Neutrophil-lymphocyte ratio: A prognostic tool in patients with in-hospital cardiac arrest.

BACKGROUND: In-hospital cardiac arrest (IHCA) portends a poor prognosis and survival to discharge rate. Prognostic markers such as interleukin-6, S-100 protein and high sensitivity C reactive protein have been studied as predictors of adverse outcomes after return of spontaneous circulation (ROSC); however; these variables are not routine laboratory tests and incur additional cost making them difficult to incorporate and less attractive in assessing patient's prognosis. The neutrophil-lymphocyte ratio (NLR) is a marker of adverse prognosis for many cardiovascular conditions and certain types of cancers and sepsis. We hypothesize that an elevated NLR is associated with poor outcomes including mortality at discharge in patients with IHCA. AIM: To determine the prognostic significance of NLR in patients suffering IHCA who achieve ROSC. METHODS: A retrospective study was performed on all patients who had IHCA with the advanced cardiac life support protocol administered in a large urban community United States hospital over a one-year period. Patients were divided into two groups based on their NLR value (NLR < 4.5 or NLR ≥ 4.5). This cutpoint was derived from receiving operator characteristic curve analysis (area under the curve = 0.66) and provided 73% positive predictive value, 82% sensitivity and 42% specificity for predicting in-hospital death after IHCA. The primary outcome was death or discharge at 30 d, whichever came first. RESULTS: We reviewed 153 patients with a mean age of 66.1 ± 16.3 years; 48% were female. In-hospital mortality occurred in 65%. The median NLR in survivors was 4.9 (range 0.6-46.5) compared with 8.9 (0.28-96) in non-survivors (P = 0.001). A multivariable logistic regression model demonstrated that an NLR above 4.55 [odds ratio (OR) = 5.20, confidence interval (CI): 1.5-18.3, P = 0.01], older age (OR = 1.03, CI: 1.00-1.07, P = 0.05), and elevated serum lactate level (OR = 1.20, CI: 1.03-1.40, P = 0.02) were independent predictors of death. CONCLUSION: An NLR ≥ 4.5 may be a useful marker of increased risk of death in patients with IHCA.

Coronary Artery Embolism: Two Case Reports and a Review of the Literature.

Coronary embolism (CE) is an uncommon and unique cause of acute myocardial infarction. In this report, we review 216 cases of CE including 2 new cases from our institution. The mean patient age was 52.5 years and 62% of the patients were males. Chest pain was the most common presenting symptom followed by dyspnea, and the most commonly affected vessel was the left anterior descending artery. Leading etiologies of the embolus were atrial fibrillation, septic emboli, and iatrogenic causes. Treatment approaches varied with thrombus aspiration being used in 30% of cases. In-hospital mortality rate was 36% and 13% of the cases were complicated by cerebrovascular accident. CE is a unique pathology that leads to acute myocardial infarction. It portends a high mortality rate and requires a high level of suspicion as symptoms may be misleading. Further research is needed in order to improve recognition and management and to lower associated mortality.

Rupture of sinus of Valsalva aneurysm: Two case reports and a concise review of the literature.

BACKGROUND: The rupture of sinus of Valsalva aneurysm (RSoVA) is a rare disorder that affects the integrity of the cardiovascular system, disrupting its dynamics and resulting in a variety of manifestations. In this report, we discuss two cases of RSoVA that we encountered and review similar cases reported in the literature. METHODS: literature review of reported cases of RSoVA in PubMed and Google Scholar. RESULTS: A total of 223 cases were found and the final analysis included 225 cases, of which 69% occurred in males and the mean age was 38.9 years. Dyspnea was the most common presenting symptom and 76% of the cases described continuous murmur on examination. The right sinus was affected in 61% of the cases and the fistula connected to the right chambers of the heart 73% of the time. CONCLUSION: RSoVA is a rare condition that is difficult to diagnose, it should be considered in the right context, particularly in young patients with symptoms of heart failure and the presence of continuous murmur on cardiac examination.