World Journal of Cardiovascular Diseases, 2013, 3, 458-463 WJCD
http://dx.doi.org/10.4236/wjcd.2013.37072 Published Online October 2013 (http://www.scirp.org/journal/wjcd/)
White blood cell count and mortality in acute
myocardial infarction
Negar Salehi1, Rahimeh Eskandarian2*, Hamid Reza Sanati3, Ata Firouzi3, Farshad Shakerian3,
Seyfollah Abdi3, Homan Bakhshandeh4, Mojde Nasiri Ahmad Abadi5, Negin Nouri6,
Anoushiravan Vakili-Zarch3
1College of Osteopathic Medicine, Michigan State University, Michigan, USA
2Department of Interventional Cardiology, Semnan University of Medical Sciences, Semnan, Iran
3Department of Interventional Cardiology, Tehran University of Medical Sciences, Tehran, Iran
4Department of Epidemiology, Tehran University of Medical Sciences, Tehran, Iran
5Department of Epidemiology and Biostatistic, Michigan State University, Michigan, USA
6Digestive Disease Research Center, Tehran University of Medical Sciences, Tehran, Iran
Received 8 August 2013; revised 8 September 2013; accepted 25 September 2013
Copyright © 2013 Negar Salehi et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Introduction: Coronary atherosclerosis is increasingly
viewed as an inflammatory process. We assessed the
relation between WBC count on admission and mor-
tality in STEMI patients treated with primary PCI.
Material & Method: Totally 205 patients with STEMI
less than 24 hours before ad mission who admitted for
primary angioplasty enrolled in study. Study end
points were defined as myocardial adverse cardiac
event (MACE) and mortality at one month and one
year follow-up. Result: Totally 205 patients (166 men)
with mean age 56 ± 11 were enrolled in study. The
mean WBC count was 8983 ± 34 and mean follow-up
was 12.24 months. WBC count remained a significant
predictor of mortality after multivariable adjustment
in one month and 12 months follow-up (p = 0.02, p =
0.04). Conclusion: Our results extend previous find-
ings that WBC count is an independent marker of
cardiac mortality.
Keywords: Myocardial Infarction; Primary
Percutaneous Coronary Intervention; WBC Count;
Inflammation
1. INTRODUCTION
Coronary atherosclerosis is increasingly viewed as an
inflammatory process [1-3]. Previous studies confirmed
an association between inflammatory markers and athe-
rosclerosis plaque formation, progression, and instability
of plaque, adverse clinical outcome and development of
myocardial infarction [4,5]. Leucocytes are major me-
diators of inflammation. They have a key role in host
defense to injury. Increasing of white blood cell (WBC)
count is a risk factor for future cardiovascular events in
individuals without cardiovascular disease [6,7]. It is as-
sociated with worse outcome in patients with stable an-
gina and acute coronary syndrome [8-15]. The baseline
WBC count is an independent predictor of mortality in
ST elevation myocardial infarction (STEMI) patients [16,
17]. Moreover, in STEMI patients undergoing primary
percutaneous coronary intervention (PCI) WBC count
predicts short term mortality [18]. Although in one study
this association was not significant. Gurm et al. showed
that WBC count is an independent predictor for long
term mortality in patients undergoing PCI either in the
setting of stable angina or primary PCI [19,20]. The aim
of our study was to assess the relation between on ad-
mission WBC count and clinical data and short term and
long term mortality in STEMI patients treated with pri-
mary PCI.
2. MATERIAL & METHOD
This prospective study was done from Nov 2008 to Dec
2011. Totally 205 patients with STEMI (ST elevation
≥0.1 mV in more than 2 limb leads or ≥0.2 mV in chest
lead or new LBBB at presentation, patients with chest
pain during less than 24 hours before presentation who
admitted for primary angioplasty in Shahid Rajaie hos-
pital in Tehran, Iran enrolled in study.
In all patients, primary angioplasty was performed
*Corresponding author.

N. Salehi et al. / World Journal of Cardiovascular Diseases 3 (2013) 458-463 459
according standard technique after loading dose of ASA
325 mg and 600 mg of clopidoigrel. Integrilin prescribed
based on discretion physician performing procedure.
Demographic, clinical and angiographic data including
sex, age, coronary risk factor, MI location, blood pres-
sure, heart rate, previous presentation before MI and time
from onset to admission was determined and recorded.
Exclusion criteria included the following: any form of
steroid medication or non steroidal anti-inflammatory
drugs or antibiotics use in the preceding month, acute
infection in the last 2 weeks, surgery within the last 2
weeks, history of liver or renal failure, history of malig-
nancy or vacuities and admission more than 24 hour
from onset of symptoms. Pre- and post-procedural an-
giograms were analyzed by two operators blinded to the
study. Study protocol was approved by the local ethics
committee.
Study end point was major adverse cardiac events
(MACE) including mortality, MI, target vessel revascu-
larization (TVR) and stent thrombosis. Follow up per-
formed based on records of monthly visits in outpatient
clinic and telephone interview to evaluate symptoms and
admission note.
Baseline WBC count values were analyzed as con-
tinuous variable. To assess the relation between WBC
count and baseline clinical data multivariable linear re-
gression was applied.
Study end points were defined as MACE and mortality
at one month and one year follow-up (minimum 1moth
to 33 months for all subjects). Continuous data are pre-
sented as mean values with standard deviation and com-
pared by use of Student’s t-test. Categorical data are pre-
sented as frequencies and analyzed with χ2 tests. The
relation between one-year mortality and clinical factors’
including WBC count is examined with stepwise, multi-
variable logistic regression. Risk ratios are reported with
regression model that adjust for factors that are inde-
pendently associated with the outcome variable. Data
analysis is performed using SPSS 16.0.
3. RESULT
Total of 205 patients (166 men and 39 women) with AMI
with mean age 56.9 ± 11.154 (range 28 - 86 years) were
enrolled in study. The mean WBC count was 8983 ± 34
and mean follow up was 12.24 month (range 1 to 33). In
patient with current smoking, mean WBC was signifi-
cantly higher than non smoker patients [10,021 ± 53
versus 8319 ± 55 (p = 0.002)]. Others risk factors such as
diabetes mellitus, hypertension, family history of coro-
nary disease, hypercholesterolemia, age and sex had no
significant relation with WBC (Table 1). Table 1 De-
scribes baseline characteristics of patients including cor-
onary risk factors and association with mean WBC.
We assessed the relation of MI location, history of pre-
vious PCI or CABG, MI history and symptoms before
the presentation and presence or absence of shock and
their relationship with WBC count. There was a signifi-
cant statistical relation with history of PCI (Table 2).
WBC count in patients with single vessel and multi
vessel involvement had no significant difference in our
data. LAD lesion diagnosed in 53.7%, LCX lesion in
12.2%, and RCA lesion in 32.7% of patients (p = 0.028).
Moreover, 80.5% of patient had thrombotic lesion. Data
Table 1. Baseline characteristics of patients.
Variables Number Percent WBC count mean ± SD p value
Male 166 81 9091 ± 65
Sex
Female 39 19 8535 ± 48
0.739
Current 87 42.4 10,021 ± 53
Smoking
Non 118 57.6 8319 ± 55
0.002
Yes 43 21 8323 ± 71
Diabetes
No 162 79 9169 ± 36
0.179
Yes 72 35.1 8360 ± 78
Hypertension
No 133 64.9 9350 ± 45
0.077
Yes 24 11.7 8962 ± 38
Family history of coronary disease
No 181 88.3 8986 ± 38
0.976
Yes 82 40 8713 ± 33
Hypercholesterolemia
No 123 60 9190 ± 12
0.384
>70 25 13.2 9204 ± 32
Age
Up to 70 178 88.8 8953 ± 25
0.765

N. Salehi et al. / World Journal of Cardiovascular Diseases 3 (2013) 458-463 460
Table 2. Clinical and para clinic finding and association with mean WBC count in PPCI.
Variable Number Mean ± SD WBC count p value
Anterior MI or new LBBB 111 8882 ± 15
No anterior MI 94 9096 ± 40
0.694
History of myocardial infarction 41 8058 ± 87
No history of myocardial infarction 164 9198 ± 18
0.100
History of PCI 22 7320 ± 00
No history of PCI 183 9156 ± 47
0.047
History of CABG 4 9250 ± 28
No history of CABG 164 8976 ± 33
0.875
Pre presentation unstable angina 67 8990 ± 76
Asymptomatic 71 9092 ± 11
Chronic stable angina 21 8590 ± 95
0.987
Shock in presentation 13 9170 ± 45
No shock 146 8966 ± 58
0.837
IABP, impella 9.9 9912 ± 22 0.402
Abbreviations: MI = myocardial infarction, LBBB = left bundle branch block.
are summarized in Table 3. Moreover, WBC counts were
not significantly different between patients with different
TIMI frame count (Table 4).
In one month follow up mean WBC counts were 8970
± 13, 9330 ± 97 and 8250 ± 58 in no death (n = 200),
cardiac death (n = 4) and non cardiac death (n = 1)
groups respectively (p = 0.02). In 12 month follow up,
mean WBC count were 8983 ± 14, 11,002 ± 70 and 8992
± 30 in no death (n = 190), cardiac death (n = 8) and non
cardiac death (n = 2) groups respectively (p = 0.04).
The overall rate of MACE (death, MI, re-stenosis,
stent thrombosis) was 10.2% in one year follow up.
Mean WBC count was 9330 in this group compared to
8970 in patients without MACE which was not signifi-
cant (p = 0.859) (Table 5).
4. DISCUSSION
Based on our study results, a significant relationship ob-
served between baseline WBC count and cardiac mortal-
ity in patient with STEMI and primary PCI during one
and 12 months follow up. Previous studies investigated
the association between increased inflammatory markers
and outcome in coronary artery disease [21-25].
Other studies showed the association between WBC
count and short term mortality in AMI. Barron et al.
demonstrated in patients with AMI that received throm-
bolytic, higher baseline WBC count was associated with
worse short term outcome, reduced myocardial perfusion,
thromboresistance and higher incidence of new CHF and
death [26-28]. On the other hand in PAMI trial there was
no association between WBC count and mortality in AMI
and primary PCI [19]. Mehran et al. described associa-
tion between WBC and MACE (MI, death, TVR, stroke)
in one month in primary PCI [28]. In another investiga-
tion in patients undergoing PCI (other than primary PCI)
baseline WBC count in group with history of MI, heart
failure, and type C lesion was higher. PCI success rate
between groups was equal and three years mortality had
linear association with WBC count [29]. In other study,
total WBC count could predicted one year’s mortality in
patients with acute coronary syndrome which treated
with percutaneous coronary intervention, leucocytes count
had predicted mortality across all of the subgroups [30].
The association between thrombotic and inflammatory
pathways in MI has been explored in numerous studies.
Leukocytosis is common in acute STEMI. It results from
inflammatory response of neurohormonal system. The
infiltration of WBCs into necrotic tissue in response to
ischemia and reperfusion has major role in secreting me-
diators which contribute to oxidative and proteolytic in-
jury. Furthermore, the distal embolisation of leukocytes
and platelet-leukocyte aggregates may reduce microvas-
cular perfusion and contribute to thrombosis and wide-
spread myocardial inflammation [11]. In addition to in-
flammatory response in acute MI, post procedural in-
flammatory response in patients undergoing PCI has a
wide range of mechanisms, including mechanical disrup-
tion of atherosclerotic plaque, endothelial cell injury

N. Salehi et al. / World Journal of Cardiovascular Diseases 3 (2013) 458-463 461
Table 3. Baseline procedural data and association with mean WBC in PPCI.
Variables Number Mean ± SD WBC count p value
Multi vessel disease 94 8936 ± 18
Single vessel disease 65 9051 ± 23 0.835
LAD 84 8788 ± 11
LCX 17 11,141 ± 18
Culprit vessel
RCA 55 8405 ± 89
0.028
Ostia 16 9425 ± 39
Proximal 68 9496 ± 93
Mid portion 61 8362 ± 79
Distal 8 9088 ± 75
Location invessel
Bifurcation 6 8150 ± 44
0.383
A 2 9200 ± 55
B 29 9202 ± 97 Type of Lesion
C 128 8930 ± 24
0.924
Thrombotic 131 8963 ± 62
Non thrombotic 28 9077 ± 71 0.872
Stenosis <100 36 9544 ± 61
Stenosis 100% 123 8818 ± 90 0.263
Glycoprotein IIb/IIIa use 46 9484 ± 59
No glycoprotein IIb/IIIa use 113 8779 ± 12 0.238
Table 4. TIMI flow before and after PCI.
Variables Number Mean ± SD WBC count p value
TIMI flow before PCI
0
1
2
3
123
9
14
13
8818 ± 90
9691 ± 11
10,169 ± 71
8770 ± 58
0.765
TIMI flow after PCI
0
1
2
3
3
3
20
123
7100 ± 81
9966 ± 67
9461 ± 57
8931 ± 66
0.666
Table 5. Clinical outcome and association with mean WBC in PPCI.
Variables Number Mean ± SD WBC count p value
Outcome 1 month
Death 5 8500 ± 40
Stent thrombosis 3 8066 ± 67
Restenosis 1 9200 ± 36
Re-PCI 3 8066 ± 67
CABG 2 10,800 ± 61
0.295
Outcome 12 month
Death 10 11002.50
Stent thrombosis 6 7400 ± 51
Restenosis 7 8822 ± 35
Re-PCI 9 8387 ± 41
CABG 8 8337 ± 50
Ischemia, MI 10 9567 ± 78
Total outcome 50 9335 ± 81
0.079

N. Salehi et al. / World Journal of Cardiovascular Diseases 3 (2013) 458-463 462
caused by proteolytic and oxidative stress, arterial wall
injury, myocardial necrosis due to distal embolisation,
vessel plugging effecting the blood flow through the car-
diac microvasculature, hyper coagulable state with de-
crease epicardial patency and increased ischemic burden
[31,32]. Moreover, reduced patency of coronary arteries
and higher thrombus burden was observed in patients
with elevated WBC count [33].
It is possible that endothelial dysfunction and mi-
crovascular plugging due to elevated level of WBC play
an important role in developing of future heart failure in
STEMI patients [34].
5. CONCLUSION
Our results extend previous findings that WBC count can
be an independent marker of cardiac mortality, in short
term and long-term mortality prediction in STEMI treated
with revascularization. Increased WBC count is a simple
non-specific marker of inflammation; it may serve as an
available and inexpensive tool for risk stratification in
acute SEMI.
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