Improving Awareness about Patient Blood Management in Portugal: A Call for Action Arising from a Delphi Panel.

INTRODUCTION: Anaemia and iron deficiency are associated with increased mortality and poor surgical outcomes. Consensus in their definitions is expected to optimize their management, which is encompassed by patient blood management, providing patient-centred care while improving patient safety and clinical outcomes. Patient blood management implementation is even more relevant in contingency times and faces barriers due to lack of standardization, among others. The aim is to establish a consensus on these diagnoses and implement patient blood management principles in clinical practice in Portugal. MATERIAL AND METHODS: Eight experts in Transfusion Medicine, Haematology, Anaesthesiology, Internal Medicine, and Obstetrics/Gynaecology were assembled; a focus group was conducted, defining 33 statements. A Delphi panel was conducted, with experts from the clinical specialities named above as well as from General Surgery, Urology, and Orthopaedics. RESULTS: The Delphi panel's rounds had 70 (Round 1) and 46 (Round 2) respondents. Specialists were consensual in only two statements, on the existence of a preoperative patient blood management consultation for candidates to elective surgeries in which the use of blood derivatives is anticipated and, on the importance of the correction of postoperative anaemia and iron deficiency. Of the remaining 31 statements, 27 reached high agreement or disagreement by the respondents. CONCLUSION: Consensus was reached in only two (6%) of the 33 statements. There was a consensual agreement on the relevance of establishing patient blood management as the standard of care and of valuing preoperative and postoperative patient blood management interventions. Nevertheless, our results point to the lack of awareness regarding patient blood management principles - which could result in better postoperative outcomes, shorter hospitalizations, reduced costs and increased availability of beds. Training and literacy initiatives could help further implement patient blood management standards in Portuguese hospitals.

Introdução: A anemia e ferropenia estão associadas a um aumento da mortalidade e a piores resultados no período pós-operatório. Consensualizar as suas definições permitirá otimizar a sua gestão. O patient blood management engloba essa gestão, com relevo acrescido em situações de contingência, focado nos cuidados centrados no doente e na melhoria da segurança e dos outcomes. As barreiras à implementação de princípios patient blood management prendem-se, entre outras, com falta de padronização. Pretende--se estabelecer um consenso sobre estes diagnósticos e implementação de patient blood management na prática clínica em Portugal. Material e Métodos: Foram reunidos oito especialistas em Imuno-hemoterapia, Hematologia Clínica, Anestesiologia, Medicina Interna e Obstetrícia/ Ginecologia. Foi realizado um focus group, onde foram definidas 33 afirmações. Além disso, foi realizado um painel Delphi, com especialistas das áreas mencionadas acima, assim como de Cirurgia Geral, Urologia e Ortopedia. Resultados: As duas rondas do painel Delphi tiveram, respetivamente, 70 e 46 respondedores. Estes foram consensuais em apenas duas afirmações, na existência de consulta pré-operatória de patient blood management para os candidatos a cirurgias eletivas em que se antecipa o uso de hemoderivados e, na importância da correção da anemia e ferropenia pós-operatórias. Das 31 afirmações restantes, 27 atingiram alta concordância ou discordância pelos respondentes. Conclusão: Foi alcançado consenso em apenas duas (6%) das 33 afirmações. Houve consenso sobre a relevância de estabelecer o patient blood management como standard of care e a valorização das intervenções de patient blood management pré e pós-operatórias. No entanto, os resultados indiciam falta de consciencialização sobre os princípios de patient blood management ­ que poderiam levar a melhores resultados pós-operatórios, com redução do tempo de hospitalização e dos custos e maior disponibilidade de camas. Iniciativas de formação e literacia poderiam ajudar a uma melhor implementação dos princípios de patient blood management nos hospitais portugueses.

Association of Neutrophil-Lymphocyte and Platelet-Lymphocyte Ratio with Adverse Events in Endovascular Repair for Abdominal Aortic Aneurysm.

The association of chronic inflammatory markers with the clinical outcome after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) was investigated. We included 230 patients, treated electively with EVAR. The values of neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) were measured pre- and postoperatively. Any major adverse cardiovascular event (MACE) and acute kidney injury (AKI) were recorded. Adverse events occurred in 12 patients (5.2%). Seven patients suffered from MACE and five from AKI. Median NLR and PLR values were significantly increased after the procedure (NLR: from 3.34 to 8.64, p < 0.001 and PLR: from 11.37 to 17.21, p < 0.001). None of the patients or procedure characteristics were associated with the occurrence of either a MACE or AKI. Receiver operating characteristic curve analysis showed that postoperative NLR and PLR were strongly associated with AKI. A threshold postoperative NLR value of 9.9 was associated with the occurrence of AKI, with a sensitivity of 80% and specificity of 81%. A threshold postoperative PLR value of 22.8 was associated with the occurrence of AKI, with a sensitivity of 80% and specificity of 83%. Postoperative NLR and PLR have been associated with the occurrence of AKI after EVAR for AAA.

Clinical Characteristics and Laboratory Biomarkers for Patients with Suspected COVID-19 Infection Within HCA Healthcare.

Background: The coronavirus infection (COVID-19), also known as the Severe Acute Respiratory Syndrome Virus 2 (SARS-CoV-2), caused significant illness and a worldwide pandemic beginning in 2020. Early case reports showed common patient characteristics, clinical variables and laboratory values in these patients. We compared a large population of American COVID-19 patients to see if they had similar findings to these smaller reports. In addition, we examined our population to identify any differences between mild or severe COVID-19 infections. Methods: We retrospectively accessed a de-identified, multi-hospital database managed by HCA Healthcare to identify all adult emergency department (ED) patients that were tested for COVID-19 from January 1st, 2020-April 30th, 2020. We collected clinical variables, comorbidities and laboratory values to identify any differences in those with or without a SARS-CoV-2 infection. Results: We identified 44,807 patients who were tested for SARS-CoV-2. Of those patients, 6,158 were positive for COVID-19. Male patients were more likely to test positive than female ones (15.0% vs. 12.6%, p < 0.001). The most frequently positive tests occurred in age groups 40-49, 50-59 and 60-69 (16.9%, 15.3% and 14.1% respectively). Both African Americans (20.2%) and Hispanics (20.8%) were more likely to test positive than Caucasians (8.3%, p < 0.001). Hypertension and diabetes were more common in those with positive tests, and multiple laboratory biomarkers showed significant differences in severe infections. Conclusions: This broad cohort of American COVID-19 patients showed similar trends in gender, age groups and race/ethnicity as previously reported. Severe COVID-19 disease was also associated with many positive laboratory biomarkers.

NSE as a predictor of death or poor neurological outcome after non-shockable cardiac arrest due to any cause: Ancillary study of HYPERION trial data.

PURPOSE: Prognostication of hypoxic-ischaemic brain injury after resuscitation from cardiac arrest is based on a multimodal approach including biomarker assays. Our goal was to assess whether plasma NSE helps to predict day-90 death or poor neurological outcome in patients resuscitated from cardiac arrest in non-shockable rhythm. METHODS: All included patients participated in the randomised multicentre HYPERION trial. Serum blood samples were taken 24, 48, and 72 h after randomisation; pre-treated, aliquoted, and frozen at -80 °C at the study sites; and shipped to a central biology laboratory, where the NSE assays were performed. Primary outcome was neurological status at day 90 assessed by Cerebral Performance Category (1 or 2 versus. 3, 4 or 5). RESULTS: NSE was assayed in 235 assessable blood samples from 101 patients. In patients with good versus poor outcomes, median NSE values at 24, 48, and 72 h were 22.6 [95%CI, 14.6;27.3] ng/mL versus 33.6 [20.5;90.0] ng/mL (p < 0.04), 18.1 [11.7;29.7] ng/mL versus 76.8 [21.5;206.6] ng/mL (p < 0.0029), and 9 [6.1;18.6] ng/mL versus 80.5 [22.9;236.1] ng/mL (p < 0.001), respectively. NSE at 48 and 72 h predicted the neurological outcome with areas under the receiver-operating curve of 0.79 [95%CI, 0.69;0.96] and 0.9 [0.81;0.96], respectively. NSE levels did not differ significantly between the groups managed at 33°C and 37°C (p = 0.59). CONCLUSIONS: Data from a multicentre trial on cardiac arrest with a non-shockable rhythm due to any cause confirm that NSE values at 72 h are associated with 90-day outcome. NSE levels did not differ significantly according to the targeted temperature. REGISTRATION IDENTIFIER: ClinicalTrial NCT02722473.

Blood-based Biomarkers for Early Diagnosis of Lung Cancer: A Review Article.

Lung cancer is the severe leading cause of cancer-related mortality worldwide. Early detection of lung cancer can significantly increase their survival rate. However, conventional lung cancer screening methods such as sputum cytology, chest X-rays, low-dose computed tomography, positron emission tomography, and magnetic resonance imaging, are radiational, and also expensive methods. Similarly, lung tumor tissue as invasive and difficult to obtain and potentially risky procedures, there is the immediate need of non-invasive, novel sensitive and reliable blood-based tumor markers which now has become an important area on research. This review will mainly focus on recently identified circulating biomarkers: circulating tumor cells, circulating tumor deoxyribonucleic acid, tumor-derived exosomes, circulating ribonucleic acid and micro ribonucleic acid, and tumoreducated platelets which may enable earlier diagnosis of lung cancer and their application in clinical practices.

Incidence and Predictors of Obstructive Coronary Artery Disease and the Role of Cardiac Troponin Assays in Patients with Unstable Angina.

In a time when cardiac troponin assays are widely used to detect myocardial injury, data remain scarce concerning the incidence and predictors of substantial obstructive coronary artery disease that causes unstable angina. This retrospective single-center study included consecutive patients hospitalized for unstable angina from January 2015 through January 2016. Patients with troponin I levels above the upper reference limit and those who did not undergo angiography were excluded. Multivariate logistic regression analysis was used to identify predictors of obstructive coronary artery disease that warranted revascularization and of major adverse cardiac events up to 6 months after discharge from the hospital. Of the 114 patients who met the inclusion criteria, 46 (40%) had obstructive coronary artery disease. In the univariate analysis, male sex, white race, history of coronary artery disease, prior revascularization, hyperlipidemia, chronic kidney disease, aspirin use, long-acting nitrate use, and Thrombolysis in Myocardial Infarction score ≥3 were associated with obstructive coronary artery disease. History of coronary artery disease, prior revascularization, hyperlipidemia, and long-acting nitrate use were associated with major adverse cardiac events. Male sex was an independent predictor of obstructive coronary artery disease (adjusted odds ratio=4.82; 95% CI, 1.79-13; P=0.002) in the multivariate analysis. Our results showed that coronary artery disease warranting revascularization is present in a considerable proportion of patients who have unstable angina. The association that we found between male sex and obstructive coronary artery disease suggests that the risk stratification of patients presenting with unstable angina may need to be refined to improve outcomes.

Vascular cell adhesion molecule 1 in patients with severe osteoarthritis of the hip : A prospective cross-sectional study.

BACKGROUND: Osteoarthritis (OA) of the hip is a frequent and debilitating joint disease. Only few clinical risk factors for hip OA are established and clinically applicable biomarkers to identify patients at risk are still lacking. The glycoprotein vascular cell adhesion molecule 1 (VCAM-1) is expressed by chondrocytes and synovial tissue and was a predictive marker for development of severe large joint OA in a previous study. OBJECTIVE: It was tested whether increased serum levels of VCAM-1 are prevalent in patients with severe OA of the hips. METHODS: In this prospective, multicenter, cross-sectional study, risk factors of severe hip OA were investigated in patients scheduled for hip joint arthroplasty and 100 patients were randomly selected for validation of VCAM-1 as a potential biomarker for hip OA. Serum samples were analyzed by an enzyme-linked immunosorbent assay and compared with a sex and age-matched control cohort. RESULTS: The groups were similar in age, gender ratio and prevalence of diabetes. Serum concentrations of VCAM-1 were 8% higher in OA patients compared to controls, without reaching statistical significance (818 ng ml-1, 95% confidence interval, CI 746-891 ng ml-1 versus 759 ng m-1, 95% CI 711-807 ng ml-1; P = 0.4839). CONCLUSION: The results of this study show that serum concentrations of VCAM-1 cannot distinguish patients with severe hip OA from age and sex-matched controls.

[Assessment of the extent of myocardial necrosis following radiofrequency catheter ablation of different supraventricular arrhythmias]. / A myocardialis necrosis mértékének vizsgálata eltéro supraventricularis szívritmuszavarok rádiófrekvenciás katéterablatiós kezelését követoen.

INTRODUCTION: Levels of cardiac necroenzymes, high-sensitive troponin (hsTnT) and creatine kinase muscle-brain (CKMB) increase as a result of a myocardial damage following catheter ablation. AIM: To analyze the mid-term alteration of hsTnT and CKMB levels following radiofrequency ablation (RFCA) for atrial fibrillation (AF), atrial flutter (AFlu), AV-nodal reentry tachycardia (AVNRT) and electrophysiological studies (EPS) without ablation. METHOD: Patients undergoing RFCA for various indications and EPS were consecutively enrolled in our prospective study. Concentrations of hsTnT and CKMB were measured from serial blood samples directly before and after the procedure, 4 and 20 hours later and at 3 months follow-up. RESULTS: Forty-seven patients (10 EPS, 12 AVNRT, 13 AFlu, 12 AF) with mean age of 55 ± 13 were included. hsTnT levels increased significantly in all groups after the procedures, while CKMB changed only in the AF group. hsTnT exceeded the reference value in all patients with ablation and in 80% of patients with EPS 4 hours post-ablation. Peak average hsTnT levels for EPS, AVNRT, AFlu were 24 ± 11, 260 ± 218 and 541 ± 233 ng/L, respectively. The highest hsTnT level was measured in the AF group (799 ± 433 ng/L). We found a positive correlation between hsTnT levels and ablation time after RFCA. CONCLUSIONS: The hsTnT levels significantly change after EPS and RFCA, in all patients who underwent ablation, and in 80% of those with EPS had hsTnT positivity in the early post-procedural phase. hsTnT levels depended significantly on the type of the subgroups and correlated with the ablation time. Awareness of those observations is essential to correctly interpret elevated hsTnT levels following RFCA. Orv Hetil. 2019; 160(14): 540-548.

Carcinoid Heart Disease: Review of Current Knowledge.

Carcinoid heart disease is the collective term for all cardiac manifestations in patients who have carcinoid syndrome. Carcinoid heart disease has a multifactorial pathophysiology, and the right side of the heart is usually involved. Symptoms and signs vary depending upon the affected cardiac components; most typical is right-sided heart failure secondary to diseased tricuspid and pulmonary valves. Despite no single ideal diagnostic test, strong suspicion, coupled with serologic and imaging results, usually enables diagnosis. Advances in imaging, such as speckle-tracking echocardiography and cardiac magnetic resonance, have improved the diagnostic yield. Treatment is challenging, warrants a multidisciplinary approach, and can be medical or surgical depending on the cardiac manifestations. Investigators are exploring the therapeutic use of monoclonal antibodies and new somatostatin analogues. In this review, we cover current knowledge about the pathophysiology, diagnosis, and treatment of carcinoid heart disease.

GDF-15 in Pulmonary and Critical Care Medicine.

GDF-15 (growth differentiation factor 15) acts both as a stress-induced cytokine with diverse actions at different body sites and as a cell-autonomous regulator linked to cellular senescence and apoptosis. For multiple reasons, this divergent transforming growth factor-ß molecular superfamily member should be better known to pulmonary researchers and clinicians. In ambulatory individuals, GDF-15 concentrations in peripheral blood are an established predictive biomarker of all-cause mortality and of adverse cardiovascular events. Concentrations upon admission of critically ill patients (without or with sepsis) correlate with organ dysfunction and independently predict short- and long-term mortality risk. GDF-15 is a major downstream mediator of p53 activation, but it can also be induced independently of p53, notably by nonsteroidal antiinflammatory agents. GDF-15 blood concentrations are markedly elevated in adults and children with pulmonary hypertension. Concentrations are also increased in chronic obstructive pulmonary disease, in which they contribute to mucus hypersecretion, airway epithelial cell senescence, and impaired antiviral defenses, which together with murine data support a role for GDF-15 in chronic obstructive pulmonary disease pathogenesis and progression. This review summarizes biological and clinical data on GDF-15 relevant to pulmonary and critical care medicine. We highlight the recent discovery of a central nervous system receptor for GDF-15, GFRAL (glial cell line-derived neurotrophic factor family receptor-α-like), an important advance with potential for novel treatments for obesity and cachexia. We also describe limitations and controversies in the existing literature, and we delineate research questions that must be addressed to determine whether GDF-15 can be therapeutically manipulated in other clinical settings.

Assessment of the Relationship between Monocyte to High-Density Lipoprotein Ratio and Myocardial Bridge / Avaliação da Relação entre a Razão de Monócitos para Lipoproteínas de Alta Densidade e a Ponte Miocárdica

Abstract Background: Assessing the monocyte to high-density lipoprotein ratio (MHR) is a new tool for predicting inflamation, which plays a major role in atherosclerosis. Myocardial bridge (MB) is thought to be a benign condition with development of atherosclerosis, particularly at the proximal segment of the brigde. Objective: To evaluate the relationhip between MHR and the presence of MB. Methods: We consecutively scanned patients referred for coronary angiography between January 2013- December 2016, and a total of 160 patients who had a MB and normal coronary artery were enrolled in the study. The patients' angiographic, demographic and clinic characteristics of the patients were reviewed from medical records. Monocytes and HDL-cholesterols were measured via complete blood count. MHR was calculated as the ratio of the absolute monocyte count to the HDL-cholesterol value. MHR values were divided into three tertiles as follows: lower (8.25 ± 1.61), moderate (13.11 ± 1.46), and higher (21.21 ± 4.30) tertile. A p-value of < 0.05 was considered significant. Results: MHR was significantly higher in the MB group compared to the control group with normal coronary arteries. We found the frequency of MB (p = 0.002) to increase as the MHR tertiles rose. The Monocyte-HDL ratio with a cut-point of 13.35 had 59% sensitivity and 65.0% specificity (ROC area under curve: 0.687, 95% CI: 0.606-0.769, p < 0.001) in accurately predicting a MB diagnosis. In the multivariate analysis, MHR (p = 0.013) was found to be a significant independent predictor of the presence of MB, after adjusting for other risk factors. Conclusion: The present study revealed a significant correlation between MHR and MB.

Resumo Fundamento: A avaliação da razão de monócitos para lipoproteínas de alta densidade (MHR, sigla em inglês) é uma nova ferramenta para se prever o processo inflamatório, o qual desempenha um papel importante na aterosclerose. A ponte miocárdica (PM) é considerada uma condição benigna com desenvolvimento de arteriosclerose, particularmente no segmento proximal da ponte. Objetivo: Avaliar a relação entre a MHR e a presença de PM. Métodos: Examinamos concecutivamente pacientes encaminhados para angiografia coronariana entre janeiro de 2013 e dezembro de 2016, e um total de 160 pacientes, uma parcela dos quais com PM, e outra com artérias coronárias normais, foram incluídos no estudo. As características angiográficas, demográficas e clínicas dos pacientes foram revisadas a partir de registros médicos. Monócitos e colesteróis HDL foram medidos através de hemograma completo. A MHR foi calculada como a razão entre a contagem absoluta de monócitos e o valor do colesterol HDL. Os valores de MHR foram divididos em três tercis, da seguinte forma: tercil inferior (8,25 ± 1,61); tercil moderado (13,11 ± 1,46); e tercil superior (21,21 ± 4,30). Considerou-se significativo um valor de p < 0,05. Resultados: A MHR foi significativamente maior no grupo com PM, em comparação com grupo controle com artérias coronárias normais. Verificamos que a prevalência de PM (p=0,002) aumentou à medida que se elevavam os tercis de MHR. A razão monócitos-colesterol HDL com ponto de corte de 13,35 apresentou sensibilidade de 59% e especificidade de 65,0% (área ROC sob a curva: 0,687, IC95%: 0,606-0,769, p < 0,001) na predição acurada do diagnóstico de PM. Na análise multivariada, a MHR (p = 0,013) mostrou-se um preditor independente significativo da presença de PM, após ajustes para outros fatores de risco. Conclusão: O presente estudo revelou uma correlação significativa entre MHR e PM.

Serum MicroRNA-27b as a Screening Biomarker for Left Ventricular Hypertrophy.

MicroRNA-27b (miR-27b) is frequently upregulated in pressure-overloaded hypertrophic hearts. The clinical implications of aberrant circulating miR-27b in the diagnosis and management of left ventricular hypertrophy warrant study. We investigated whether serum miR-27b is a biomarker for left ventricular hypertrophy (LVH). We used stem-loop reverse-transcription quantitative polymerase chain reaction techniques to analyze serum miR-27b levels in 200 hypertensive patients with LVH, 100 hypertensive patients without LVH, and 100 healthy volunteers. We found that serum miR-27b levels were significantly higher in the hypertensive patients with LVH than in the hypertensive patients without LVH and in the healthy volunteers. Upon receiver operating characteristic curve analysis, serum miR-27b had an area under the curve of 0.885 with 91% sensitivity and 73% specificity in distinguishing hypertensive patients with LVH from healthy volunteers (P=0.021), and an area under the curve of 0.818 with 79.1% sensitivity and 70.3% specificity in distinguishing hypertensive patients with LVH from those without LVH (P=0.036). We conclude that circulating miR-27b might serve as a specific, noninvasive biomarker in screening for LVH.

Accuracy of transient elastography-FibroScan®, acoustic radiation force impulse (ARFI) imaging, the enhanced liver fibrosis (ELF) test, APRI, and the FIB-4 index compared with liver biopsy in patients with chronic hepatitis C

OBJECTIVES: Although liver biopsy is the gold standard for determining the degree of liver fibrosis, issues regarding its invasiveness and the small amount of liver tissue evaluated can limit its applicability and interpretation in clinical practice. Non-invasive evaluation methods for liver fibrosis can address some of these limitations. The aim of this study was to evaluate the accuracy of transient elastography-FibroScan®, acoustic radiation force impulse (ARFI), enhanced liver fibrosis (ELF), the aspartate aminotransferase-to-platelet ratio index (APRI), and the FIB-4 index compared with liver biopsy in hepatitis C. METHODS: We evaluated chronic hepatitis C patients who were followed at the Division of Clinical Gastroenterology and Hepatology, Hospital das Clínicas, Department of Gastroenterology of University of São Paulo School of Medicine, São Paulo, Brazil, and who underwent liver biopsy. The accuracy of each method was determined by a receiver operating characteristic (ROC) curve analysis, and fibrosis was classified as significant fibrosis (≥F2), advanced fibrosis (≥F3), or cirrhosis (F4). The Obuchowski method was also used to determine the diagnostic accuracy of each method at the various stages of fibrosis. In total, 107 FibroScan®, 51 ARFI, 68 ELF, 106 APRI, and 106 FIB-4 analyses were performed. RESULTS: A total of 107 patients were included in the study. The areas under the ROC curve (AUROCs) according to fibrosis degree were as follows: significant fibrosis (≥F2): FibroScan®: 0.83, FIB-4: 0.76, ELF: 0.70, APRI: 0.69, and ARFI: 0.67; advanced fibrosis (≥F3): FibroScan®: 0.85, ELF: 0.82, FIB-4: 0.77, ARFI: 0.74, and APRI: 0.71; and cirrhosis (F4): APRI: 1, FIB-4: 1, FibroScan®: 0.99, ARFI: 0.96, and ELF: 0.94. The accuracies of transient elastography, ARFI, ELF, APRI and FIB-4 determined by the Obuchowski method were F0-F1: 0.81, 0.78, 0.44, 0.72 and 0.67, respectively; F1-F2: 0.73, 0.53, 0.62, 0.60, and 0.68, respectively; F2-F3: 0.70, 0.64, 0.77, 0.60, and 0.67, respectively; and F3-F4: 0.98, 0.96, 0.82, 1, and 1, respectively. CONCLUSION: Transient elastography remained the most effective method for evaluating all degrees of fibrosis. The accuracy of all methodologies was best at F4.

White Blood Cell Subtypes Are Associated with a Greater Long-Term Risk of Death after Acute Myocardial Infarction.

We evaluated the association between white blood cell counts and long-term mortality rates in 2,129 patients (mean age, 65.3 ± 13.5 yr; 69% men) who had survived acute myocardial infarction. We obtained white blood cell counts and differential counts of white blood cell subtypes within the first 72 hours of hospital admission. The primary outcome was all-cause death at 1, 5, and 10 years after acute myocardial infarction. In regard to death in the long term, we found significant negative linear associations (lymphocytes), positive linear associations (neutrophils and the neutrophil-to-lymphocyte ratio), and nonlinear U-shaped associations (basophils, eosinophils, monocytes, and total white blood cell count). After multivariate adjustment for the Soroka Acute Myocardial Infarction risk score, lymphocytes (strongest association), neutrophil-to-lymphocyte ratio, and eosinophils were independently associated with death for up to 10 years after hospital discharge. The independent associations weakened over time. We conclude that lymphocyte count, neutrophil-to-lymphocyte ratio, and eosinophil count are independently and incrementally associated with death in the long term after acute myocardial infarction.