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Eosinophil-To-Monocyte Ratio Is a Potential Predictor of Prognosis in Acute Ischemic Stroke Patients After Intravenous Thrombolysis

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Eosinophil-To-Monocyte Ratio Is a Potential Predictor of Prognosis in Acute Ischemic Stroke Patients After Intravenous Thrombolysis Clinical Interventions in Aging Dovepress open access to scientific and medical research Open Access Full Text Article ORIGINAL RESEARCH Eosinophil-to-Monocyte Ratio is a Potential Predictor of Prognosis in Acute Ischemic Stroke Patients After Intravenous Thrombolysis Yueping Chen1,* Background: Eosinophil and monocyte have been demonstrated separately to be indepen­ Junli Ren2,3,* dent predictors of acute ischemic stroke (AIS). This study aimed to evaluate the association Naiping Yang2,3,* between eosinophil-to-monocyte ratio (EMR) and 3-month clinical outcome after treatment Honghao Huang2,3 with recombinant tissue plasminogen activator (rt-PA) for AIS patients. Simultaneously, we Xueting Hu2,3 made a simple comparison with other prognostic indicators, such as 24h neutrophil-to- lymphocyte ratio (NLR) and 24h platelet-to-lymphocyte ratio (PLR) to investigate the Fangyue Sun2,3 prognostic value of EMR. Tian Zeng2,3 2,3 Methods and Results: A total of 280 AIS patients receiving intravenous thrombolysis were Xinbo Zhou retrospectively recruited for this study. Complete blood count evaluations for EMR were 2,3 Wenjing Pan conducted on 24 hours admission. The poor outcome at 3-month was defined as the modified 2,3 Jingyu Hu Rankin Scale (mRS) of 3–6 and the mRS score for death was 6. The EMR levels in patients 4 Beibei Gao with AIS were lower than those in the healthy controls and showed a negative correlation 2 Shunkai Zhang with the NIHSS score. At the 3-month follow-up, multivariate logistic regression analysis Guangyong Chen 2 indicated an association among EMR, poor outcome and mortality. In addition, EMR had a higher predictive ability than popular biomarkers like NLR and PLR for 3-month mortality. 1Clinical Laboratory, The Third Affiliated Hospital of Wenzhou Medical University, Conclusion: The lower levels of EMR were independently associated with poor outcome Wenzhou, People’s Republic of China; and dead status in AIS patients. 2Department of Neurology, The Third Affiliated Hospital of Wenzhou Medical Keywords: acute ischemic stroke, eosinophil-to-monocyte ratio, intravenous thrombolysis, University, Wenzhou, People’s Republic treatment outcome, modified rankin scale of China; 3School of the First Clinical Medical Sciences, Wenzhou Medical University, Wenzhou, People’s Republic of China; 4Department of Internal Medicine, The Third AffiliatedHospital of Introduction Wenzhou Medical University, Wenzhou, Acute ischemic stroke (AIS) possesses a high morbidity and mortality. And its People’s Republic of China pathophysiology, an inflammatory process involving endothelial activation, blood- *These authors contributed equally to brain barrier disruption, oxidant and inflammatory mediator accumulation, contri­ this work. butes to brain injury.1 Leukocytes, such as neutrophils, monocytes and lympho­ cytes, are vital inflammatory cells and play essential roles in atherosclerosis development and progression. Ratio indices, calculated by subtypes of white blood cells, such as neutrophil-to-lymphocyte ratio (NLR) and platelet-to- Correspondence: Shunkai Zhang; lymphocyte ratio (PLR), can be easily performed in routine practice as well as Guangyong Chen 2,3 Department of Neurology, The Third have strong prognostic effects on clinical outcomes of AIS patients. Affiliated Hospital of Wenzhou Medical Consequently, there is a growing trend for ratio indices to be used in predictions University, No. 108 Wansong Road, Wenzhou, 325000, Zhejiang, People’s of thrombolytic outcome in AIS patients. Some reports indicated that eosinophils Republic of China were inflammatory cells and were associated with severity of AIS.4 It has been Email [email protected]; [email protected] reported that eosinophil-to-monocyte ratio (EMR) is a popular research topic for Clinical Interventions in Aging 2021:16 853–862 853 © 2021 Chen et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php). Chen et al Dovepress inflammatory hematologic scores and has an association consisting of rt-PA followed by endovascular therapy. They with mortality in patients with ST-elevation myocardial were excluded for the following exclusion criteria: (1) with infarction undergoing primary percutaneous coronary rheumatic immune diseases; (2) with malignant tumor; (3) intervention.5,6 Both myocardial infarction and AIS are with acute myocardial infarction; (4) with the incomplete vascular obstructive diseases, which means EMR may data [laboratory data such as eosinophil counts and monocyte possibly connect with the clinical outcome of AIS patients. counts, evaluation data such as modifiedRankin Scale (mRS)]; However, the association between EMR and the outcome (5) with severe liver damage; (6) with severe kidney damage; of AIS patients receiving thrombolysis has not been fully (7) with chronic inflammatory diseases. Finally, 280 cases clarified. Therefore, the purpose of this article was to were included in this analysis. Meanwhile, after propensity explore the relationship between EMR and 3-month clin­ score matching, 130 cases were included as healthy con­ ical outcome after thrombolytic therapy with recombinant trols (HCs). tissue plasminogen activator (rt-PA) for AIS patients. Data Collection Data of patients was collected through the illness record: Methods demographics, medical history (hypertension, diabetes melli­ Study Subjects tus, hyperlipidemia and atrial fibrillation) and National As shown in Figure 1, a total of 486 consecutive patients with Institutes of Health Stroke Scale (NIHSS) on admission. a clinical diagnosis of AIS from 2016 to 2019 were retro­ Additionally, 3-month mRS after the onset of AIS, collected spectively recruited, in which 76 received a bridging therapy by two trained physicians on phone interview, was used to Figure 1 Flow diagram showing the patient selection process. 854 https://doi.org/10.2147/CIA.S309923 Clinical Inter ventions in Aging 2021:16 DovePress Dovepress Chen et al evaluate the functional outcome. Moreover, the variables distribution was evaluated by the Kolmogorov–Smirnov test. related to clinical outcomes such as Trial of Org 10,172 in Continuous variables were expressed as the mean with stan­ Acute Stroke Treatment (TOAST), infarct volume, Alberta dard deviation (mean ± SD) or medians and interquartile range Stroke Program Early CT Score (ASPECT), symptomatic (median, IQR) while categorical variables were described as intracranial hemorrhage (sICH), door to needle time (DNT) counts and percentages. Independent sample t test, Mann– and onset of needle time (ONT) were also collected. Whitney U-test, one-way analysis of variance (ANOVA) or ASPECTS was rated on a scale from 10 (no early signs of Kruskal–Wallis test were used appropriately for the compar­ ischemia) to 0 (early ischemic changes in all 10 regions). One ison of continuous data. For categorical variables, chi-square point was subtracted from 10 for each of the defined regions.7 test was performed. The Fisher exact test was used if the SICH was defined as evidence of hemorrhage on CT or MRI expected frequency was equal to or less than 5. To compare that seemed to be associated with an increase in NIHSS score whether there were differences in EMR between HCs and AIS 8 of ≥ 4. patients, people were divided into AIS group and HCs group. The propensity score matching was used to match the age and Assessment of Eosinophil-to-Monocyte sex between the two groups with a match tolerance set at 0.02. Ratio Baseline characteristics according to EMR tertiles and AIS outcomes were also displayed. The Spearman and Chi-square The whole blood samples were collected on 24 hours tests were used to analyze the correlation between EMR levels admission and white blood cell counts and peripheral differential counts were measured. EMR was calculated and the severity of AIS. In order to investigate the association using eosinophil counts divided by monocyte counts. between EMR and AIS outcomes, univariate logistic regres­ According to the EMR on 24 hours admission, all patients sion analysis was used. In the case where the univariable were divided into tertiles. analysis achieved statistical significance (p < 0.05), multivari­ able test was performed in addition. The receiver operating curve (ROC) was applied to analyze the accuracy of the prog­ Definitions of Outcome and Severity nosis of 24h EMR, 24h NLR, and 24h PLR for the 3-month With respect to NIHSS scores on admission, which could outcome of AIS patients receiving thrombolysis. The differ­ evaluate the severity of AIS, AIS patients were grouped as ences in discriminative ability were tested using the DeLong three levels: mild stroke (NIHSS scores: 0–5), moderate stroke method.11 Statistical significance was set at p < 0.05. (NIHSS scores: 6–10), severe stroke (NIHSS scores: > 10).9 In The study was approved by the Ethics Committee of accordance with 3-month mRS score, all patients were grouped our hospital and was performed in accordance with the as two levels: good outcome
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