Association Between Platelet/Lymphocyte Ratio and CHA2DS2-VASc Score in Patients with Nonvalvular Atrial Fibrillation

Abstract

Introduction: The most commonly used scoring system in determining the risk of thromboembolism in atrial fibrillation (AF) patients is CHA2DS2-VASc score. Platelet/lymphocyte ratio (PLR) is recently reported as an important indicator of inflammation especially in patients with malignancy. In this study, our aim was to investigate the association between PLR and CHA2DS2-VASc scores in patients with nonvalvular AF.

Patients and Methods: In this retrospective study, medical records of 184 patients (Mean age 6 8 ± 11.4 years and 51.6% men) admitted to our clinic with nonvalvular AF between the years 2010 and 2016 were examined.

Results: Patients with high risk of stroke according to CHA2DS2-VASc score had greater PLR, less left ventricular ejection fraction (LVEF), and less white blood cell counts compared to those of low and moderate risk groups combined. Glomerular filtration rate (GFR) values were also found lower in high risk group, albeit with a borderline statistical significance. In correlation analysis, CHA2DS2-VASc score demonstrated moderate positive correlation with PLR (r= 0.3, p< 0.01), moderate negative correlation with LVEF (r= -0.383, p< 0.01), and a weak negative correlation with GFR (r= -0.235, p= 0.01) and WBC (r= -0.235, p= 0.01). In multivariate logistic regression analysis, PLR and LVEF were shown to be independent predictors of CHA2DS2-VASc score. Area under the curve (AUC) was 0.61 (0.53-0.7, p< 0.05) for PLR and 0.69 (0.61-0.77, p< 0.001) for LVEF. The PLR value 112.5 predicted high CHA2DS2-VASc scores with a sensitivity of 65% and specifity of 61%.

Conclusion: Our findings suggest PLR as a predictor of CHA2DS2-VASc scores in patients with nonvalvular AF.

Keywords

• Atrial fibrillation,platelet to lymphocyte ratio,CHA2DS2-VASc score,thromboembolism risk

Kapağa Bağlı Olmayan Atriyal Fibrilasyonlu Hastalarda Trombosit/Lenfosit Oranı ile CHA2DS2-VASc Skoru Arasındaki İlişki

Abstract

Giriş: Atriyal fibrilasyonlu hastalarda tromboemboli riskini belirlemede en yaygın kullanılan skorlama sistemi CHA2DS2-VASc skorudur. Trombosit/lenfosit oranı (TLO) özellikle kanser hastalarında tanımlanan inflamasyonun önemli bir belirtecidir. Bizim bu çalışmamızın amacı kapağa bağlı olmayan atriyal fibrilasyonlu (KBOAF) hastalarda, TLO ile CHA2DS2-VASc skoru arasındaki ilişkiyi araştırmaktır.

Hastalar ve Yöntem: Bu retrospektif çalışmada, kliniğimize 2010 ve 2016 yılları arasında başvuran 184 kapağa bağlı olmayan atriyal fibrilasyonlu hastanın (ortalama yaş 68 ±  11.4 ve % 51.6 erkek) medikal kayıtları retrospektif olarak tarandı.

Bulgular: CHA2DS2-VASc skoruna göre yüksek riskli grubun düşük-orta olan gruba oranla daha yüksek TLO, daha düşük sol ventrikül ejeksiyon fraksiyonu (SVEF) ve daha düşük beyaz küre sayısı (BK)’na sahip olduğu saptanmıştır. İstatistiksel önemi düşük olsa da glomerüler filtrasyon hızı (GFH), yüksek risk grubunda daha düşük saptanmıştır. Korelasyon analizinde, CHA2DS2-VASc skoru TLO ile orta pozitif korelasyon (r= 0.3, p< 0.01), SVEF ile orta negatif korelasyon (r= -0.383, p< 0.01), GFH (r= 0.235, p= 0.01) ve BK (r= 0.235, p= 0.01) ile zayıf negatif korelasyona sahip olduğu görüldü. Çok değişkenli lojistik regresyon analizinde, trombosit/lenfosit oranı ve SVEF CHA2DS2-VASc skorunun bağımsız belirleyicileri oldukları saptandı. Roc analizinde eğri altında kalan alan TLO için 0.61 (0.53-0.7, p< 0.05) ve SVEF için 0.69 (0.61-0.77, p< 0.001) olarak saptanmıştır. TLO için  %65 duyarlılık ve %61 özgüllük ile yüksek CHA2DS2-VASc skorunu saptamada eşik değer 112.5 olarak tespit edildi.

Sonuç: KBOAF’li hastalarda TLO’nun yüksek CHA2DS2-VASc skoruyla korelasyon gösterdiği ve bu hasta grubunda tromboemboli açısından yüksek riski belirlemede skorlama sistemine ek ve yardımcı bir parametre olarak kullanılabileceğini ortaya koyduk.

Keywords

• Atriyal fibrilasyon,trombosit/lenfosit oranı,CHA2DS2-VASc skoru,tromboemboli riski

References

1. 1. Nattel S. New ideas about atrial fibrillation 50 years on. Nature 2002;415:219-26.
2. 2. Korantzopoulos P, Kolettis TM, Goudevenos JA, Siogas K. Errors and pitfalls in the non-invasive management of atrial fibrillation. Int J Cardiol 2005;104:125-30.
3. 3. Bruins P, te Velthuis H, Yazdanbakhsh AP, Jansen PG, Van Hardevelt FW, de Beaumont EM, et al. Activation of the complement system during and after cardiopulmonary bypass surgery postsurgery activation involves C-reactive protein and is associated with postoperative arrhythmia. Circulation 1997;96:3542-8.
4. 4. Ommen SR, Odell JA, Stanton MS. Atrial arrhythmias after cardiothoracic surgery. New N Engl J Med 1997;336:1429-34.
5. 5. Gabay C, Kushner I. Acute-phase proteins and other systemic responses to inflammation. N Engl J Med 1999;340:448-54.
6. 6. Smith RA, Bosonnet L, Raraty M, Sutton R, Neoptolemos JP, Campbell F, et al. Preoperative platelet-lymphocyte ratio is an independent significant prognostic marker in resected pancreatic ductal adenocarcinoma. Am J Surg 2009;197:466-72.
7. 7. Azab B, Shah N, Akerman M, McGinn Jr JT. Value of platelet/lymphocyte ratio as a predictor of all-cause mortality after non-ST-elevation myocardial infarction. J Thromb Thrombolysis 2012;34:326-34.
8. 8. Demirağ MK, Bedir A. Evaluation of preoperative neutrophil-lymphocyte ratio and platelet-lymphocyte ratio in patients undergoing major vascular surgery. Turk Gogus Kalp Dama 2013;21:930-5.

9. 9. Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA 2001;285:2864-70.
10. 10. Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest 2010;137:263-72.
11. 11. Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. The Task Force for the management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESCEndorsed by the European Stroke Organisation (ESO). European Journal of Cardio-Thoracic Surgery 2016:ezw313.
12. 12. Griffin BP. Manual of Cardiovascular Medicine. 4th ed. Lippinco tt Williams and Wilkins 2013:424-4.
13. 13. Chugh SS, Havmoeller R, Narayanan K, Singh D, Rienstra M, Benjamin EJ, et al. Worldwide epidemiology of atrial fibrillation: a Global Burden of Disease 2010 Study. Circulation 2014;129:837-47.
14. 14. Colilla S, Crow A, Petkun W, Singer DE, Simon T, Liu X. Estimates of current and future incidence and prevalence of atrial fibrillation in the US adult population. Am J Cardiol 2013;112:1142-7.
15. 15. Kishore A, Vail A, Majid A, Dawson J, Lees KR, Tyrrell PJ, et al. Detection of atrial fibrillation after ischemic stroke or transient ischemic attack: a systematic review and meta-analysis. Stroke 2014;45:520-6.
16. 16. Henriksson KM, Farahmand B, Asberg S, Edvardsson N, Terent A. Comparison of cardiovascular risk factors and survival in patients with ischemic or hemorrhagic stroke. Int J Stroke 2012;7:276-81.
17. 17. Grond M, Jauss M, Hamann G, Stark E, Veltkamp R, Nabavi D, et al. Improved detection of silent atrial fibrillation using 72-hour Holter ECG in patients with ischemic stroke: a prospective multicenter cohort study. Stroke 2013;44:3357-64.
18. 18. Sunbul M, Gerin F, Durmus E, Kivrak T, Sari I, Tigen K, et al. Neutrophil to lymphocyte and platelet to lymphocyte ratio in patients with dipper versus non-dipper hypertension. Clin Exp Hypertens 2014;36:217-21.
19. 19. Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke 1991;22:983-8.
20. 20. Camm A, Lip G, De Caterina R, Savelieva I, Atar D, Hohnloser S, et al. CPG; Document Reviewers. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation-developed with the special contribution of the European Heart Rhythm Association. Europace 2012;14:1385-413.
21. 21. Aviles RJ, Martin DO, Apperson-Hansen C, Houghtaling PL, Rautaharju P, Kronmal RA, et al. Inflammation as a risk factor for atrial fibrillation. Circulation 2003;108:3006-10.
22. 22. Dernellis J, Panaretou M. C-reactive protein and paroxysmal atrial fibrillation: evidence of the implication of an inflammatory process in paroxysmal atrial fibrillation. Acta Cardiol 2001;56:375-80.
23. 23. Chung MK, Martin DO, Sprecher D, Wazni O, Kanderian A, Carnes CA, et al. C-reactive protein elevation in patients with atrial arrhythmias inflammatory mechanisms and persistence of atrial fibrillation. Circulation 2001;104:2886-91.
24. 24. Anne W, Willems R, Roskams T, Sergeant P, Herijgers P, Holemans P, et al. Matrix metalloproteinases and atrial remodeling in patients with mitral valve disease and atrial fibrillation. Cardiovasc Res 2005;67:655-66.
25. 25. Chimenti C, Russo MA, Carpi A, Frustaci A. Histological substrate of human atrial fibrillation. Biomed Pharmacother 2010;64:177-83.
26. 26. Nguyen BL, Fishbein MC, Chen LS, Chen PS, Masroor S. Histopathological substrate for chronic atrial fibrillation in humans. Heart Rhythm 2009;6:454-60.
27. 27. Frustaci A, Chimenti C, Bellocci F, Morgante E, Russo MA, Maseri A. Histological substrate of atrial biopsies in patients with lone atrial fibrillation. Circulation 1997;96:1180-4.
28. 28. Venteclef N, Guglielmi V, Balse E, Gaborit B, Cotillard A, Atassi F, et al. Human epicardial adipose tissue induces fibrosis of the atrial myocardium through the secretion of adipo-fibrokines. Eur Heart J 2015;36:795-805a.
29. 29. Röcken C, Peters B, Juenemann G, Saeger W, Klein HU, Huth C, et al. Atrial amyloidosis an arrhythmogenic substrate for persistent atrial fibrillation. Circulation 2002;106:2091-7.
30. 30. Schotten U, Ausma J, Stellbrink C, Sabatschus I, Vogel M, Frechen D, et al. Cellular mechanisms of depressed atrial contractility in patients with chronic atrial fibrillation. Circulation 2001;103:691-8.
31. 31. Lim HS, Willoughby SR, Schultz C, Gan C, Alasady M, Lau DH, et al. Effect of atrial fibrillation on atrial thrombogenesis in humans: impact of rate and rhythm. J Am Coll Cardiol 2013;61:852-60.
32. 32. Hijazi Z, Oldgren J, Siegbahn A, Granger CB, Wallentin L. Biomarkers in atrial fibrillation: a clinical review. Eur Heart J 2013;34:1475-80.
33. 33. Madrid AH. C-reactive protein and atrial fibrillation. An old marker looking for a new target. Rev Esp Cardiol 2006;59:94-8.
34. 34. Engelmann MD, Svendsen JH. Inflammation in the genesis and perpetuation of atrial fibrillation. Eur Heart J 2005;26:2083-92.
35. 35. Conway DS, Buggins P, Hughes E, Lip GY. Relationship of interleukin-6 and C-reactive protein to the prothrombotic state in chronic atrial fibrillation. J Am Coll Cardiol 2004;43:2075-82.
36. 36. Dernellis J, Panaretou M. Relationship between C-reactive protein concentrations during glucocorticoid therapy and recurrent atrial fibrillation. Eur Heart J2004;25:1100-7.
37. 37. Psychari SN, Apostolou TS, Sinos L, Hamodraka E, Liakos G, Kremastinos DT. Relation of elevated C-reactive protein and interleukin-6 levels to left atrial size and duration of episodes in patients with atrial fibrillation. Am J Cardiol 2005;95:764-7.
38. 38. Turkmen K, Erdur FM, Ozcicek F, Ozcicek A, Akbas EM, Ozbicer A, et al. Platelettolymphocyte ratio better predicts inflammation than neutrophiltolymphocyte ratio in endstage renal disease patients. Hemodial Int 2013;17:391-6.
39. 39. Akbas EM, Hamur H, Demirtas L, Bakirci EM, Ozcicek A, Ozcicek F, et al. Predictors of epicardial adipose tissue in patients with type 2 diabetes mellitus. Diabetol Metab Syndr 2014;6:55.
40. 40. Uçar FM, Açar B, Gul M, Özeke Ö, Aydogdu S. The Association between platelet/lymphocyte ratio and coronary artery disease severity in asymptomatic low ejection fraction patients. Korean Circ J 2016;46:821-6.
41. 41. Oylumlu M, Yıldız A, Yüksel M, Korkmaz A, Aydın M, Bilik MZ, et al. Usefulness of platelet-lymphocyte ratio to predict stent thrombosis in patients with ST elevation myocardial infarction. Kosuyolu Heart J 2014;17:81-5.
42. 42. Gürsoy OM, Karakoyun S, Kalçık M, Gökdeniz T, Yesin M, Gündüz S, et al. Usefulness of novel hematologic inflammatory parameters to predict prosthetic mitral valve thrombosis. The Am J Cardiol 2014;113:860-4.
43. 43. Altintas O, Tasal A, Niftaliyev E, Kucukdagli OT, Asil T. Association of platelet-to-lymphocyte ratio with silent brain infarcts in patients with paroxysmal atrial fibrillation. Neurol Res 2016;38:753-8.