Professional Documents
Culture Documents
52]
Research Article
DOI:
10.4103/0253-7613.186205 Edem Efe, Ibrahim Kocayiit1, Pabuccu Mustafa Trker1, Kkukur Murat2,
Alpaslan Erkan3, Ta Sedat3, il Alper3, Aksoy Murat Necati1,
Vural Mustafa Gkhan1, Akdeniz Bahri3
Abstract:
Objectives: Dual antiplatelet therapy (DAPT), consisting of clopidogrel and aspirin, is the mainstay treatment
of acute coronary syndromes (ACS). However, major adverse cardiovascular events may occur even in patients
undergoing DAPT, and this has been related to the variable pharmacodynamic efficacy of these drugs, especially
clopidogrel. Platelettolymphocyte ratio (PLR) and neutrophiltolymphocyte ratio (NLR) are novel inflammatory
markers for cardiovascular risk stratification, which may reflect an inflammatory state and thus high ontreatment
platelet reactivity (HPR).
Methods: We investigated the usefulness of PLR and NLR in predicting HPR in clopidogreltreated patients
with ACS. A total of 244 patients were enrolled in this study, and 43 of them were nonresponsive to clopidogrel.
Results: Logistic regression analysis indicated that PLR was significantly associated with HPR (P < 0.001).
Using a cutoff level of 331, PLR predicted HPR with a sensitivity of 73% and a specificity of 69% (odds ratio:
376.15, 95% confidence interval = 37.8133741.728 P < 0.001, receiver operating characteristic curve: 0.885).
Conclusions: We suggest that more attention should be paid to the PLR values of these patients on admission
to identify individuals who may not benefit from clopidogrel during the course of ACS.
Key words:
Acute coronary syndrome, clopidogrel, drug resistance, lymphocyte, neutrophil, platelet
risk prediction of these two parameters into one. PLR, in Blood samples were collected at rest in a fasting state after
particular, offers information about both the aggregation and careful antecubital vein puncture with a 21gauge needle.
inflammation pathways and it may be more valuable than Collection of blood samples was performed in the morning,
either platelet or lymphocyte count alone in the prediction of usually between 7:00 a.m. and 10:00 a.m. The blood samples
inflammatory burden, and thus HPR. Herein, we investigated for HPR were collected 72 h after the first dose, and the last
the usefulness of novel cardiovascular risk markers (PLR and dose intake of aspirin or clopidogrel was administered 24 1 h
NLR) in predicting HPR in clopidogreltreated patients with before the collection of blood samples to guarantee assessment
ACS. of the exact level of platelet inhibition. The first few milliliters
of blood were disposed of to avoid spontaneous platelet
Methods activation.
Study Population and Study Protocol Assessment of High Ontreatment Platelet Reactivity
This study is a singlecenter and retrospectively designed HPR was evaluated using adenosine diphosphate
study. The study protocol was approved by a local noninvasive (ADP)induced platelet aggregometry, which was conducted
Ethics Committee. We screened 262 patients who were using a multiplate electrode aggregometry (MEA) device
hospitalized due to ACS between January 2011 and December called the Multiplate Analyzer (Dynabyte, Munich, Germany).
2014 in our clinic. Among the 262 patients screened, we The multiplate analyzer analyses the function of platelets
enrolled 244 patients whose personal and hospital data were in whole blood at 37C via attachment of platelets on metal
sufficient. Eightyone patients were diagnosed with non electrodes, resulting in a change of the electrical impedance,
STelevation myocardial infarction (NSTEMI), and 163 patients which was simultaneously recorded. Hirudinanticoagulated
were diagnosed with STEMI. A loading dose of 300 mg was whole blood was then diluted and stirred for 3 min in the test
administered to each patient on admission, and this was cuvettes. Finally, ADP in a concentration of 6.4 mmol/L (ADP
followed by a daily dose of 75 mg. In the case of primary test) was added, and aggregation was continually recorded
PCI, the patients were administered a 600 mg loading dose of for 5 min. The increase of impedance caused by the attachment
clopidogrel just before the procedure. of platelets to metal electrodes was detected and transformed
to arbitrary aggregation units, which were plotted against
Demographic and clinical variables of the patients (including time. Aggregation measured with MEA was reported as the
age, gender, and history of diabetes mellitus, hyperlipidemia, area under the curve of arbitrary units (AUmin), and HPR
hypertension, and smoking) were recorded. A detailed physical was detected as a change in maximal aggregation 20% from
examination was performed for all of the patients included the baseline.
in the study, and they were questioned about their history
of previous MI, diabetes mellitus, smoking, hypertension, Platelettolymphocyte Ratio and Neutrophiltolymphocyte
noncardiac diseases, and family history of CAD. Arterial Ratio Analysis
hypertension was defined as having at least three repeated Samples for PLR analysis were drawn on admission and
measurements of blood pressure above 140 mmHg systolic analyzed within 1 h after sampling by a Beckman Coulter LH
and 90 mmHg diastolic or active use of antihypertensive 780 Analyzer (Pasadena, California, USA). The blood samples
drugs. Diabetes mellitus was considered in patients with were stored in ethylenediaminetetraacetic acidcontaining
fasting plasma glucose levels above 126 mg/dL in at least tubes. PLR was defined as the absolute platelet count divided
two different measurements or current use of antidiabetic by the absolute lymphocyte count. NLR was defined as the
drugs. Smoking was defined as active smoking at the time of absolute neutrophil count divided by the absolute lymphocyte
the cardiovascular event date. Exsmokers were not counted count.
as active smokers and were classified with patients who had
never smoked. A positive family history for CAD was defined Statistical Analysis
as having a history of CAD or sudden cardiac death in a SPSS Version 15.0 (SPSS Inc., Chicago, Illinois, USA) was
firstdegree relative before the age of 55 years for men and used for the statistical analysis. Continuous variables are
65 years for women. STEMI was defined as acute chest pain described as means and standard deviation. Categorical
and persistent 2 mm STsegment elevation (>20 min) in at variables are presented as percentages. The normality of
least in two contiguous leads. NSTEMI was defined as acute distribution for continuous variables was confirmed with the
chest pain with transient STsegment depression or Twave KolmogorovSmirnov test. An independentsample ttest or
inversion, flat T waves, pseudonormalization of T waves, or the MannWhitney Utest was used for continuous variables
no electrocardiogram changes at presentation accompanied by according to the distribution pattern of the continuous
the detection of a rise and/or fall of cardiac biomarker values variables. A Chisquare test was used for categorical variables.
(preferably cardiac troponin) with at least one value above the A receiver operating characteristic (ROC) curve analysis was
99th percentile upper reference limit. performed to determine the optimum cutoff PLR value to
predict the existence of HPR. Independent associations between
Patients with advanced valvular heart disease clinically HPR and independent variables were evaluated by logistic
decompensated congestive heart failure, malignancy, regression analysis by including all parameters showing a
hematological disorders, severe renal or hepatic insufficiency, P < 0.1 on multivariate analysis (platelet count, lymphocyte
systemic inflammatory conditions, active infection, autoimmune count, neutrophil count, NLR, and PLR) [Table 1]. A twotailed
disorders, and patients using steroids were excluded from the P < 0.05 was considered to indicate a statistically significant
study. difference between the groups.
lymphocytes as a response to a chronic inflammatory state. There are also some confounding factors in our study population
Lymphocytes exhibit a more convenient immunological such as smoking, diabetes mellitus and hypertension related
response; however, neutrophils demonstrate a much more to the existence of HPR. Enhanced clopidogrel response in
destructive inflammatory reaction.[18] The diagnostic and smokers, defined as the smokers paradox, is not universal but
prognostic practicability of a low lymphocyte count have been was observed only in cytochrome P450 CYP1A2 Aallele carriers
previously indicated in patients with ACS, and Ommen et al. which indicate a genotypedependent impact of smoking on
found low lymphocyte count to be significantly associated clopidogrel responsiveness.[26] In our study, the existence of
with survival in patients with stable CAD.[19] They suggested smokers paradox was also confirmed. Hypertension and
that a low lymphocyte count was a novel prognostic indicator diabetes were also considered to be other risk factors for HPR
in patients with stable CAD. Therefore, it is reasonable to in recently conducted studies; however, in our study, we did
suppose that the lymphocyte count represents an early marker not observe such kind of relationships.[27,28]
of systemic inflammation.
In our study, the PLR values of participants were significantly
Leukocyte count is a cheap and easily accessible indicator of the associated with AUmin values, which support the hypothesis
inflammatory response. It has been suggested that neutrophils that PLR as an indicator of inflammatory state in the body may
participate in each step leading to acute coronary events and be an independent parameter for predicting HPR in patients
can expose prooxidant and prothrombotic mediators, causing with ACS. Increased proliferation in megakaryocytic series and
endothelial damage and thrombocyte aggregation. Previous relative thrombocytosis are consequences of the continuing
studies have revealed that an increase in total white blood inflammatory state in the body, and they cause a prothrombotic
cell (WBC) is related with MACE after acute MI.[20] After the condition. It has been stated previously that healthy individuals
realization of a more essential role for immune response in the with increased platelet counts have an augmented risk of
pathogenesis of CAD, attention has been directed to leukocyte experiencing cardiovascular events. High platelet and low
subgroups, especially the NLR. As a combined inflammatory lymphocyte counts have been demonstrated to be risk factors
marker, NLR defines the effects of a nonspecific inflammatory for worse cardiovascular outcomes in the previous studies.[29]
response mediated by neutrophils as well as the subsequent High PLR, as a novel prognostic marker, combines the risk
regulatory immune response involving lymphocytes. iek prediction potential of these two parameters into one. The
et al. demonstrated that the combination of PLR and NLR can be advantage of PLR calculation could be that it provides a picture
useful for the prediction of inhospital and longterm mortality of the extent of both aggregation and inflammation and it could
in patients undergoing primary percutaneous primary be more reliable than either lymphocyte or platelet count alone
intervention.[21] In this study, we demonstrated that NLR level in the prediction of coronary inflammatory burden and thus
alone was not associated with HPR in clopidogreltreated in the prediction of HPR.
patients with ACS.
Conclusions
Previously conducted studies have shown that 600 mg dose
of clopidogrel was associated with higher levels of platelet In this study, we found that PLR value at the time of admission
inhibition and lower mean posttreatment reactivity of ADP was significantly associated with the existence of HPR in
than the 300 mg loading dose.[22] In the CURRENT OASIS7 patients hospitalized due to ACS. We believe that more
(Doubledose versus standarddose clopidogrel and high dose attention should be paid to the PLR values of these patients on
versus lowdose aspirin in individuals undergoing PCI for admission to identify individuals who may not benefit from
ACS) trial, a total of 25,087 patients with ACS were randomized clopidogrel therapy during the course of ACS.
to a highdose regimen (600 mg loading dose of clopidogrel,
followed by 150 mg/day for 1 week) or the standard regimen Study Limitations
(300 mg on the 1st day followed by 75 mg/day). A total of This study has a few limitations. The first is the retrospective
600 mg loading dose of clopidogrel in ACS + PCI population design of the study. The present study was not an interventional
demonstrated some benefits. This trial, however, indicated study; therefore, the results of the study should not be interpreted
a significant reduction in definite stent thrombosis.[23] In the as causative but rather associative and hypothesisgenerating.
CLEAR PLATELETS (Clopidogrel Loading with Eptifibatide Another limitation is the variations in the presence of clinical
to Arrest the Reactivity of Platelets) study, 600 mg loading dose predictors of clopidogrel response, such as genotyping variants.
was associated with a superior pharmacodynamic antiplatelet Additional validation cohorts are required to confirm the
activity compared to a 300 mg loading dose of clopidogrel.[24] applicability of these results to other patients suffering from
similar clinical conditions.
In 2015, Sharma et al. conducted a study to evaluate the specific
relationship between circulating blood leukocytes, troponin Financial Support and Sponsorship
I, and cardiovascular risk factors. They demonstrated that Nil.
the neutrophils, lymphocytes, and total WBC along with its
ratios predicted mortality and are more likely to be elevated Conflicts of Interest
in the presence of cardiovascular risk factors.[25] In our study, There are no conflicts of interest.
we did not investigate other hematological parameters except
total WBC, lymphocyte, neutrophil counts, PLR, and NLR References
regarding association with HPR. Among these parameters,
multivariate logistic regression analysis indicated that only 1. Gurbel PA, Tantry US. Do platelet function testing and genotyping
PLR was significantly associated with HPR (P < 0.001). improve outcome in patients treated with antithrombotic agents?
platelet function testing and genotyping improve outcome complexity of coronary artery disease: An observational study.
in patients treated with antithrombotic agents. Circulation Anadolu Kardiyol Derg 2013;13:6627.
2012;125:127687. 17. Kaya H, Ertas F, Islamoglu Y, Kaya Z, Atilgan ZA, il H,
2. Gachet C, Aleil B. Testing antiplatelet therapy. Eur Heart J 2008;10 et al. Association between neutrophil to lymphocyte ratio and
Suppl A: A28. severity of coronary artery disease. Clin Appl Thromb Hemost
3. Bouman HJ, van Werkum JW, Hackeng CM, Verheugt FW, 2014;20:504.
Ten Berg JM. The importance of anticoagulant agents in measuring 18. Zouridakis EG, GarciaMoll X, Kaski JC. Usefulness of the
platelet aggregation in patients treated with clopidogrel and blood lymphocyte count in predicting recurrent instability and
aspirin. J Thromb Haemost 2008;6:10402. death in patients with unstable angina pectoris. Am J Cardiol
4. Michos ED, Ardehali R, Blumenthal RS, Lange RA, Ardehali H. 2000;86:44951.
Aspirin and clopidogrel resistance. Mayo Clin Proc 2006;81:51826. 19. Ommen SR, Gibbons RJ, Hodge DO, Thomson SP. Usefulness of
5. Buch AN, Singh S, Roy P, Javaid A, Smith KA, George CE, the lymphocyte concentration as a prognostic marker in coronary
et al. Measuring aspirin resistance, clopidogrel responsiveness, artery disease. Am J Cardiol 1997;79:8124.
and postprocedural markers of myonecrosis in patients 20. Husser O, Bodi V, Sanchis J, Nunez J, Mainar L, Chorro FJ, et al.
undergoing percutaneous coronary intervention. Am J Cardiol White blood cell subtypes after STEMI: Temporal evolution,
2007;99:151822. association with cardiovascular magnetic resonance Derived
6. Nikolsky E, Grines CL, Cox DA, Garcia E, Tcheng JE, infarct size and impact on outcome. Inflammation 2011;34:7384.
Sadeghi M, et al. Impact of baseline platelet count in patients 21. iek G, Aikgoz SK, Bozbay M, Altay S, Ugur M, Uluganyan M,
undergoing primary percutaneous coronary intervention in acute et al. Neutrophillymphocyte ratio and plateletlymphocyte ratio
myocardial infarction (from the CADILLAC trial). Am J Cardiol combination can predict prognosis in patients with STsegment
2007;99:105561. elevation myocardial infarction undergoing primary percutaneous
7. Iijima R, Ndrepepa G, Mehilli J, Bruskina O, Schulz S, Schmig A, coronary intervention. Angiology 2015;66:4417.
et al. Relationship between platelet count and 30day clinical 22. Ray S. Clopidogrel resistance: The way forward. Indian Heart J
outcomes after percutaneous coronary interventions. Pooled 2014;66:5304.
analysis of four ISAR trials. Thromb Haemost 2007;98:8527. 23. Mehta SR, Tanguay JF, Eikelboom JW. CURRENTOASIS 7 trial
8. Thaulow E, Erikssen J, Sandvik L, Stormorken H, Cohn PF. Blood investigators Doubledose versus standarddose clopidogrel and
platelet count and function are related to total and cardiovascular highdose versus lowdose aspirin in individuals undergoing
death in apparently healthy men. Circulation 1991;84:6137. percutaneous coronary intervention for acute coronary
9. Smith RA, Ghaneh P, Sutton R, Raraty M, Campbell F, syndromes (CURRENTOASIS 7): A randomised factorial trial.
Neoptolemos JP. Prognosis of resected ampullary adenocarcinoma Lancet 2010;376:123343.
by preoperative serum CA199 levels and plateletlymphocyte 24. Gurbel PA, Bliden KP, Zaman KA, Yoho JA, Hayes KM, Tantry US.
ratio. J Gastrointest Surg 2008;12:14228. Clopidogrel loading with eptifibatide to arrest the reactivity of
10. Ge H, Zhou Y, Liu X, Yang Q, Nie X, Wang Z, Guo Y, et al. platelets: Results of the clopidogrel loading with eptifibatide to
Relationship Between Plasma Inflammatory Markers and Platelet arrest the reactivity of platelets (CLEAR PLATELETS) study.
Aggregation in Patients With Clopidogrel Resistance After Circulation 2005;111:11539.
Angioplasty. Angiology 2012;63:62-6. 25. Sharma KH, Shah KH, Patel I, Patel AK, Chaudhari S. Do
11. Caruso R, Rocchiccioli S, Gori AM, Cecchettini A, Giusti B, Parodi circulating blood cell types correlate with modifiable risk factors
G, et al. Inflammatory and antioxidant pattern unbalance in and outcomes in patients with acute coronary syndrome (ACS)?
"clopidogrel resistant" patients during acute coronary syndrome. Indian Heart J 2015;67:44451.
Mediators Inflamm 2015;2015:710123. 26. Edem E, Kirdk AH, Kinay AO, Tekin I, Tas S, Alpaslan E,
12. Yksel M, Yildiz A, Oylumlu M, Akyz A, Aydin M, Kaya H, et al. et al. Does smokers paradox exist in clopidogreltreated
The association between platelet/lymphocyte ratio and coronary Turkish patients with acute coronary syndrome. Platelets
artery disease severity. Anatol J Cardiol 2015;15:6407. 2016;27:2404.
13. Ozcan Cetin EH, Cetin MS, Aras D, Topaloglu S, Temizhan A, 27. Akturk IF, Caglar FN, Erturk M, Tuncer N, Yalcin AA, Surgit O,
Kisacik HL, et al. Platelet to lymphocyte ratio as a prognostic et al. Hypertension as a risk factor for aspirin and clopidogrel
marker of inhospital and longterm major adverse cardiovascular resistance in patients with stable coronary artery disease. Clin
events in STsegment elevation myocardial infarction. Angiology Appl Thromb Hemost 2014;20:74954.
2016;67:33645. 28. Nakagawa I, Park HS, Yokoyama S, Wada T, Hironaka Y,
14. Akboga MK, Canpolat U, Yayla C, Ozcan F, Ozeke O, Topaloglu S, Motoyama Y, et al. Influence of diabetes mellitus and cigarette
et al. Association of platelet to lymphocyte ratio with inflammation smoking on variability of the clopidogrelinduced antiplatelet
and severity of coronary atherosclerosis in patients with stable effect and efficacy of active management of the target P2Y12
coronary artery disease. Angiology 2016;67:8995. reaction unit range in patients undergoing neurointerventional
15. Akboga MK, Canpolat U, Balci KG, Akyel A, Sen F, Yayla C, et al. procedures. J Stroke Cerebrovasc Dis 2016;25:16371.
Increased platelet to lymphocyte ratio is related to slow coronary 29. Thomson SP, Gibbons RJ, Smars PA, Suman VJ, Pierre RV,
flow. Angiology 2016;67:216. Santrach PJ, et al. Incremental value of the leukocyte differential
16. Snmez O, Ertas G, Bacaksiz A, Tasal A, Erdogan E, Asoglu E, et al. and the rapid creatine kinaseMB isoenzyme for the early diagnosis
Relation of neutrophiltolymphocyte ratio with the presence and of myocardial infarction. Ann Intern Med 1995;122:33541.