE patients endothelial dysfunction may play a role in the development of probable cardiovascular events in future.
Acknowledgement We, as the authors of the present study, gratefully acknowledge the support and generosity of Turkish Respiratory Society in translation of the manuscript into English.
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