Letter to the Editor
Red cell distribution width is a predictor of mortality in patients with major bleeding
A largura de distribuição dos eritrócitos é um preditor de mortalidade em pacientes com hemorragia grave
Sevket Balta
, Sait Demirkol, Murat Unlu, Turgay Celik
Corresponding author
Department of Cardiology, Gulhane Medical Academy, Ankara, Turkey
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"cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Reply to the Letter to the Editor “Contrast-enhanced multidetector computed tomography: A new prognosticator in acute pulmonary embolism?”" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "841" "paginaFinal" => "842" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Resposta à Carta ao Editor «Angiografia pulmonar por tomografia computadorizada: uma nova ferramenta prognóstica na tromboembolia pulmonar aguda?»" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Rui Baptista, Rogério Teixeira, Elisabete Jorge, Pedro Monteiro" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Rui" "apellidos" => "Baptista" ] 1 => array:2 [ "nombre" => "Rogério" "apellidos" => "Teixeira" ] 2 => array:2 [ "nombre" => "Elisabete" "apellidos" => "Jorge" ] 3 => array:2 [ "nombre" => "Pedro" "apellidos" => "Monteiro" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204913002341?idApp=UINPBA00004E" "url" => "/21742049/0000003200000010/v1_201312121254/S2174204913002341/v1_201312121254/en/main.assets" ] "en" => array:16 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Red cell distribution width is a predictor of mortality in patients with major bleeding" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "843" "paginaFinal" => "844" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Sevket Balta, Sait Demirkol, Murat Unlu, Turgay Celik" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Sevket" "apellidos" => "Balta" "email" => array:1 [ 0 => "drsevketb@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Sait" "apellidos" => "Demirkol" ] 2 => array:2 [ "nombre" => "Murat" "apellidos" => "Unlu" ] 3 => array:2 [ "nombre" => "Turgay" "apellidos" => "Celik" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Cardiology, Gulhane Medical Academy, Ankara, Turkey" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "A largura de distribuição dos eritrócitos é um preditor de mortalidade em pacientes com hemorragia grave" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We have read with great enthusiasm the recently published article entitled “Impact of red blood cell distribution width on risk for bleeding events in patients with non-ST elevation acute coronary syndromes” by Gonçalves et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In this well-presented article they aimed to determine the prognostic value of red blood cell distribution width (RDW) in patients with non-ST segment elevation acute coronary syndromes (NSTE-ACS), particularly regarding the risk of major bleeding. They concluded that RDW was an independent predictor of major bleeding in patients with non-ST segment elevation myocardial infarction (NSTEMI). They suggested that higher RDW values were associated with greater in-hospital mortality and were an independent predictor of in-hospital major bleeding in patients with NSTE-ACS. The ready availability of this parameter at no additional cost may encourage its wider use in clinical practice in the future. We thank the authors for their contribution.</p><p id="par0010" class="elsevierStylePara elsevierViewall">It is known that anemia is an important predictor of short- and medium-term mortality after ACS.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In the present study, there were significant differences between the third tertile of RDW compared to the other groups. Anemia can be an independent risk factor of ACS patients with major bleeding in the present study. RDW is a standard laboratory parameter that shows variation in red blood cell size on a standard hemogram and is usually used in assessing blood diseases. It has recently been reported as an independent predictor of all-cause long-term mortality in patients with coronary artery disease.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> However, conditions in the differential diagnosis of anemias can affect RDW and so this parameter might change in the presence of abnormalities such as thyroid disease, renal or hepatic dysfunction (creatinine >1.5 mg/dl or aspartate aminotransferase and alanine transaminase more than twice the upper limit of normal, respectively), inflammatory diseases, and use of medications which could influence RDW. On the other hand, it is also reported that an increased RDW is associated with nutritional deficiency (of iron, vitamin B<span class="elsevierStyleInf">12</span>, and folic acid) and ethnicity.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Recent clinical studies have considered the importance of bleeding events in the prognosis in patients with ACS. In fact, the risk for cardiovascular complications associated with bleeding is similar to that of a myocardial infarction (MI). Some bleeding risk scores are now available that dependably quantify the likelihood of an ACS patient experiencing a bleeding complication. There is a strong relationship between bleeding and some conditions including older age,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> renal impairment, female gender, and an invasive management approach. Although patients who tend to bleed frequently have more comorbidities than their non-bleeding counterparts, several lines of experimental and clinical evidence suggest an independent causal pathway for bleeding-associated cardiovascular risk. When possible, bleeding should be avoided, and strategies such as use of risk scores, novel antithrombotics (such as bivalirudin and fondaparinux), vascular closure devices and radial access may decrease major bleeding.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Reduced glomerular filtration rate (GFR) may be also associated with adverse outcomes in patients with cardiovascular disease. The authors used the Cockcroft-Gault (CG) equation for GFR. However, compared to the Modification of Diet in Renal Disease (MDRD) formula, the CG equation can give lower GFR measurements in younger age groups but higher GFR measurements in older individuals. The value of GFR in predicting various cardiovascular endpoints in patients with MI is established. Compared to the CG formula, the MDRD formula is significantly more accurate in predicting the severity of coronary artery disease and two-year cardiovascular risk in patients admitted to the intensive care unit with MI.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> For this reason, it can be useful, and the results of the study might have been different if the authors had also used the MDRD formula.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In a previous study it was found that elevated levels of inflammatory molecules are markers of in-hospital major bleeding and also indicate an increased risk for the progression of NSTEMI. These molecules can be reduced by medications including antihypertensive therapy<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> and aspirin. Additionally, as well as RDW, neutrophil/lymphocyte ratio, gamma-glutamyltransferase, C-reactive protein, mean platelet volume and uric acid are also easy methods to assess patients’ cardiovascular disease.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Moreover, hypoalbuminemia on admission is also a strong independent predictor of long-term mortality and development of advanced HF in patients with STEMI undergoing percutaneous coronary intervention.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> These markers might be useful in clinical practice.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Finally, it would have been better if the authors had defined how much time they specified for measuring RDW levels, since delaying blood sampling can cause abnormal results in RDW measurements.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In conclusion, we strongly believe that the findings of the current study will lead to further large-scale studies examining the relationship between RDW and in-hospital major bleeding in patients presenting with ACS. However, one should keep in mind that RDW alone, without other inflammatory markers, may not give precise information to clinicians about their patients’ inflammatory condition and prognostic indication. So, on this basis we think that it should be evaluated together with other serum inflammatory markers.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">1</span><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-02-08" "fechaAceptado" => "2013-02-21" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">At the time of publication, the authors of the article had not responded to requests for a response.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Impact of red blood cell distribution width on risk for bleeding events in patients with non-ST elevation acute coronary syndromes" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "S. 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[Epub ahead of print]" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21742049/0000003200000010/v1_201312121254/S2174204913002353/v1_201312121254/en/main.assets" "Apartado" => array:4 [ "identificador" => "21592" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letter to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21742049/0000003200000010/v1_201312121254/S2174204913002353/v1_201312121254/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204913002353?idApp=UINPBA00004E" ]
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| 2020 December | 39 | 7 | 46 |
| 2020 November | 21 | 11 | 32 |
| 2020 October | 14 | 8 | 22 |
| 2020 September | 42 | 7 | 49 |
| 2020 August | 13 | 6 | 19 |
| 2020 July | 47 | 9 | 56 |
| 2020 June | 32 | 2 | 34 |
| 2020 May | 20 | 7 | 27 |
| 2020 April | 26 | 8 | 34 |
| 2020 March | 39 | 6 | 45 |
| 2020 February | 47 | 33 | 80 |
| 2020 January | 21 | 8 | 29 |
| 2019 December | 27 | 5 | 32 |
| 2019 November | 31 | 1 | 32 |
| 2019 October | 16 | 4 | 20 |
| 2019 September | 34 | 8 | 42 |
| 2019 August | 16 | 6 | 22 |
| 2019 July | 24 | 10 | 34 |
| 2019 June | 25 | 4 | 29 |
| 2019 May | 29 | 18 | 47 |
| 2019 April | 23 | 13 | 36 |
| 2019 March | 45 | 8 | 53 |
| 2019 February | 37 | 15 | 52 |
| 2019 January | 25 | 5 | 30 |
| 2018 December | 36 | 7 | 43 |
| 2018 November | 80 | 4 | 84 |
| 2018 October | 209 | 21 | 230 |
| 2018 September | 28 | 9 | 37 |
| 2018 August | 94 | 12 | 106 |
| 2018 July | 39 | 6 | 45 |
| 2018 June | 50 | 6 | 56 |
| 2018 May | 76 | 8 | 84 |
| 2018 April | 96 | 3 | 99 |
| 2018 March | 98 | 10 | 108 |
| 2018 February | 70 | 5 | 75 |
| 2018 January | 30 | 12 | 42 |
| 2017 December | 57 | 13 | 70 |
| 2017 November | 19 | 3 | 22 |
| 2017 October | 20 | 14 | 34 |
| 2017 September | 23 | 7 | 30 |
| 2017 August | 24 | 25 | 49 |
| 2017 July | 17 | 16 | 33 |
| 2017 June | 35 | 9 | 44 |
| 2017 May | 27 | 6 | 33 |
| 2017 April | 22 | 4 | 26 |
| 2017 March | 44 | 37 | 81 |
| 2017 February | 38 | 3 | 41 |
| 2017 January | 24 | 2 | 26 |
| 2016 December | 48 | 8 | 56 |
| 2016 November | 18 | 2 | 20 |
| 2016 October | 19 | 3 | 22 |
| 2016 September | 17 | 5 | 22 |
| 2016 August | 6 | 4 | 10 |
| 2016 July | 8 | 3 | 11 |
| 2016 June | 7 | 1 | 8 |
| 2016 May | 11 | 2 | 13 |
| 2016 April | 25 | 1 | 26 |
| 2016 March | 34 | 8 | 42 |
| 2016 February | 42 | 10 | 52 |
| 2016 January | 28 | 10 | 38 |
| 2015 December | 19 | 3 | 22 |
| 2015 November | 25 | 5 | 30 |
| 2015 October | 41 | 7 | 48 |
| 2015 September | 29 | 4 | 33 |
| 2015 August | 28 | 7 | 35 |
| 2015 July | 19 | 4 | 23 |
| 2015 June | 6 | 2 | 8 |
| 2015 May | 20 | 3 | 23 |
| 2015 April | 16 | 7 | 23 |
| 2015 March | 26 | 10 | 36 |
| 2015 February | 35 | 3 | 38 |
| 2015 January | 23 | 3 | 26 |
| 2014 December | 29 | 6 | 35 |
| 2014 November | 16 | 3 | 19 |
| 2014 October | 23 | 8 | 31 |
| 2014 September | 29 | 5 | 34 |
| 2014 August | 19 | 1 | 20 |
| 2014 July | 28 | 11 | 39 |
| 2014 June | 13 | 1 | 14 |
| 2014 May | 20 | 3 | 23 |
| 2014 April | 12 | 6 | 18 |
| 2014 March | 24 | 6 | 30 |
| 2014 February | 27 | 8 | 35 |
| 2014 January | 42 | 12 | 54 |
| 2013 December | 11 | 6 | 17 |
Show all
