1

CHAPTER - I

INTRODUCTION

Myocardial Infarction is a common condition and frequently encountered in

emergency departments. The Patients are normally assessed by diagnostic flow

charts including clinical and electrocardiographic data, as well as myocardial

necrosis markers i.e. CK-MB (creatine phosphokinase) (Zazula, A D et al 2008).

Coronary heart disease is associated with the multifactorial condition

atherosclerosis. (I.J.Kullo 2010). Atherogenesis is an active inflammatory process

triggered by endothelial injury. (S. Anwaruddin et al 2007). Since it is an

inflammatory disease, some inflammatory markers have been proposed /

suggested for evaluation of cardiovascular risk. (LI Dong-bao et al 2009). Recent

data suggests that some specific subtypes of leukocytes and Neutrophil /

Lymphocyte (N/L) ratio have higher predictive value in assessing the

cardiovascular risk (LI Dong–bao, et al, 2009).. In patients prescribed angioplasty

N/L ratio is independent predictor of long term mortality (Duffy BK, et al, 2006).

Neutrophil / Lymphocyte (N/L) ratio act as a better acceptable marker for acute

coronary syndrome; such possibility is based on two distinctive mechanisms. (G.

Ndrepepa et al 2009). Undoubtedly Neutrophilia would reflect systemic

inflammatory status and as a consequence of high cardiovascular risk and

lymphopenia would reflect the acute stress presented by MI. (G. Ndrepepa et al

2009). Recent studies have demonstrated that evaluation of white blood cell

(WBC) count during acute myocardial infarction is associated with reduced

epicardial blood flow in myocardial reperfusion and adverse outcome. (Coller B.

S, 2005). Chatzizisis Y et al in 2007 have suggested that Atherosclerosis is

characterized by intimal lesions called atheromas that protrude into vessel

2

lumen .Besides mechanically obstructing blood flow, atherosclerotic plaques can

rupture, leading to catastrophic vessel thrombosis (Marijn C et al 2007). Because

coronary artery disease is an important manifestation of MI, epidemiologic data

related to atherosclerosis mortality typically reflect deaths caused by Myocardial

Infarction (Braunwald E et al 2008). Inflammatory cells and pathways contribute

to the initiation, progression, and complications of atherosclerotic lesions leading

to MI (Alain T 2006). Although normal vessels do not bind inflammatory cells,

early in atherogenesis, dysfunctional arterial endothelial cells express adhesion

molecules that encourage leukocyte adhesion; ICAM-2 in particular, binds

neutrophils (Bjorn P et al 2008 & Abigail W et al 2009). After these cells adhere

to the endothelium, they migrate into the intima under the influence of locally

produced Chemokines. (Alain T 2006). Most myocardial infarcts are transmural,

in which the ischemic necrosis involves the full or nearly full thickness of the

ventricular wall in the distribution of a single coronary artery (Woo KM 2009). In

contrast, a subendocardial (nontransmural) infarct constitutes an area of

ischemic necrosis limited to the inner one third to one half of the ventricular wall.

(Woo KM 2009). Owing to the characteristic electrocardiograph changes resulting

from myocardial ischemia / necrosis in various distributions, transmural infarcts

are often referred to as “ST elevation infarcts” and subendocardial infarcts are

known as “non-ST elevation infarcts.” (Goodcare S et al 2009). The overall total

mortality within the first year is about 30% (Beaglehole R et al 2007). Thereafter

there is 3% to 4% mortality among survivors with each passing year as per data

available in literature (Gaziano TA 2005).

3

OBJECTIVES

1. To estimate the Neutrophil / Lymphocyte ratio in patients of Myocardial

Infarction.

2. To evaluate the association between Neutrophil / Lymphocyte ratio and

different risk factors.

3 To define a tool for determination of early action in cases with possible

risk of morbidity and mortality after the index event.

4

CHAPTER -II

REVIEW OF LITERATURE

1. Demography

The human heart is a remarkably efficient, durable, and reliable pump that

propels over 6000 liters of blood through the body daily and beats more than 40

million times a year, thereby providing the tissues with a steady supply of vital

nutrients and facilitating the excretion of waste products. As might be anticipated,

cardiac dysfunction can be associated with devastating physiologic

consequences. Cardiovascular disease is the number one cause of death

worldwide, with about 80% of the burden occurring in developing countries.

(Gaziano, TA. 2005., Beaglehole, R. et al, 2007). In the United States, heart

disease accounts for nearly 40% of all postnatal deaths, totaling about 750,000

individuals annually; this is nearly 1.5 times the number of deaths caused by all

forms of cancer combined. It is estimated that one third of Americans have one

or more types of cardiovascular disease. Moreover, 32% of heart disease deaths

are “premature,” occurring in individuals younger than age 75 (Heart Association

statistics Committee, 2007). If all major forms of cardiovascular disease were

eliminated, life expectancy would increase by 7 years.

2. Cardiac Structure and Specializations

Heart weight varies with body height and weight; it normally averages

approximately 250 to 300 gm in females and 300 to 350 gm in males, or roughly

0.4% to 0.5% of body weight. The usual thickness of the free wall of the right

ventricle is 0.3 to 0.5 cm, and that of the left ventricle 1.3 to 1.5 cm. Increases in

5

cardiac size and weight accompany many forms of heart disease. Greater heart

weight or ventricular thickness indicates hypertrophy, and an enlarged chamber

size implies dilation. An increase in cardiac weight or size or both (resulting from

hypertrophy and/or dilation) is termed cardiomegaly.

The efficient pumping of blood by the heart to the entire body requires the

normal function of each of its key components, the myocardium, valves,

conduction system, and coronary arterial circulation.

2.1 Blood Supply

To meet their energy needs, cardiac myocytes rely almost exclusively on

oxidative phosphorylation, which is manifest by the abundant mitochondria that

are found in these cells.[5] Oxydative phosphorylation requires oxygen, making

cardiac myocytes extremely vulnerable to ischemia. A constant supply of

oxygenated blood is thus essential for cardiac function. Most of the myocardium

depends on nutrients and oxygen delivered via the coronary arteries, which arise

immediately distal to the aortic valve, initially running along the external surface

of the heart (epicardial coronary arteries) and then penetrating the myocardium

(intramural arteries). These small penetrating arteries yield arterioles and,

ultimately, provide a rich network of capillaries enveloping individual cardiac

muscle cells.

The three major epicardial coronary arteries are

(1) The left anterior descending (LAD)

(2) The left circumflex (LCX) arteries, Both arising from branches of the left

(main) coronary artery,

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(3) The right coronary artery. Branches of the LAD are called “diagonal” and

“septal perforators,” and those of the LCX are “obtuse marginals.”

Most coronary arterial blood flow to the myocardium occurs during ventricular

diastole, when the microcirculation is not compressed by cardiac contraction.

2.2 Ischemic Heart Disease

Ischemic heart disease (IHD) is the leading cause of death worldwide for

both men and women (7 million per year). IHD is the generic designation for a

group of pathophysiologically related syndromes resulting from myocardial

ischemia—an imbalance between the supply (perfusion) and demand of the

heart for oxygenated blood. Ischemia brings not only an insufficiency of oxygen,

but also reduces the availability of nutrients and the removal of metabolites For

this reason, ischemia is generally less well tolerated by the heart than pure

hypoxia, such as may be seen with severe anemia, cyanotic heart disease, or

advanced lung disease.

In more than 90% of cases, the cause of myocardial ischemia is reduced

blood flow due to obstructive atherosclerotic lesions in the coronary arteries.

Thus, IHD is often termed coronary artery disease (CAD) or coronary heart

disease. In most cases there is a long period (up to decades) of silent, slow

progression of coronary lesions before symptoms appear. Thus, the syndromes

of IHD are only the late manifestations of coronary atherosclerosis that may have

started during childhood or adolescence.

In addition to coronary atherosclerosis, myocardial ischemia may be

caused by coronary emboli, blockage of small myocardial blood vessels, and

lowered systemic blood pressure (e.g., shock). Moreover, in the setting of

7

coronary arterial obstruction, ischemia can be aggravated by an increase in

cardiac energy demand (e.g., as occurs with myocardial hypertrophy or

increased heart rate [tachycardia]), by diminished availability of blood or oxygen

due to shock, or by hypoxemia. Some conditions have several deleterious

effects; for example, tachycardia increases oxygen demand (because of more

contractions per unit time) and decreases supply (by decreasing the relative time

spent in diastole, when cardiac perfusion occurs).

3. Pathogenesis

The dominant cause of the IHD syndromes is insufficient coronary

perfusion relative to myocardial demand, due to chronic, progressive

atherosclerotic narrowing of the epi-cardial coronary arteries, and variable

degrees of superimposed acute plaque change, thrombosis, and vasospasm.

3.1 Chronic Atherosclerosis.

More than 90% of patients with IHD have atherosclerosis of one or more

of the epicardial coronary arteries. The clinical manifestations of coronary

atherosclerosis are generally due to progressive narrowing of the lumen leading

to stenosis (“fixed” obstructions) or to acute plaque disruption with thrombosis,

both of which compromise blood flow. A fixed lesion obstructing 75% or greater

of the lumen is generally required to cause symptomatic ischemia precipitated by

exercise (most often manifested as chest pain, known as angina); with this

degree of obstruction, compensatory coronary arterial vasodilation is no longer

sufficient to meet even moderate increases in myocardial demand. Obstruction of

90% of the lumen can lead to inadequate coronary blood flow even at rest. The

progressive myocardial ischemia induced by slowly developing occlusions may

8

stimulate the formation of collateral vessels over time, which can protect against

myocardial ischemia and infarction and mitigate the effects of high-grade

stenosis (Regieli, JJ. et al, 2007).

Although only a single major coronary epicardial trunk may be affected,

two or all three—the left anterior descending (LAD), the left circumflex (LCX), and

the right coronary artery (RCA)—are often involved by atherosclerosis. Clinically

significant stenosing plaques may be located anywhere within these vessels but

tend to predominate within the first several centimeters of the LAD and LCX and

along the entire length of the RCA. Sometimes the major secondary epicardial

branches are also involved (i.e., diagonal branches of the LAD, obtuse marginal

branches of the LCX, or posterior descending branch of the RCA), but

atherosclerosis of the intramural (penetrating) branches is rare.

3.2 Acute Plaque Change

The risk of an individual developing clinically important IHD depends in

part on the number, distribution, structure, and degree of obstruction of

atheromatous plaques. However, the varied clinical manifestations of IHD cannot

be explained by the anatomic disease burden alone. This is particularly true for

the so-called acute coronary syndromes, unstable angina, acute MI, and sudden

death. The acute coronary syndromes are typically initiated by an unpredictable

and abrupt conversion of a stable atherosclerotic plaque to an unstable and

potentially life-threatening atherothrombotic lesion through rupture, superficial

erosion, ulceration, fissuring, or deep hemorrhage. In most instances, the plaque

change causes the formation of a superimposed thrombus that partially or

completely occludes the affected artery (Fuster, V, et al, 2007, Falk, E, et al,

9

2005). These acute events are often associated with intralesional inflammation,

which mediates the initiation, progression, and acute complications of

atherosclerosis.

3.3 Consequences of Myocardial Ischemia.

In each syndrome the critical consequence is downstream myocardial

ischemia. Stable angina results from increases in myocardial oxygen demand

that outstrip the ability of stenosed coronary arteries to increase oxygen delivery;

it is usually not associated with plaque disruption. Unstable angina is caused by

plaque rupture complicated by partially occlusive thrombosis and

vasoconstriction, which lead to severe but transient reductions in coronary blood

flow. In some cases, microinfarcts can occur distal to disrupted plaques due to

thromboemboli. In MI, acute plaque change induces total thrombotic occlusion

and the subsequent death of heart muscle. Finally, sudden cardiac death

frequently involves an atherosclerotic lesion in which a disrupted plaque causes

regional myocardial ischemia that induces a fatal ventricular arrhythmia.

4. Myocardial Infarction (MI)

MI, also known as “heart attack,” is the death of cardiac muscle due to

prolonged severe ischemia. It is by far the most important form of IHD. About 1.5

million individuals in the United States suffer an MI annually.

4.1 Incidence and Risk Factors.

MI can occur at virtually any age, but its frequency rises progressively with

increasing age and when predispositions to atherosclerosis are present. Nearly

10% of myocardial infarcts occur in people under age 40, and 45% occur in

people under age 65. Blacks and whites are equally affected. Throughout life,

10

men are at significantly greater risk than women (Mendelsohn ME, et al, 2005)

Indeed, except for those having some predisposing atherogenic condition,

women are protected against MI and other heart diseases during the

reproductive years. However, the decrease of estrogen following menopause is

associated with rapid development of CAD, and IHD is the most common cause

of death in elderly women. Postmenopausal hormonal replacement therapy is not

currently felt to protect against atherosclerosis and IHD (Wenger NK, et al 2004).

4.2 Coronary Arterial Occlusion.

In the typical case of MI, the following sequence of events is considered

most likely

The initial event is a sudden change in an atheromatous plaque,

which may consist of intraplaque hemorrhage, erosion or ulceration, or

rupture or fissuring.

When exposed to subendothelial collagen and necrotic plaque

contents, platelets adhere, become activated, release their granule

contents, and aggregate to form microthrombi.

Vasospasm is stimulated by mediators released from platelets.

Tissue factor activates the coagulation pathway, adding to the bulk

of the thrombus.

Frequently within minutes, the thrombus evolves to completely occlude the

lumen of the vessel.

Compelling evidence for this sequence has been obtained from

(1) Autopsy studies of patients dying of acute MI.

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(2) Angiographic studies demonstrating a high frequency of thrombotic occlusion

early after MI.

(3) The high success rates of coronary revascularization (i.e., thrombolysis,

angioplasty, stent placement, and surgery) following MI and

(4) The demonstration of residual disrupted atherosclerotic lesions by

angiography after thrombolysis. Coronary angiography performed within 4 hours

of the onset of an MI shows a thrombosed coronary artery in almost 90% of

cases. However, when angiography is delayed until 12 to 24 hours after onset,

occlusion is seen only about 60% of the time, suggesting that some occlusions

resolve due to fibrinolysis, relaxation of spasm, or both.

4.3 Myocardial Response.

Coronary arterial obstruction compromises the blood supply to a region of

myocardium, causing ischemia, myocardial dysfunction, and potentially myocyte

death. The anatomic region supplied by that artery is referred to as the area at

risk. The outcome depends predominantly on the severity and duration of flow

deprivation.

The early biochemical consequence of myocardial ischemia is the

cessation of aerobic metabolism within seconds, leading to inadequate

production of high-energy phosphates (e.g., creatine phosphate and adenosine

triphosphate) and accumulation of potentially noxious metabolites (such as lactic

acid) Because of the exquisite dependence of myocardial function on oxygen,

severe ischemia induces loss of contractility within 60 seconds. This cessation of

function can precipitate acute heart failure long before myocardial cell death.

Ultrastructural changes (including myofibrillar relaxation, glycogen depletion, cell

12

and mitochondrial swelling) also develop within a few minutes of the onset of

ischemia. Nevertheless, these early changes are potentially reversible. As

demonstrated both experimentally and in clinical studies, only severe ischemia

lasting 20 to 30 minutes or longer leads to irreversible damage (necrosis) of

cardiac myocytes. Ultrastructural evidence of irreversible myocyte injury (primary

structural defects in the sarcolemmal membrane) develops only after prolonged,

severe myocardial ischemia (such as occurs when blood flow is 10% or less of

normal).

A key feature that marks the early phases of myocyte necrosis is the

disruption of the integrity of the sarcolemmal membrane, which allows

intracellular macromolecules to leak out of cells into the cardiac interstitium and

ultimately into the microvasculature and lymphatics in the region of the infarct.

Tests that measure the levels of myocardial proteins in the blood are important in

the diagnosis and management of MI. With prolonged severe ischemia, injury to

the microvasculature then follows.

In most cases of acute MI, permanent damage to the heart occurs when

the perfusion of the myocardium is severely reduced for an extended interval

(usually at least 2 to 4 hours), This delay in the onset of permanent myocardial

injury provides the rationale for rapid diagnosis in acute MI—to permit early

coronary intervention, the purpose of which is to establish reperfusion and

salvage as much “at risk” myocardium as possible.

Ischemia is most pronounced in the subendocardium; thus, irreversible

injury of ischemic myocytes occurs first in the subendocardial zone. With more

extended ischemia, a wave front of cell death moves through the myocardium to

13

involve progressively more of the transmural thickness and breadth of the

ischemic zone. The precise location, size, and specific morphologic features of

an acute MI depend on:

Necrosis is usually complete within 6 hours of the onset of severe

myocardial ischemia. However, in instances where the coronary arterial collateral

system, stimulated by chronic is-chemia, is better developed and thereby more

effective, the progression of necrosis may follow a more protracted course

(possibly over 12 hours or longer).

Knowledge of the areas of myocardium perfused by the three major

coronary arteries helps correlate sites of vascular obstruction with regions of

myocardial infarction. Typically, the left anterior descending branch of the left

coronary artery (LAD) supplies most of the apex of the heart (distal end of the

ventricles), the anterior wall of the left ventricle, and the anterior two thirds of the

ventricular septum. By convention, the coronary artery (either the right coronary

artery [RCA] or the left circumflex artery [LCX] that perfuses the posterior third of

the septum is called “dominant” (even though the LAD and LCX collectively

perfuse the majority of the left ventricular myocardium). In a right dominant

circulation, present in approximately four fifths of individuals, the LCX generally

perfuses only the lateral wall of the left ventricle, and the RCA supplies the entire

right ventricular free wall, the posterobasal wall of the left ventricle, and the

posterior third of the ventricular septum. Thus, occlusions of the RCA (as well as

the left coronary artery) can cause left ventricular damage. The right and left

coronary arteries function as end arteries, although anatomically most hearts

have numerous intercoronary anastomoses (connections called the collateral

14

circulation). Little blood courses through the collateral circulation in the normal

heart. However, when one artery is severely narrowed, blood flows via collaterals

from the high- to the low-pressure system, and causes the channels to enlarge.

Thus, progressive dilation and growth of collaterals, stimulated by ischemia, may

play a role in providing blood flow to areas of the myocardium otherwise deprived

of adequate perfusion.

4.4 Transmural versus Sub-endocardial Infarction.

The distribution of myocardial necrosis correlates with the location and

cause of the decreased perfusion. Most myocardial infarcts are transmural, in

which the ischemic necrosis involves the full or nearly full thickness of the

ventricular wall in the distribution of a single coronary artery. This pattern of

infarction is usually associated with a combination of chronic coronary

atherosclerosis, acute plaque change, and superimposed thrombosis. In

contrast, a subendocardial (nontransmural) infarct constitutes an area of

ischemic necrosis limited to the inner one third to one half of the ventricular wall.

As the subendocardial zone is normally the least perfused region of myocardium,

this area is most vulnerable to any reduction in coronary flow. A subendocardial

infarct can occur as a result of a plaque disruption followed by a coronary

thrombus that becomes lysed before myocardial necrosis extends across the full

thickness of the wall; in this case the infarct will be limited to the distribution of

the coronary artery that suffered plaque change. However, subendocardial

infarcts can also result from prolonged, severe reduction in systemic blood

pressure, as in shock superimposed on chronic, otherwise noncritical, coronary

stenoses. In the subendocardial infarcts that occur as a result of global

hypotension, myocardial damage is usually circumferential, rather than being

15

limited to the distribution of a single major coronary artery. Owing to the

characteristic electrocardiograph changes resulting from myocardial

ischemia/necrosis in various distributions, transmural infarcts are often referred

to as “ST elevation infarcts” and subendocardial infarcts are known as “non-ST

elevation infarcts.”

Biochemical abnormalities may also persist for a period of days to several

weeks in myocytes that are rescued from ischemia by reperfusion. These are

thought to underlie a phenomenon referred to as stunned myocardium, a state of

reversible cardiac failure that usually recovers after several days (Kloner RA, et

al, 2001). Reperfusion also frequently induces arrhythmias. Myocardium that is

subjected to chronic, sublethal ischemia may also enter into a state of lowered

metabolism and function that is referred to as hibernation (Heush G, et al, 2005)

The function of hibernating myocardium may be restored by revascularization

(e.g., by CABG surgery, angioplasty, or stenting). Paradoxically, repetitive short-

lived transient severe ischemia may protect the myocardium against infarction (a

phenomenon known as preconditioning) by mechanisms that are not understood

(Eisen A, et al, 2004).

5. Clinical Features.

MI is diagnosed by clinical symptoms, laboratory tests for the presence of

myocardial proteins in the plasma, and characteristic electrocardiographic

changes. Patients with MI often present with a rapid, weak pulse and profuse

sweating (diaphoresis). Dyspnea due to impaired contractility of the ischemic

myocardium and the resultant pulmonary congestion and edema is common.

However, in about 10% to 15% of patients the onset is entirely asymptomatic and

the disease is discovered only by electrocardiographic changes or laboratory

16

tests that show evidence of myocardial damage. Such “silent” MIs are particularly

common in elderly patients and in the setting of diabetes mellitus.

The laboratory evaluation of MI is based on measuring the blood levels of

proteins that leak out of fatally injured myocytes; these molecules include

myoglobin, cardiac troponins T and I, the MB fraction of creatine kinase (CK-MB),

lactate dehydrogenase, and many others (Jaffe AS, et al, 2004). The diagnosis of

myocardial injury is established when blood levels of these cardiac biomarkers

are increased in the clinical setting of acute ischemia. The rate of appearance of

these markers in the peripheral circulation depends on several factors, including

their intracellular location and molecular weight, the blood flow and lymphatic

drainage in the area of the infarct, and the rate of elimination of the marker from

the blood.

The most sensitive and specific biomarkers of myocardial damage are

cardiac-specific proteins, particularly Troponins I and T (proteins that regulate

calcium-mediated contraction of cardiac and skeletal muscle). Troponins I and T

are not normally detectable in the circulation. Following an MI, levels of both

begin to rise at 2 to 4 hours and peak at 48 hours. Formerly the “gold standard,”

cardiac creatine kinase remains useful. Creatine kinase, an enzyme that is

present in brain, myocardium, and skeletal muscle, is a dimer composed of two

isoforms designated “M” and “B.” MM homodimers are found predominantly in

cardiac and skeletal muscle; BB homodimers in brain, lung, and many other

tissues; and MB heterodimers principally in cardiac muscle, with lesser amounts

also being found in skeletal muscle. As a result, the MB form of creatine kinase

(CK-MB) is sensitive but not specific, since it is also elevated when skeletal

muscle is injured. CK-MB begins to rise within 2 to 4 hours of the onset of MI,

17

peaks at about 24 hours, and returns to normal within approximately 72 hours.

Although the diagnostic sensitivities of cardiac troponin and CK-MB

measurements are similar in the early stages of MI, elevated troponin levels

persist for approximately 7 to 10 days after acute MI, well after CK-MB levels

have returned to normal. Troponin and CK-MB levels peak earlier in patients

whose hearts are successfully reperfused, because proteins are washed out of

the necrotic tissue more rapidly. An unchanged level of CK-MB and troponin over

a period of 2 days essentially excludes the diagnosis of MI.

6. Consequences and Complications of MI.

Long-term prognosis after MI depends on many factors, the most

important of which are the quality of residual left ventricular function and the

extent of vascular obstructions in vessels that perfuse the viable myocardium.

The overall total mortality within the first year is about 30%. Thereafter there is

3% to 4% mortality among survivors with each passing year. Infarct prevention

through control of risk factors in individuals who have never experienced MI

(primary prevention) and prevention of reinfarction in those who have recovered

from an acute MI (secondary prevention) are important strategies that have

received much attention and achieved considerable success.

6.1 Acute coronary syndrome (ACS)

Acute coronary syndrome (ACS) is usually one of three diseases that

involved the coronary arteries: ST elevation myocardial infarction (30%), non ST

elevation myocardial infarction (25%), or unstable angina (38%) (Torres, M. et al.

2007).

6.2 Signs and symptoms

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The cardinal sign of decreased blood flow to the heart is chest pain

experienced as tightness around the chest and radiating to the left arm and the

left angle of the jaw. This may be associated with diaphoresis (sweating), nausea

and vomiting, as well as shortness of breath. In many cases, the sensation is

"atypical", with pain experienced in different ways or even being completely

absent (which is more likely in female patients and those with diabetes). Some

may report palpitations, anxiety or a sense of impending doom and a feeling of

being acutely ill. The description of the chest discomfort as a pressure has little

utility in aiding a diagnosis as it is not specific for ACS (Woo, KM, et al, 2009).

6.3 Biomarkers for diagnosis

The aim of diagnostic markers is to identify patients with ACS even when

there is no evidence of heart muscle damage.

• Ischemia-Modified Albumin (IMA) - In cases of Ischemia - Albumin undergoes a

conformational change and loses its ability to bind transitional metals (copper or

cobalt). IMA can be used to assess the proportion of modified albumin in

ischemia. Its use is limited to ruling out ischemia rather than a diagnostic test for

the occurrence of ischemia.

Glycogen Phosphorylase Isoenzyme BB-(GPBB) is an early marker of

cardiac ischemia and is one of three isoenzyme of Glycogen Phosphorylase.

Troponin is a late cardiac marker of ACS Biomarkers for Risk

Stratification.

19

Natriuretic Peptide - Both B-type Natriuretic peptide (BNP) and N-terminal

Pro BNP can be applied to predict the risk of death and heart failure following

ACS.

Myeloperoxidase (MPO) - The levels of circulating MPO, a leukocyte

enzyme, elevate early after ACS and can be used as an early marker for the

condition.

Myeloperoxidase (MPO) is a well-known enzyme, mainly released by

activated neutrophils, characterized by powerful pro-oxidative and

proinflammatory properties. Recently, myeloperoxidase has been proposed as a

useful risk marker and diagnostic tool in acute coronary syndromes and in

patients admitted to emergency room for chest pain.

7. Pathophysiological Role of Myeloperoxidase in Ischemic Heart Disease

Oxidative stress and inflammation play important roles in the

pathogenesis of destabilization of coronary artery disease (CAD) leading to acute

coronary syndromes (ACS). Infiltrating macrophages and neutrophils participate

in the transformation of stable coronary artery plaques to unstable lesions

(Takahiko, N, et al. 2002, Sugiyama, S. et al. 2001).

Recently, there has been a renewed interest in MPO, a proinflammatory

enzyme that is abundant in ruptured plaque (Mulane, K.M, et al. 1985) and can

be measured in peripheral blood.

20

MPO is a hemoprotein that is stored in azurophilic granules of

polymorphonuclear neutrophils. MPO catalyzes the conversion of chloride and

hydrogen peroxide to hypochlorite and is secreted during inflammatory condition.

It has been implicated in the oxidation of lipids contained within LDL cholesterol.

In addition, MPO consumes endothelial-derived NO, thereby reducing NO

bioavailability and impairing its vasodilating and anti-inflammatory properties.

Major evidence for MPO as enzymatic catalyst for oxidative modification of

lipoproteins in the artery wall has been suggested in a number of studies

performed with low-density lipoprotein (Holvoet, P. et al 1998).

In contrast to low-density lipoprotein, plasma levels of high-density

lipoprotein (HDL)-cholesterol and apoAI, the major apolipoprotein of HDL,

inversely correlate with the risk of developing coronary artery disease. There is

now strong evidence that HDL is a selective in vivo target for MPO-catalyzed

oxidation, which may represent a specific molecular mechanism for converting

the cardioprotective lipoprotein into a dysfunctional form, raising the possibility

that the enzyme represents a potential therapeutic target for preventing vascular

disease in humans (Saffitz JE, et al, 2006). (Shao, B, et al. 2006) showed that

atorvastatin reduced serum MPO and CRP concentrations in patients with ACS.

MPO activity can be measured in blood and tissues by spectrophotometric

assays using hydrogen peroxide and odianisidine dihydrochloride as substrates.

In addition, MPO content can be measured in neutrophils as an index of

degranulation with the Coulter counter and flow cytometry and circulating MPO

by ELISA.

21

There is extensive evidence to support a pathogenic role for both local and

systemic inflammation in acute coronary syndromes. There is also evidence that

increased concentrations of inflammatory markers at presentation can identify

patients at high risk of future ischemic events, suggesting that the intensity of the

inflammatory response influences clinical outcome in acute coronary syndromes.

More recent data suggest that the inflammatory process is sustained long after

the clinical event has resolved and that this ongoing inflammation is associated

with an increase in subsequent ischemic events.

However, some important questions relating to inflammation in acute

coronary syndromes remain unanswered. Firstly, it remains to be elucidated

whether the inflammatory process observed is a precursor or a consequence of

coronary plaque rupture; the emerging data suggest that the inflammatory

process is indeed a precursor of the clinical event.

22

CHAPTER – III

MATERIAL AND METHODS

1. Setting

Coronary Care Units (CCU) of Isra University Hospital, Dewan Mushtaq

Civil Hospital Hyderabad and Red Crescent Chest Pain Unit Latifabad,

Hyderabad.

1.1 Study Design:

Cross – sectional

1.2 Sample Size:

140 Subjects were divided into three groups:

1) Non Cardiac Group: Comprising of 42 individuals having non cardiac chest

pain and a normal electrocardiogram (ECG) and CKMB.

2) AMI with ST-segment Elevation (STE) Group: Comprising 58 patients with

Myocardial infarction having STE on electrocardiogram.

3) AMI with Non-ST Segment Elevation (NSTE) Group: Comprising 40 patients

of myocardial infarction having NSTE on the electrocardiogram.

1.3 Inclusion Criteria:

All the patients of either gender having ages over 35 years, presenting at

emergency department / CCU with AMI.

1.4 Exclusion Criteria:

23

Patients with age under 35 years.

Patients with a history of trauma, surgery and infectious diseases in the 30

days prior to admission.

Patients with neoplasia

Patients on prolonged immune-suppressors therapy (Corticoids & NSAIDs

included).

1.5 Sample Collection

[

l Blood was collected by veinipuncture from the antecubital fossa in

disposable 3.0 cc syringes under aseptic conditions and preserved in EDTA

bottles from every patient admitted with complaints of severe chest pain in

said hospital locations.

l The collected sample bottles were marked with patients name and DOA

along with the record number from their files.

l A Proforma was duly filled by this researcher when each patient was

stabilized after explaining to them the purpose. The same was explained to their

relatives at the time of admission and before the blood was drawn.

l The TLC and other cardiac markers were determined by automatic analyzers

in the clinical laboratories of the said CP & CC Us.

l Slides were prepared for manual DLC and stained with Leishmann’s stain

using the Standard protocols.

l The findings were interpreted and correlated with the patient’s clinical

condition and Proforma.

24

PROTOCOL FOR LEISHMANN'S STAIN PREPARATION:

l Add 15 Gms Leishmann's powder (Eosinate of Methylene blue) in 100%

methanol. (Use after 24hrs.)

PHOSPHATE BUFFER (Sorensen)

l STOCK A: (0.2M sodium di-hydrogen orthophosphate [mw 156].

To prepare dissolve 3.12g in 100ml distilled water.

l STOCK B: (0.2M di-sodium hydrogen orthophosphate [mw 142].

To prepare dissolve 2.83g in 100ml distilled water.

l FOR PH 6.8: add 25.5ml of Stock A to 24.5ml of Stock B and make up to

100ml with distilled water.

1.6 Method of Staining:

Put slides on a rack and cover with 1-2 ml of Prepared Leishmann's stain

for 20 seconds.

Add 2ml of pH6.8 buffer and tip the rack up and down to mix the solutions,

stain for 7 minutes.

Rinse quickly in distilled water then treat with pH6.8 buffer for 2 minutes.

Rinse quickly in distilled water, shake off the excess and carefully air dry at

room temperature.

Mount on the observation platform of a light microscope and observe using a

10x eye piece and (Cedar Wood) oil immersion objective lens: (100 x) to increase

the magnification 1000 times.

1.7 Observations.

25

NEUTROPHILS - dark purple nuclei, pale pink cytoplasm, reddish-lilac

small granules.

EOSINOPHILS - blue nuclei, pale pink cytoplasm, red to orange-red large

granules.

LYMPHOCYTES - dark purple to deep bluish purple nuclei, sky blue

cytoplasm.

BASOPHILS - purple to dark blue nucleus, dark purple, almost black large

granules.

MONOCYTES – Light to dark pink cytoplasm with color less cytoplasm and

occasional deep pink large granule.

STATISTICS

DATA ANALYSIS

The data collected through duly filled Proforma was computerized and the

variables were analyzed by using SPSS version 16.

A p - value of ? 0.05 was considered to be significant.

Mean & SD were calculated.

T-test was applied to continuous variables.

Chi-square test was applied to categorical variables.

The N/L Ratio was subjected to the following parameters as well

Sensitivity

Specificity

Positive predictive value

26

Negative predictive value

Odds Ratio

27

CHAPTER-IV

RESULT

The study was conducted on 140 individuals, between the age group of 35

years to 85 years. 140 individuals divided in to 05 groups that ranges 10 year in

each groups Tab: IV-01.

Gender distribution was also recorded in each group that is shown in table

#I V-01.

The highest ratio of the individuals were recorded between the age of 45-

55 years with significant p value<0.05.

All the groups of individuals were analyzed in three categories i.e. non

cardiac cases, AMI-with STE & AMI with NSTE.

The neutrophil count was recorded in all three categories for all

individuals. Study results show the neutrophil count to be within normal range in

non cardiac cases however it showed a marked increased in AMI with STE

Fig.IV-1.

Similarly lymphocyte count was also recorded in all three categories for all

140 individuals. The lymphocyte count was significantly raised in non-cardiac

cases but it was found to be significantly decreased in AMI with STE as

compared to with AMI with NSTE, Fig. IV-02.

The total leukocyte count was also recorded in all 140 individuals. It was

found to be gradually increased from non cardiac cases to AMI with STE.

28

In AMI with NSTE it was also increased but not as much as in AMI with

STE. Fig.IV-03.

In graph # the results of N/L ratio are shown that reveals that neutrophil /

lymphocyte ratio is significantly increased in AMI with STE (p< 0.01) Fig.IV-04.

The analytical output of this study shows that odds ratio is significantly

increased for N/L ratio (5.67). This is highly significant.

Furthermore, sensitivity and specificity analysis results revealed that N/L

ratio is about (94.83%) sensitive and 95.21% specific for the objective to be

recorded for the study. In view of the results of sensitivity and specificity, positive

predictive value and negative predictive values were also estimated, that has

shown a significant calculation. Odds for neutrophils, lymphocytes and

leukocytes was also analyzed Tab.IV-02.

In non-cardiac cases CKMB was found normal i.e. 92.9% individuals

having normal CKMB count while 7.1% having increased.

In AMI, NSTE it was raised in 62.5% individuals while it was not done in

37.5% individuals. In AMI with STE, CKMB was found significantly increased in

all the individuals of this group Tab.IV-03.

In non cardiac cases Trop.T was negative in all individuals of this group

while in AMI with NSTE it was raised in 42.5% of individuals and 57.5% of

individuals it was not done. In AMI with STE it was increased in 66.5% of

individual while in 34.5% of individuals it was not checked. The results were

significant Tab.IV-04.

29

Table IV-01. Distribution of Cases by Age & Gender

(n=140)AGE GROUPS

(YEARS35-45

46-55

56-65

66-75

76-85

Male101535158Female81320124Total1218285527

30

Table IV-02. Comprehensive Analytical Out Put

ANALY T IC AL OU T PU T

O d d s R a tio

S en sit iv ity(% )

S p ec ific ity (% )

P o sit iv eP red ic t iv e

V a lu e(% )

N eg a tiv e P red ic t iv e

V a lu e (% )

N /L R a tio 5 .6 7 9 4.83 9 5.21 9 3.89 9 1.72

N eu tro p h ils 3 .8 4

L y m p h o cy tes 0 .7 6

L eu cocy tes 2 .3 7

ANALY T IC AL OU T PU T

O d d s R a tio

S en sit iv ity(% )

S p ec ific ity (% )

P o sit iv eP red ic t iv e

V a lu e(% )

N eg a tiv e P red ic t iv e

V a lu e (% )

N /L R a tio 5 .6 7 9 4.83 9 5.21 9 3.89 9 1.72

N eu tro p h ils 3 .8 4

L y m p h o cy tes 0 .7 6

L eu cocy tes 2 .3 7

Table # 02

31

32

Table IV-03. Risk Factors Association with N/L Ratio

Risk Factors Associa tion With N/L Ratio

BMI Dia be tes Me llitus Sm oking Hypertension

Norm a l Yes No Yes No Yes No Yes No

N /L R atio

NIL NIL

Fam ily History of CAD

Over W e ight

Unde r W e ight

Non cardia c che st pa in

(42 = n)

2.38 (n=% )

80.95(n=% )

16.66(n=% )

100(n=% )

11.90 (n=% )

88.09(n=% )

21.42 (n=% )

78.57(n=% )

100(n=% )

(1.5 - 3) (1.5 – 2.5) (1.5 – 2.5) (1.5 - 3) (1.5 - 3) (1.5 - 3) (1.5 – 2.5) (1.5 – 3.9) (1.5 - 3) (1.5 – 2.5) (1.5 – 2.5)

AMINSTE

(40 = n)

30.00 (n=% )

45.00(n=% )

25.00(n=% )

50.00(n=% )

50.00(n=% )

35.00 (n=% )

65.00(n=% )

52.50 (n=% )

47.50(n=% )

77.50(n=% )

22.50(n=% )

(2.5 – 3.5) (2.5 – 3.5) (2.5 – 3.5) (2.5 – 3.5) (2.5 – 3.5) (2.5 – 3.5) (2.5 – 3.5) (2.5 – 4.0) (2.5 – 3.5) (2.5 – 3.5) (2.5 – 3.5)

AMISTE

(58 = n)

44.82 (n=% )

46.55(n=% )

8.62(n=% )

55.17(n=% )

44.82(n=% )

41.37 (n=% )

58.62(n=% )

56.89 (n=% )

43.10(n=% )

81.03(n=% )

18.96(n=% )

(3.5 – 5.5)P < 0.01

(3.5 – 4.5)p < 0.05

(3.5 – 4.5)p < 0.05

(4.5 – 6.5)P < 0.01

(3.5 – 4.5)p < 0.05

(5.5 – 6.5)P < 0.01

(3.5 – 4.5)p < 0.05

(5.5 – 6.5)P < 0.01

(3.5 – 4.5)p < 0.05

(4.5 – 5.5)P < 0.01

(3.5 – 4.5)p < 0.05

Table # 03

33

Table IV-04. ECG Changes

NC AMI-STE NSTE-AMI Total

42 58 40 140

34

35

Table IV-05. Percentage of sample with regard to BMI

36

Table IV-06. Gender Distribution (n=140)

37

Table IV-07. Percentage of sample size with / without DM

38

Table IV-08. Percentage of patients with prevalence of Smoking

Y e s N o

N C 11 .9 0 8 8 .1 0

A M I-N S T E 3 5 6 5

A M I-S T E 4 1 .3 7 5 8 .6 3

Y e s N o

N C 11 .9 0 8 8 .1 0

A M I-N S T E 3 5 6 5

A M I-S T E 4 1 .3 7 5 8 .6 3

H yp e r te n s io n (% )

Y e s N o

N C N il 1 0 0

A M I

N S T E7 7 .5 2 2 .5

A M I S T E 8 1 .0 4 1 8 .9 6

H yp e r te n s io n (% )

Y e s N o

N C N il 1 0 0

A M I

N S T E7 7 .5 2 2 .5

A M I S T E 8 1 .0 4 1 8 .9 6

Table # 08: Smoking

Table # 09: HTN

39

Table IV-09. Percentage of cases with / without Hypertension

Y e s N o

N C 11 .9 0 8 8 .1 0

A M I-N S T E 3 5 6 5

A M I-S T E 4 1 .3 7 5 8 .6 3

Y e s N o

N C 11 .9 0 8 8 .1 0

A M I-N S T E 3 5 6 5

A M I-S T E 4 1 .3 7 5 8 .6 3

H yp e r te n s io n (% )

Y e s N o

N C N il 1 0 0

A M I

N S T E7 7 .5 2 2 .5

A M I S T E 8 1 .0 4 1 8 .9 6

H yp e r te n s io n (% )

Y e s N o

N C N il 1 0 0

A M I

N S T E7 7 .5 2 2 .5

A M I S T E 8 1 .0 4 1 8 .9 6

Table # 08: Smoking

Table # 09: HTN

40

Table IV-10. Association of major risk factors with MI.

N C A M I-N S T E A M I-S T E P value

G end erM ale - 64 .28

F em ale – 35.71M ale – 65

F em ale – 35M ale 65 .5 1

F em ale – 34.48--

B M I (% ) 16 .6 50 46 .55 < 0 .05

D M (% ) N il 50 44 .82 < 0 .05

S m oking (% ) 11 .90 35 41 .37 < 0 .05

F am ily (% ) 21 .42 65 72 .41 < 0 .01

H T N (% ) N il 77 .5 81 .03 < 0 .01

C K -M B N il 625 50 < 0 .05

N C A M I-N S T E A M I-S T E P value

G end erM ale - 64 .28

F em ale – 35.71M ale – 65

F em ale – 35M ale 65 .5 1

F em ale – 34.48--

B M I (% ) 16 .6 50 46 .55 < 0 .05

D M (% ) N il 50 44 .82 < 0 .05

S m oking (% ) 11 .90 35 41 .37 < 0 .05

F am ily (% ) 21 .42 65 72 .41 < 0 .01

H T N (% ) N il 77 .5 81 .03 < 0 .01

C K -M B N il 625 50 < 0 .05

Table # 10

41

Table IV-11. CKMB Cross tabulation

42

Case * CKM B Crosstabulation

CKMB Total

Raised Norm al Not done

Case NC Count 3 39 0 42

% within C ase 7.1% 92.9% .0% 100.0%

% within CKMB 5.3% 100.0% .0% 30.0%

AMI-N STE Count 25 0 15 40

% within C ase 62.5% .0% 37.5% 100.0%

% within CKMB 43.9% .0% 34.1% 28.6%

AMI-STE Count 29 0 29 58

% within C ase 50.0% .0% 50.0% 100.0%

% within CKMB 50.9% .0% 65.9% 41.4%

Total Count 57 39 44 140

% within C ase 40.7% 27.9% 31.4% 100.0%

% within CKMB 100.0% 100.0% 100.0% 100.0%

Case * CKM B Crosstabulation

CKMB Total

Raised Norm al Not done

Case NC Count 3 39 0 42

% within C ase 7.1% 92.9% .0% 100.0%

% within CKMB 5.3% 100.0% .0% 30.0%

AMI-N STE Count 25 0 15 40

% within C ase 62.5% .0% 37.5% 100.0%

% within CKMB 43.9% .0% 34.1% 28.6%

AMI-STE Count 29 0 29 58

% within C ase 50.0% .0% 50.0% 100.0%

% within CKMB 50.9% .0% 65.9% 41.4%

Total Count 57 39 44 140

% within C ase 40.7% 27.9% 31.4% 100.0%

% within CKMB 100.0% 100.0% 100.0% 100.0%

Table # 11

43

44

Table IV-12. Trop t Cross tabulation

Case * Trop t Crosstabulation

Trop t Tota l

P os itive N egative N ot done

C ase N C C ount 0 42 0 42

% w ithin Case .0% 100.0% .0% 100.0%

% w ithin Trop t .0% 100.0% .0% 30.0%

A M I-N S TE C ount 17 0 23 40

% w ithin Case 42.5% .0% 57.5% 100.0%

% w ithin Trop t 30.9% .0% 53.5% 28.6%

A M I-S TE C ount 38 0 20 58

% w ithin Case 65.5% .0% 34.5% 100.0%

% w ithin Trop t 69.1% .0% 46.5% 41.4%

Tota l C ount 55 42 43 140

% w ithin Case 39.3% 30.0% 30.7% 100.0%

% w ithin Trop t 100.0% 100.0% 100.0% 100.0%

Case * Trop t Crosstabulation

Trop t Tota l

P os itive N egative N ot done

C ase N C C ount 0 42 0 42

% w ithin Case .0% 100.0% .0% 100.0%

% w ithin Trop t .0% 100.0% .0% 30.0%

A M I-N S TE C ount 17 0 23 40

% w ithin Case 42.5% .0% 57.5% 100.0%

% w ithin Trop t 30.9% .0% 53.5% 28.6%

A M I-S TE C ount 38 0 20 58

% w ithin Case 65.5% .0% 34.5% 100.0%

% w ithin Trop t 69.1% .0% 46.5% 41.4%

Tota l C ount 55 42 43 140

% w ithin Case 39.3% 30.0% 30.7% 100.0%

% w ithin Trop t 100.0% 100.0% 100.0% 100.0%

Table # 12

45

46

Graph IV-01. Absolute Neutrophils Count of Cases Neutrophils Count of Cases

02 0 0 04 0 0 06 0 0 08 0 0 0

1 0 0 0 01 2 0 0 01 4 0 0 01 6 0 0 01 8 0 0 0

n o n ca rd ia cp a in

AMI NST E AMIST E

p < 0.05

Ne

utr

op

hils

co

un

t

Fig. # 01

C ases C ases C ases

n=140

47

Graph IV-02. Absolute Lymphocytes Count of Cases

0

5 0 0

1 0 0 0

1 5 0 0

2 0 0 0

2 5 0 0

3 0 0 0

3 5 0 0

4 0 0 0

n o n ca rd ia cp a in

AMI NST E AMIST E

p value 0.05

Ly

mp

ho

cy

tes

co

un

t

Lymphocytes Count of Cases

C ases C ases C ases

n=140

Fig. # 02

48

Graph IV-03. Total Leukocytes of Count of Cases

0

5000

10000

15000

20000

25000

non cardiacpain

AMI NSTE AMISTE

p value < 0.04

Le

uk

oc

yte

s c

ou

nt

Total Leukocytes Count of CasesFig # 03

C ases C ases C ases

n=140

49

Graph IV-04. Neutrophil/Lymphocyte Ratio

Neutrophil/Lymphocyte Ratio

0

2

4

6

8

10

12

14

16

non cardiac pain AMI NSTE AMISTE

p v alue < 0.001

N/L

ra

tio

Fig # 04

___________

50

CHAPTER-VI

DISCUSSION

It has been long known that Acute Myocardial Infarction is followed by

Neutrophilia, the early appearance of Neutrophils in the infarct zone with heavy

infiltration by 1-3 days, followed by infarct healing and replacement fibrosis as

can be seen in the researches done by (Faxon DP et al 2002; Tanya N et al in

2009 and Adelaide M et al 2008)

Neutrophilia also might indicate maladaptive processes: circulating

leukocyte-platelet aggregates appear in acute coronary syndromes and might

facilitate vascular plugging and infarct extension. (Núñez J et al 2008).

The neutrophils can make plaque disruption by releasing Myeloperoxidase

(MPO) contained in the auzerophillic granules which catalyzes the reaction

between a halide and hydrogen per oxide, while the reperfusion injury occurring

spontaneously or after therapy have been postulated to be leukocyte mediated

(Valentina L et al 2009).

The basic theme of my research is that Leukocytosis is associated with

poor prognosis and vaso-occlusive events in patient, the experimental data

suggest a direct role for leukocytes in micro vascular obstruction and (Di Stefano

R et al 2009) hold the same view

The only way to test whether leukocytes contribute directly to poor

outcome in ischemic cardiovascular disease is to assess the effect of N/L ratio

which is the mainstay of my study and has amply demonstrated that total

51

leukocyte counts, differential leukocyte counts along with N/L ratio (neutrophil /

lymphocytes ratio) are probably the only prognostic tools for the prediction of an

increased risk of morbidity and mortality in patients with Myocardial Infarction

This view was also proposed by (Barry S.C. et al 2005).

With purpose to assess whether the N/L ratio was directly associated with

MI, the study was correlated with gradual increase in N/L ratio obtained from non

cardiac chest pain patients to MI with ST segment Elevation patients.

Odds ratio was also calculated for neutrophil, lymphocyte, total leukocytes

and N/L ratio with significant results. (Table # 9).

My research showed the PPV (positive predictive value) (Table # 09) of

N/L Ratio in patients with MI which is in agreement with work done by (Matteo M

et al 2006; Lee C et al 2001 & Haim M et al 2004).

I have also discovered that Neutrophilia is an independent risk marker for

increased morbidity after an initial cardiovascular event which is totally consistent

with the work done by (Grau AJ et al 2004).

The present study has shown an independent and strong association

between N/L ratio in patients of ST segment Elevation and Non ST segment

Elevation myocardial infarction (Table# 08), Which view was put forward by Das

U. N in 2008.

My research also discovered that a very high incidence of TLC & N/L Ratio

was visible in patients with MI and these results are consistent with the studies

done by (Wheeler et al in 2004 and Papa A et al 2009), who reported that

52

increased Neutrophil counts predicts greater risk for increased morbidity and

mortality after MI than other leukocyte subtypes. (Figures 2 & 4)

Afiune et al in 2006 said that monocyte are to be associated with the

highest risk of coronary artery disease; However I strongly disagree with this

view and have shown that the N/L ratio with a high TLC works as a better

prognostic tool for MI than any other isolated subtypes of leukocytes. (Table#01)

In my research a highly significant correlation of N/L Ratio and CK-MB

level has been observed (p value <0.001) between the STE-MI & NSTE-MI

(Table# 08). On this point I am in agreement with the findings of Fox S et al,  in

whose study in 2010, the peak Neutrophil count recorded during the immediate

post infarct period showed a significant correlation with maximum CK-MB levels

along with a role of increased N/L Ratio in expansion of infarct and development

of subsequent cardiac failure. This view is also shared with (Di Stefano R et al

2009).

In consideration that atherosclerotic lesion contains macrophage infiltrates

and lymphocytes in its sub-endothelial layer as suggested by Zazula et al in

2008; I postulate that the increased Neutrophilia is a result of the increased

endothelial released cytokines viz. G-CSF for the stability of the different plaque

components and the same is postulated in the study done by (Li Dong–Bao et al

in 2009).

However in this study it has been observed that myocardial infarction with

ST Elevation presented with a drastic decrease in lymphocyte counts as

compared to MI with Non ST Elevation which finding is consistent with the study

of (Poludasu S et al 2009).

53

(SHEN Xu-hua et al 2010) stated that there is no significant relations

between the increased CK-MB with N/L ratio but in contrast my work has shown

that there is high statistical significance (p value < 0.05) in correlation between

increased CK-MB levels and N/L ratio (Table# 08).

Results from other prospective studies (Roy D et al 2006, Ommen SR, et

al 1997 & He R et al 2009) have described that absolute and relative lymphocyte

concentrations are significantly lower in patients with cardiac events and my

study is totally consistent with these views.

In my research, I have correlated the various high risk factors (Table# 08)

with Non ST segment Elevation and ST segment Elevation myocardial infarction

and shows a very high degree of Sensitivity; Specificity; NPV (Negative predictive

value) and PPV (Positive predictive value) as seen in Tables# 01 & 09. This

correlation has never been done before.

54

CHAPTER-VII

CONCLUSION

From the results of my study, it can safely be concluded that N/L ratio is

increased dramatically along with a high TLC in ST segment Elevation MI and a

moderate increase of the same is seen in Non ST segment Elevation MI as

compared to non cardiac pain subjects, and is highly sensitive, specific, with a

very high PPV.

My Research clearly states that, the N/L ratio is of strong prognostic value

for predicting an increased risk of morbidity and mortality in patients who have

already suffered a Myocardial Infarction whether a STE-MI or a NSTE-MI.

In this light, it can be positively concluded that N/L ratio can be used as

preliminary prognostic tool for increased risk of morbidity and mortality after the

initial Myocardial infarction whether STE-MI or NSTE-MI.

55

CHAPTER-VIII

SUGGESTIONS

Since this was a cross sectional study it is strongly urged that a

Prospective Cohort study starting from the Index event with a minimum 18

months follow up may be undertaken to properly assess the importance of N/L

Ratio on the morbidity and mortality in the population of Pakistan.

56

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