the goal of risk stratification after acute st elevation myocardial infarction ( stemi ) is to identify patients whose outcomes can be improved by predicting complications . currently , risk stratification after myocardial infarction has largely focused on stratification after the patient leave the hospital . although the evaluation prior to discharge remains an important component of risk stratification , the emphasis must also be placed on early and continual risk assessment done using simple bedside observations to prevent in - hospital mortality and morbidity . the reason for this is : early identification of high - risk patients allows rapid triage for cardiac catheterization , thus , reducing both inpatient stays and overall cost . ( our center does not have catheterization lab and would require at least 2 hours of transfer time . therefore , low - risk patients can be considered for shorter stays in the coronary care units , be subjected to fewer diagnostic evaluations , as well as earlier hospital discharge . white blood cell ( wbc ) count and thrombosis in myocardial infarction ( timi ) risk score are inexpensive risk markers that are routinely assessed at the time of hospital admission in clinical practice . numerous studies have demonstrated that a high wbc count is associated with a large infarct , impaired left ventricular ( lv ) function and mortality after acute myocardial infarction ( ami).[29 ] the potential deleterious roles of the wbc count in promoting blood coagulation , mediating microvascular no - reflow , and causing myocyte dysfunction have been reported . timi risk score provides independent prognostic information but is not currently used routinely in the assessment of patients with acute coronary syndromes . the objective of this study was to examine the association between hospital admissions ; peripheral total leukocyte count and timi risk score and presentation of heart failure and in - hospital mortality of patients . this study was approved by the ethics committees at two participating hospitals that lack interventional capabilities . as such , thrombolytic therapy was performed on all these patients except if the patient has had a contraindication to thrombolytics , then , angioplasty will be preferred modality . this cross - sectional study was carried out on 105 patients from january 15 , 2008 to june 31 , 2009 with a diagnosis of stemi who were admitted to our two coronary care units located , in the two university hospitals , but 70 patients was qualified . acute stemi was defined by a combination of two of three characteristics i.e. , chest pain consistent with ongoing myocardial ischemia that persisted 30 minutes , electrocardiographic changes and positive troponin 1 . the following criteria were used to define st - segment elevation : new or presumed - new st elevation at the j - point in two or more contiguous leads that is greater than or equal to 0.2 mv ( 2 mm ) in leads v1 through v6 or greater than or equal to 0.1 mv ( 1 mm ) in the other leads . patient were excluded if there were concomitant infections , inflammatory diseases , malignant diseases , hypoglycemia , corticosteroid consumption , any contraindication for thrombolytic therapy , as well as any other indications where primary pci would have been preferred . these patients were not given any other drug that could affect the wbc count ( for example , -blocker ) . ( these are not exclusion criteria . ) a blood sample was drawn for leukocyte count and blood sugar and troponin , on admission and repeated for troponin12 hours later . total wbc , neutrophils count , lymphocytes count , and monocytes count were determined using an automated blood cell analyzer ( sysmex xe-2100 ) before thrombolytic therapy . total leukocyte was categorized as low if the tbc is less than 10000/ml or high if the tbs is 10000/ml or more . echocardiogram was obtained prior to discharge by the cardiologist and the lv ejection fraction ( lvef ) , and cardiac volumes were determined according to simpson formula . the nominal regression model was used to obtain odds ratios ( or ) and 95% confidence intervals ( ci ) for in - hospital mortality . in this model , the nominal regression model was used to obtain odds ratios ( or ) and 95% confidence intervals ( ci ) for in - hospital mortality . in this model , there were five deaths ( 3.5% ) during the hospitalization 4(80% ) of them had timi risk score4 and 3 ( 60% ) wbc count10000/ml . in - hospital mortality was more likely to be higher in patients whose wbc count was > 10,000 ( 11% in high vs. 5% in low , or=2.2 , 95% ci,1.8 - 3.1 , p=0.01 . predischarge lvefs were 5612% in the low wbc group , and 5213% in the high count , ( p=0.001 ) [ tables 1 and 2 ] . study characteristics of the patients with the admitting diagnosis of stemi factors prevalence in admitted patients according to their timi score a higher timi risk score was also associated with higher in - hospital mortality ( 20% in timi  4 vs. 2% in timi < 4 , or=10 , 95% ci , 9.1 - 11 , p=0.001 ) . patients with lower timi were younger and more likely to be current smokers but less likely to be hypertensive . patients with a high wbc count had a 5.0-fold increase in - hospital congestive heart failure compared with those with a low wbc count . patients with a high timi risk score had a 10-fold increase in congestive heart failure presentation compared with those with a low timi risk score . predischarge lvefs were 5613% in the low timi , and 5212% in the high timi ( p0.001 ) . in group with timi<4 , 91% had ef 50% , while in patients with timi4 ; 92% had ef below 50% ( p=0.0001 ,  = 36 ; [ table 3 ] ) association between ejection fraction and timi in admitted patients if wbc10000 cells / ml : ef<50% in 80% and in 20% ef 50% ( p=0.02 ) . if wbc<10000 cells / ml : ef 50% in 87% and in 13% ef<50% ( p<0.05 ,  = 33.1 ) [ table 4 ] . association between wbc and ejection fraction in admitted patients table 5 weighs other variables together . in univariate analysis , ( or 1.12 per 1000/mm increase , 95% ci 1.09 - 1.11 , p<0.001 ) wbc count was associated with in - hospital mortality . multivariate analysis showed that wbc count and timi risk score were independent predictors for in - hospital mortality . comparison of two groups of variables influence of diabetes mellitus on in - hospital outcomes was also investigated . there was no significant difference in in - hospital mortality between diabetic and nondiabetic patients ( 6% vs. 7% , p=0.5 ) . when we combined wbc count and timi risk score [ table 6 ] , for predicting in - hospital outcomes , yielded a sensitivity of 86% and a specificity of 95% for identification of heart failure and a sensitivity of 100% and a specificity of 73% for prediction of mortality . this study showed that a high wbc count ( as defined 10,000 ) and timi risk score  4 ) were strong predictors for in - hospital mortality after ami . lv function decreased in a stepwise manner as wbc count and timi risk score increased . a timi risk score 4 yielded a sensitivity of 80% and a specificity of 95% for identification of heart failure and a sensitivity of 80% and a specificity of 72% for prediction of mortality . leukocytosis 10000/ml yielded a sensitivity of 82% and a specificity of 85% for identification of heart failure and a sensitivity of 60% and a specificity of 58% for prediction of mortality . these findings suggested that a combination of wbc count and timi risk score provide further information for predicting outcomes of patients with ami . timi risk scores due to its simplicity , cost - effectiveness and wide availability are a potential risk stratification tool in ami and emphasis must also be placed on its usage . several studies have demonstrated that in st - segment elevation ami a high wbc count was associated with short - term mortality and heart failure . several experimental studies have suggested that inflammation and wbc count may directly contribute to a larger infarct . evid[ence suggests that leukocytes may play an active role in the modulation of platelet function and vice versa . myocardial ischemia causes release of chemotactic factors , migration of neutrophils , peroxidation of lipids and depletion of free radical scavengers . the invading neutrophils may injure the myocardial vasculature and sarcolemma by generating oxygen - free radicals . nonetheless , it remains unclear as to whether a high wbc count results in a larger infarct or it is merely a consequence . based on recent clinical studies , a high wbc count is not a simple reflection of a larger infarct before reperfusion therapy . small numbers of patients in this study.serial leukocyte counts were not recorded ; therefore , we can not analyze the effect of peak counts on outcomes . serial leukocyte counts were not recorded ; therefore , we can not analyze the effect of peak counts on outcomes . small numbers of patients in this study.serial leukocyte counts were not recorded ; therefore , we can not analyze the effect of peak counts on outcomes . serial leukocyte counts were not recorded ; therefore , we can not analyze the effect of peak counts on outcomes . despite the use of modern reperfusion therapies , stemi patients with higher wbc count and timi risk scores are high - risk and strongly increased in - hospital mortality rates when compared with patients without these characteristics . these findings suggested that a combination of wbc count and timi risk scores provide further information for predicting in - hospital outcomes of patients with ami . this study focused on stemi that would be the importance of it as opposed to other studies which focused on the whole spectrum of acs .
introduction : admission white blood cell ( wbc ) count and thrombosis in myocardial infarction ( timi ) risk score have been associated with adverse outcomes after acute myocardial infarction ( ami ) . 
 this study investigated the joint effect of wbc count and timi risk score on predicting in - hospital outcomes in patients with ami.materials and methods : wbc count and timi risk score were measured at the time of hospital admission in 70 patients with ami . 
 echocardiogram was done on prior to discharge by a cardiologist and ejection fraction ( ef ) was determined according to the simpson formula . 
 patients were stratified into tertiles ( low and high ) based on wbc count and timi risk score.results:patients with a high wbc count had a 5.0-fold increase in - hospital congestive heart failure and 2.2 increases in mortality compared with those with a low wbc count . 
 patients with a high timi risk score had a 10-fold increase in congestive heart failure presentation and mortality compared with those with a low timi risk score . 
 when a combination of different strata for each variable was analyzed , a stepwise increase in mortality was seen . 
 there were a few number of patients with a high wbc count and low timi risk score or with a low wbc count and high timi risk score . 
 these patients had an intermediate risk , whereas those with a high wbc count and timi risk score had the highest risk.conclusion:these findings suggested that a simple combination of wbc count and timi risk score might provide further information for predicting outcomes in patients with ami .