Original Article

The relationship between complete blood count parameters and Fontaine’s Stages in patients with peripheral arterial disease

Vascular 2014, Vol. 22(6) 427–431 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1708538114522227 vas.sagepub.com

Sinan Demirtas1, Oguz Karahan1, Suleyman Yazici1, Orkut Guclu1, Ahmet Caliskan1, Celal Yavuz1, Aslihan Kucuker2 and Binali Mavitas1

Abstract Objective: The aim of the present study is to evaluate whether blood count parameters differ according to the stages of Fontaine’s classification and to investigate the relationship between hemogram parameters and the severity of the disease. Method: Eighty-two peripheral arterial disease patients were examined prospectively. Patients were classified according to the Fontaine classification system. Fifty newly diagnosed patients were included in the study. The neutrophilto-lymphocyte ratio, mean platelet volume, and red blood cell distribution width values were recorded. Results: Mean neutrophil-to-lymphocyte ratio values were found to be 3.31  1.1% in Stage I, 3.11  1.3% in Stage II, and 3.48  1.1% in Stage III (p > 0.05). Mean platelet volume values were found to be 7.8  0.6 fl (Stage I), 8.2  1.0 fl (Stage II), and 9.0  0.9 fl (Stage III) (p < 0.05). Red blood cell distribution width values were found to be 13.6  1.0% in Stage I, 14.8  1.7% in Stage II, and 15.4  2.3% in Stage III, being significantly different among all three stages (p < 0.05). Conclusion: Both red blood cell distribution width and mean platelet volume are found to be associated with the severity of atherosclerotic disease in patients with peripheral arterial disease. This finding hypothesizes that complete blood counting parameters may serve as a beneficial and cost-effective method for monitoring atherosclerotic peripheral disease.

Keywords Complete blood counting parameters, neutrophil-to-lymphocyte ratio, mean platelet volume, red blood cell distribution width, peripheral arterial disease

Introduction Peripheral arterial disease (PAD) is an important agedependent disease that is related with high morbidity rates and strongly disrupts the quality of life. In symptomatic patients, claudication is the main presenting complaint in PAD.1 There are the two valid classification systems for patients with PAD currently. Fontaine’s Stages and Rutherford’s Categories are used to identify the severity of the symptoms in PAD. Rutherford’s Categories is an improved form of Fontaine’s Stages including more subcategories. Nevertheless, basic scopes are similar in both two classification systems.2 These classification systems are based on patients’ symptomatology and do not include any laboratory parameter. In the present study, we aim to search if some of blood count parameters have a

statistically significant correlation with the severity of PAD. Recent studies have also focused on clarifying the possible interactions between routine blood parameters and disease severity. These parameters have also been investigated to see whether a relationship exists between cardiovascular risk and PAD population.3 The role of 1 Department of Cardiovascular Surgery, Medical School of Dicle University, Diyarbakir, Turkey 2 Cardiovascular Surgery Clinic, Ataturk Education and Research Hospital, Ankara, Turkey

Corresponding author: Oguz Karahan, Department of Cardiovascular Surgery, Heart Centre, Diyarbakir 21280, Turkey. Email: [email protected]

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inflammatory processes in atherosclerosis, which is closely associated with PAD, has also been well described.3,4 These data encouraged researchers to investigate the complete blood count parameters in atherosclerotic events. Interactions have been detected between platelet function and vascular events in previous reports.3,4 Thus, mean platelet volume (MPV) was investigated in atherosclerotic vascular disorders as an indicator of platelet activation and reactivity. Briefly, MPV is a descriptive indicator of increased size and more reactive platelets.5,6 Other inflammatory markers such as white blood cells and their subtypes (e.g., neutrophils, monocytes, lymphocytes, and eosinophils) have also been studied in various cardiovascular diseases.3 The neutrophil-to-lymphocyte ratio (NLR) is a current concerted version to the long list of these inflammatory markers.7 Red blood cell distribution width (RDW) a coefficient measure of the size variability of circulating erythrocytes, is shown to be strongly related with the risk of cardiovascular morbidity and mortality. The relation between RDW and atherosclerosis also has been investigated.8 In the current study, the relationship between routine blood parameters and the severity of the symptoms of PAD according to Fontaine’s Stages was investigated.

Patients and methods Study design and patient selection In this cross-sectional study, 82 consecutive PAD patients were examined prospectively. The severity of their symptoms was categorized according to Fontaine’s Stages (Table 1) as described in previous literature.2 Exclusion criteria included the following: – Fontaine Stage IV patients who have gangrenous or necrotic lesions were excluded in order to avoid the possible effect of infection in complete blood count parameters, – Patients with other systemic problems such as hematological disease, acute or chronic infections,

Table 1. Fontaine Stages in patients with peripheral arterial disease.2 Stage

Clinical

I IIa IIb III VI

Asymptomatic Mild claudication Moderate-severe claudication Ischemic rest pain Ulceration or gangrene

liver disease, and drug usage (especially, antiaggregants, anticoagulants, and steroids) were excluded.

Among 82 PAD patients, 50 newly diagnosed patients without previous treatment were included in the study. Patients were divided to three groups: Fontaine Stage I, II, and III. Ethical approval was granted from a local ethics committee. Study participants were informed about all contents of the study and informed consent was obtained.

Blood sampling Peripheral venous blood samples were obtained from each patient during a routine blood draw. Each sample was drawn into vacutainer tubes containing 0.04 mL of 7.5% K3 salt of EDTA and was analyzed within 1 h after sampling with a commercially available analyzer (CELL-DYN 3700; Abbott Diagnostics, Abbott Park, IL). The NLR (%), MPV (fl), and RDW (%) values were recorded for each patient and were compared between groups.

Statistical analysis All statistical procedures were performed using SPSS (Statistical Package for Social Sciences) software version 15.0 (SPSS Inc., Chicago, IL). Means were given together with standard errors, and frequencies were expressed as percentages. The t-test was used to compare the two independent groups. The relation between the severity of symptoms which was assessed using Fontaine’s Stages and complete blood count parameters was analyzed through the method one-way analysis of variance. A p value of 0.05 was considered statistically significant and Tukey HSD (Tukey’s honestly significant difference) was used as a post-hoc test.

Results There were 18 patients in Stage I (17 [94%] men and 1 [6%] women, with a mean age of 55.6  7.2 years), 14 patients in Stage II (13 [92%] men and 1 [8%] women, with a mean age of 50.2  10.2 years), and 18 patients in Stage III (16 [89%] men and 2 [11%] women, with a mean age of 60.4  11.7 years). The age and sex distribution of the three groups were statistically similar (p > 0.05). Demographical findings and clinical features were summarized in Table 2. The mean NLR value (mean  standard deviation) was found to be 3.31  1.1% in asymptomatic patients (Stage I). In Stages II and III, mean NLR was found to be 3.11  1.3% and 3.48  1.1%, respectively (p > 0.05).

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A comparison of NLR values regarding to the stages is shown in Table 3. Mean MPV values were detected as 7.8  0.6 fl in Stage I, 8.2  1.0 fl in Stage II, and 9.0  0.9 fl in Stage III. The MPV values in Stage III were significantly higher than in the other groups (p < 0.05). A comparison of the stages regarding to MPV values is listed in Table 4. RDW values were found to be 13.6  1.0% in Stage I, 14.8  1.7% in Stage II, and 15.4  2.3 in Stage III. In Stage III, RDW values were found to be significantly higher compared to Stages I and II (p < 0.05). Besides, in stage II, mean RDW values were significantly higher than Stage I. A comparison of RDW values is presented in Table 5.

Discussion The present study is to investigate whether routine inexpensive complete blood count parameters are related with the severity of patients with PAD. According to our results, mean MPV and RDW values strongly correlate with severity of symptoms in patients with PAD. In particular, mean RDW values were significantly increased in a symptom-dependent manner. In other words, our data support that increments in RDW and MPV values do have a relationship with the severity of disease. We also noted that differences of mean NLR values were insignificant between the stages. This report is a unique study in the literature researching the relationship between complete blood count parameters and the symptoms classification in patients with PAD.

NLR has been investigated in recent studies as a biomarker in diseases in which inflammation has been thought to play an important role in pathogenesis. Atherosclerosis is also an inflammatory process, and

Table 3. Comparison of stages according to the neutrophil-to-lymphocyte ratio. Neutrophil-to-lymphocyte ratio

p*

Stage I vs. Stage II 3.31  1.1% vs. 3.11  1.3% Stage I vs. Stage III 3.31  1.1% vs. 3.48  1.1% Stage II vs. Stage III 3.11  1.3% vs. 3.48  1.1%

0.146 0. 189 0.112

*p < 0.05 is significant.

Table 4. Comparison of stages according to the mean platelet volume. Mean platelet volume Stage I vs. Stage II 7.8  0.6 fl vs. 8.2  1.0 fl Stage I vs. Stage III 7.8  0.6 fl vs. 9.0  0.9 fl Stage II vs. Stage III 8.2  1.0 fl vs. 9.0  0.9 fl

p* 0.069

The relationship between complete blood count parameters and Fontaine's Stages in patients with peripheral arterial disease.

The aim of the present study is to evaluate whether blood count parameters differ according to the stages of Fontaine's classification and to investig...
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