Coronary Heart Disease

Angiology
2014, Vol 65(1) 60-64
A New Parameter Predicting Chronic The Author(s) 2013
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Total Occlusion of Coronary Arteries: DOI: 10.1177/0003319713486339
ang.sagepub.com
Platelet Distribution Width

Mehmet Akif Vatankulu, MD1, Osman Sonmez, MD1,

Gokhan Ertas, MD2, Ahmet Bacaksiz, MD1, Murat Turfan, MD1,
Ercan Erdogan, MD1, Abdurrahman Tasal, MD1, Seref Kul, MD1,
Huseyin Uyarel, MD1, and Omer Goktekin, MD1

Abstract
Platelet distribution width (PDW) measures the variability in platelet size and is a marker of platelet activation. We investigated
whether PDW is associated with the extent of coronary artery disease (CAD) and coronary total occlusions (CTOs). We studied
162 patients: 108 had a coronary lesion with a diameter stenosis of 50%, the CAD() group, and 54 patients had normal
coronary anatomy, the CAD() group. The CAD() group was subdivided into CAD() CTO() and CAD() CTO() groups.
Among patients with CAD, the CTO() group had a significantly greater PDW (%) than the CTO() group (16.9 + 2.8, 15.4 +
3.0, and 15.4 + 1.9, respectively; P .008). In a receiveroperating characteristic analysis, a PDW cut point of 15.7% was
identified in patients with CTO() (area under curve 0.64, 95% confidence interval 0.54-0.75). A PDW value of more than
15.7% demonstrated a sensitivity of 64% and a specificity of 66%. The PDW is a simple platelet index that may predict the presence
of CTO.

Keywords
platelet distribution width, coronary artery disease, total occlusion

Introduction Patients and Methods

Atherosclerosis is a chronic inflammatory disease that may Patient Selection
progress to thrombotic complications.1,2 Chronic coronary total
The study population included 162 patients who were referred
occlusions (CTOs) are generally considered to be lesions with for elective coronary angiography for stable angina pectoris
duration of >3 months in which the vessel shows either com-
between March 2011 and August 2012. All patients recruited
plete interruption of antegrade blood flow on angiography or
into the study had objective signs of ischemia. Patients present-
only minimal contrast penetration through the lesion without
ing with acute myocardial infarction (AMI), coronary artery
distal vessel opacification.3 The CTO most often arise from
bypass grafting, end-stage renal disease, malignancy, prior blood
thrombotic occlusion, followed by thrombus organization.4
transfusion or hematological disorder such as idiopathic throm-
The lesions are typically characterized by heavy plaque burden
bocytopenic purpura, aplastic anemia, or other diseases that have
within the artery. Mean platelet volume (MPV) and platelet dis-
direct impact on platelet size and volume were excluded from
tribution width (PDW) are simple platelet indices that increase the study. Patients (n 108) who had coronary lesion with a dia-
during platelet activation.5-10 The PDW directly measures
meter stenosis of 50% were included in the CAD() group; 54
the variability in platelet size and is a marker of platelet
activation.11 However, only few studies have investigated the
relationship between this index and coronary artery disease 1
Department of Cardiology, Faculty of Medicine, BezmiAlem Vakif University,
(CAD),5,12-14 and none have addressed the association between Istanbul, Turkey
2
PDW and CTO. Thus, the aim of the current study was to inves- Deparment of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular
tigate whether PDW is associated with the extent of CAD and Surgery Training and Research Hospital, Istanbul, Turkey
CTO. We hypothesized that PDW would be associated with a
Corresponding Author:
greater complexity of CAD as assessed using the SYNTAX Osman Sonmez, Department of Cardiology, Faculty of Medicine, BezmiAlem
score (SS) and would be associated with CTO. The SS is an Vakif University, Istanbul, Turkey.
angiographic tool used to grade the complexity of CAD. Email: osmansonmez2000@gmail.com
Vatankulu et al 61

Table 1. Baseline Characteristics of Groups.a

CAD(), n 54 CAD() CTO(), n 54 CAD() CTO(), n 54 P

Age, years 57 + 10 62 + 9 59 + 12 .08

Female/male 34/12 16/32 11/38 .0001
Diabetes, % 26 37 43 .11
Hypertension, % 43 50 50 .78
Hyperlipidemia, % 30 37 54 .02
BMI, kg/m2 28.9 + 2.5 29.9 + 2.9 31.5 + 2.7 .12
WBC count, 103 7.1 + 1.9 7.5 + 2.2 7.7 + 2.0 .40
Neutrophil count, 103 4.0 + 1.6 4.6 + 1.6 4.6 + 1.7 .07
Lymphocyte count, 103 2.2 + 0.8 2.1 + 0.8 2.0 + 0.7 .58
Platelet count, 103 268 + 67 246 + 66 230 + 56 .015 .012b
MPV, fL 9.2 + 0.9 9.3 + 1.1 9.6 + 0.9 .16
PDW, % 15.4 + 1.9 15.4 + 3.0 16.9 + 2.8 .008 .02-.02c
Hemoglobin, g/dL 12.3 + 1.7 12.4 + 1.5 13.0 + 1.9 .12
Creatinine, mg/dL 0.9 + 0.7 0.9 + 0.4 0.9 + 0.3 .99
LDL, mg/dL 121 31 146 + 39 113 + 32 .008
SYNTAX score 14.9 + 10.1 21.4 + 10.5 .008d
Aspirin, % 12 16 18 S
b-Blocker, % 5 9 13 NS
ACE inhibitor, % 20 26 29 NS
Statin, % 14 18 27 .008
Abbreviations: BMI, body mass index; WBC, white blood cell; NLR, neutrophil-to-lymphocyte ratio; MPV, mean platelet volume; PDW, platelet distribution width;
ACE, angiotensin converting enzyme; CAD, coronary artery disease; CTO, coronary total occlusion; LDL, low-density lipoprotein.
a
Results are expressed as mean + standard deviation or frequency (within group percentage). Analysis of variance and chi-square test are used.
b
Bonferroni post hoc test CAD() group and CAD() CTO() group.
c
Bonferroni post hoc test CAD(), CAD() CTO(), CAD() CTO(), and CAD() CTO() groups.
d
Student t test.

patients who had normal coronary anatomy were included in the expressed as mean + standard deviation or median (interquar-
CAD() group. The CAD() group was subdivided into the tile range) when appropriate. Categorical variables are
CAD() CTO() group and CAD() CTO() group. The CTO expressed as percentages. To compare parametric continuous
was considered to be lesions with a duration of >3 months, in variables, Student t test or analysis of variance was used; to com-
which the vessel shows no antegrade blood flow on angiography pare nonparametric continuous variables, the Mann-Whitney
or only minimal contrast penetration through the lesion without U test or the Kruskall-Wallis test was used. To compare cate-
distal vessel opacification.3 A clinical history of risk factors such gorical variables, the chi-square test was used. The Pearson
as age, sex, diabetes mellitus (DM), hypertension (HT), hyperch- correlation analysis was used to correlate MPV and SS and also
olesterolemia (HL), and family history of cardiovascular disease PDW and SS. Multivariate logistic regression analysis was
was recorded. For each patient, height, weight, and body mass used to identify the independent predictors of CTO. All vari-
index were calculated. Hemoglobin, white blood cell (WBC), ables showing significance values of less than 0.1 on univariate
platelet (Plt) count, MPV, and PDW were measured as part of analysis (age, sex, DM, HT, HL, platelet count, MPV, and
the automated complete blood count using a Sysmex XT- PDW) were included in the model. A 2-tailed P < .05 was
1800i (Sysmex Corporation, Kobe, Japan) hematology analyzer. considered significant.
Baseline neutrophil-to-lymphocyte ratio was measured by divid-
ing the neutrophil count by the lymphocyte count. Patients with
Results
WBC count >12 000 cells/mL or <4000 cells/mL and high body
temperature >38 C were excluded from the study. The baseline characteristics of the groups are presented in
Table 1. In 162 patients (mean age 59.6 + 11.9, 58% male),
SYNTAX Score PDW ranged from 10.7% to 48.7% (median 15.8%, mean
16.04 + 3.73%). Among patients with CAD, the CTO()
The SS is an angiographic index used to grade the complexity
group had a significantly greater PDW (%) value than CTO()
of CAD. Each coronary lesion with a diameter stenosis of
group (16.9 + 2.8, 15.4 + 3.0, and 15.4 + 1.9, respectively;
50%, in vessels 1.5 mm, should be scored. The online latest
P .008). Patients in the group without CAD were signifi-
updated version (2.1) was used for the calculation of the SS
cantly younger female individuals, and the CAD() CTO()
(www.syntaxscore.com).15
group had significantly more hyperlipidemia history. In con-
trast to the PDW (%), the CAD() group had a significantly
Statistical Analyses higher platelet count (103 cells/mL; 268 + 67, 246 + 66 and
The statistical analyses were performed using software (SPSS 230 + 56, respectively; P .015). There was no significant
15.0; SPSS Inc, Chicago, Illinois). Continuous variables are difference in MPV. The CAD() CTO() group had higher
62 Angiology 65(1)

Table 2. Predictors of CTO in Multivariate Logistic Regression

Analysis.

Univariate OR Multivariate OR
Variables (95% CI) P (95% CI) P

Age, years .26

Male, % (0.23-1.4) .23
Diabetes mellitus, % (0.34-1.7) .53
Hyperlipidemia, % (0.2-1.0) .06 2.0 (0.8-4.2) .09
Platelet count, 103 .21
MPV, fL .21
PDW, % .02 1.2 (1.0-1.4) .01
Abbreviations: MPV, mean platelet volume; PDW, platelet distribution width;
OR, odds ratio; CI, confidence interval; CTO, coronary total occlusion.

Figure 1. Correlation between mean platelet volume (MPV) and

SYNTAX score; Pearson test was used.

Figure 2. Correlation between platelet distribution width (PDW)

and SYNTAX score; Pearson test was used.

coronary complexity as assessed by SS than the CAD()

CTO() group (21.4 + 10.5 and 14.9 + 10.1; P .008). Figure 3. Receiveroperating characteristic analysis and curve for
In the correlation analyses, there were no correlation predicting coronary total occlusions (CTO).
between PDW and SS and also MPV and SS (Figures 1 and
2). The CAD() CTO()and CAD() CTO() groups were under curve 0.64, 95% CI 0.54-0.75). A PDW value more
compared in the univariate analysis. Variables found to be sig- than 15.7% demonstrated a sensitivity of 64% and a specificity
nificant in univariate analyses were entered into multivariate of 66% (Figure 3).
logistic regression analysis.
In univariate analysis, age, male sex, HL, platelet, MPV,
high SS, and PDW were predictors of CTO. In the multiple Discussion
logistic regression analysis, PDW (odds ratio 1.2, 95% con- We found a relation between PDW and CTO of coronary
fidence interval [CI] 1.0-1.4; P .01) and HL were identified arteries in stable CAD. Our findings suggest that high levels
as independent predictors of CTO in our model (Table 2). of PDW can predict CTO in CAD.
In a receiveroperating characteristic analysis, a cut point of Platelets play a role in every spectrum of CAD.7 The MPV
15.7% for PDW was identified in patients with CTO() (area and PDW are simple platelet indices that increase during
Vatankulu et al 63

platelet activation. The MPV is an extensively studied platelet Declaration of Conflicting Interests
activation marker in coronary atherosclerosis.5-10 The PDW The author(s) declared no potential conflicts of interest with respect to
directly measures the variability in platelet size. According to the research, authorship, and/or publication of this article.
the recent studies, PDW is a more specific marker of platelet
activation11 and may provide more information than MPV.14
Coronary artery CTO most often arises from thrombotic occlu- Funding
sion, followed by thrombus organization and tissue aging.4 The The author(s) received no financial support for the research, author-
histopathological progress of CTO is not clearly defined. A ship, and/or publication of this article.
thrombus develops after coronary artery occlusion, and then
they progress to an organized thrombus that is more solid than
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