Red cell distribution width as a predictor of systemic hypertension

Dissertation on

RED CELL DISTRIBUTION WIDTH AS A PREDICTOR OF SYSTEMIC HYPERTENSION

Submitted in partial fulfillment for the Degree of

M.D GENERAL MEDICINE BRANCH – I

THE TAMIL NADU DR.M.G.R MEDICAL UNIVERSITY CHENNAI

THE TAMIL NADU DR.M.G.R MEDICAL UNIVERSITY INSTITUTE OF INTERNAL MEDICINE

MADRAS MEDICAL COLLEGE CHENNAI – 600003

CERTIFICATE

This is to certify that the dissertation titled “RED CELL DISTRIBUTION WIDTH AS A PREDICTOR OF SYSTEMIC HYPERTENSION” is the bonafide original work done by Dr SINJU SANKAR.P, post graduate student, Institute of Internal medicine, Madras medical college, Chennai-3, in partial fulfillment of the University Rules and Regulations for the award of MD Branch -1 General Medicine, under our guidance and supervision, during the academic year 2015-2018.

Prof. S.MAYILVAHANAN M.D.,

Director & Professor,

Institute of Internal Medicine, Madras Medical College & RGGGH, Chennai – 600003.

Prof.S.USHALAKSHMI M.D., FMMC

Professor of Medicine, Institute of Internal Medicine, Madras Medical College & RGGGH, Chennai – 600003

Prof.R.NARYANABABU. M.D., DCH. DEAN,

Madras Medical College & Rajiv Gandhi

DECLARATION

I, Dr. SINJU SANKAR.P, solemnly declare that dissertation titled

“RDW AS A PREDICTOR OF SYSTEMIC HYPERTENSION” is a bonafide work done by me at Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai-3 during March 2017 to August

2017 under the guidance and supervision of my unit chief Prof. S.USHALAKSHMI.M.D.FMMC., Professor of Medicine, Madras

Medical College and Rajiv Gandhi Government General Hospital, Chennai.

This dissertation is submitted to Tamilnadu Dr. M.G.R Medical University, towards partial fulfillment of requirement for the award of M.D. DEGREE IN GENERAL MEDICINE BRANCH-I.

Place: Chennai -03

Date: Dr.SINJU SANKAR P

MD General Medicine,

INSTITUTE OF INTERNAL MEDICINE MADRAS MEDICAL COLLEGE

CHENNAI 600003

ACKNOWLEDGEMENT

I owe my thanks to Dean Prof.R.NARYANABABU.M.D.,DCH,

Madras Medical College and Rajiv Gandhi Government General

Hospital, Chennai-3. for allowing me to avail thefacilities needed for

my dissertation work.

I am grateful to beloved mentor Prof. S.MAYILVAHANAN

M.D., Director and Professor, Institute of Internal Medicine, Madras Medical College and Rajiv Gandhi Government General Hospital,

Chennai-03 for permitting me to do the study and for his encouragement.

With extreme gratitude, I express my indebtedness to my beloved

Chief and teacher Prof. S.USHALAKSHMI.M.D.,FMMC., for his

motivation, advice and valuable criticism, which enabled me to complete

this work.

I am extremely thankful to my Assistant Professor

Dr.APARNA SURESH, M.D., and Dr.M.SHARMILA M.D., for their

guidance and encouragement.

I am also thankful to all my unit colleagues and other post

graduates in our institute for helping me in this study and my sincere

thanks to all the patients and their families who were co-operative during

CONTENTS

S NO TITLE PAGE NO

1 INTRODUCTION 1

2 AIMS AND OBJECTIVES 3

3 REVIEW OF LITERATURE 4

4 MATERIALS AND METHODS 42

5 OBSERVATION AND RESULTS 46

6 DISCUSSION 73

7 CONCLUSION 75

8 LIMITATIONS 76

9 BIBLIOGRAPHY 77

10 ANNEXURES

PROFORMA 88

ETHICAL COMMITTEE 91

PLAGIARISM REPORT 92

PLAGIARISM CERTIFICATE 94

INFORMATION SHEET 95

CONSENT FORM 96

MASTER CHART

ABBREVIATION

CBC - Complete Blood Count

MCV - Mean Corpuscular Volume

RDW - Red Cell Distribution width

MCHC - Mean Corpuscular Hemoglobin Concentration

TC - Total Count

Hb - Hemoglobin

BP - Blood Pressure

HTN - Hypertension

DM - Diabetes Mellitus

CHD - Coronary Heart Disease

Pre-HTN - Prehypertension

CHF - Congestive heart failure

ANS - Autonomic nervous system

ARB - Angiotensin receptor blocker

ACEI - Angiotensin converting enzyme inhibitor

1

INTRODUCTION

1_{Hypertension is the leading cause of global burden of disease.}

Hypertension increases the risk of CVD including CHD, CHF, ischemic

and hemorrhagic cerebrovascular accident, renal failure and peripheral

vascular disease.

2_{Red cell distribution width (RDW) is a parameter that measures}

variation in red blood cell size or red blood cell volume. RDW is

increased according to the variation in red cell size (anisocytosis), i.e.,

when elevated RDW is reported on CBC, increased anisocytosis

(increased variation in red cell size) is expected on peripheral blood

smear review.

36_{Red cell distribution width (RDW), a red blood cell index, is}

used to evaluate different types of anaemia and also is an important

predictor of morbidity and mortality in a variety of settings, especially

in many cardiovascular diseases. Several studies have suggested

increased RDW can be used as a marker of adverse clinical outcomes

such as heart failure, hypertension and coronary artery disease

3_{Several lines of evidences found that inflammatory status is}

significantly related to ineffective erythropoiesis, and it has been

suggested that inflammatory cytokines, such as interleukin (IL)-1 β,

2

progenitors to erythropoiesis, and inhibit red blood cell maturation and

inturn promote anisocytosis. Increased RDW may be due to an

underlying inflammatory state.

38_{Considering the above situation, we hypothesis that high blood}

pressure does damage to endothelia cells promoting the secretion of

inflammatory cytokines which supresses the erythropoiesis and inhibit

red cell maturation and anisocytosis. Therefore, as a sensitive index of

inflammatory status in this process, RDW could be a potential

predictor of hypertension in pre-hypertensive and normal individual.

37_{Based on these factors current study is aimed to use RDW as}

predictor of hypertension in normal individuals and pre-hypertensive

3

AIMS AND OBJECTIVES

To study the red cell distribution as a predictor of systemic

hypertension in medicine department in Rajiv Gandhi Government

hospital, Chennai

40_{To study the importance of determining red cell distribution}

width in predicting the onset of hypertension in pre-hypertensive

4

REVIEW OF LITERATURE RED CELL DISTRIBUTION WIDTH

3_{Red cell distribution width is a parameter of red blood cell which}

measures the variation in red cell size or volume.

35_{If RDW is elevated in complete blood count, it means that there}

is increased variation in size of red blood cell in peripheral blood

smear.RDW can be reported either as coefficient of variation (CV) that is

RDW CV or it can be expressed as standard deviation (SD) that is

RDW-SD.

RDW-CV(%)

It is calculated from standard deviation and MCV

The formula is :

RDW-CV (%) =1 SD of RBC volume /MCV * 100

Since RDW -CV is derived from MCV it is affected by the average

RBC size

RDW-SD(fl)

34_{This is the measurement of width of RBC in distribution}

histogram.

It is measured by calculating the width in femtolitre, at 20% height of

5

Elevated RDW gives clue about the presence of two different red

cell populations.

REFERENCE RANGE

32_{RDW-CV 11.6-14.6%}1

7

Increased RDW provide a clue for the diagnosis of nutritional

deficiency anaemia such as iron, folate, or vitamin B12 deficiency

anaemia

RDW becomes elevated before other red blood cell parameters.

RDW IN ANAEMIAS

30_{Normal RDW and low MCV is present in the following conditions:}

 Heterozygous thalassemia

 Haemoglobin E trait

 Anaemia of chronic disease

Increased RDW and low MCV is present in the following conditions

 Sickle cell-βthalassemia

 Iron deficiency

29_{Normal RDW and increased MCV is present in the following}

conditions:

 Chronic liver disease

 Aplastic anaemia

 Antivirals, alcohol , chemotherapy

Increased RDW and normal MCV is associated with the following

conditions:

 Early iron, vitamin B12, or folate deficiency

8  Sickle cell disease

 Chronic liver disease

31_{Elevated RDW and increased MCV is present in the following}

conditions:

 Immune haemolyticanaemia

 Cytotoxic chemotherapy

 Folate or vitamin B12 deficiency

 Chronic liver disease

Normal RDW and normal MCV is present in the following conditions:

 Anaemia of chronic disease

 Acute blood loss or hemolysis

10

5_{COLLECTION OF SAMPLES}

 Sample : venous blood, collected by venipuncture

 Tube : purple EDTA tube which contains EDTA potassium salt

11

HYPERTENSION

6_{Hypertension is among the most leading causes of global}

burden of disease. Approximately 7.6 million deaths (13–15% of the

total) and 92 million disability-adjusted life years worldwide were

attributable to high blood pressure in 20012_{. Hypertension increases by}

two times the risk of cardiovascular diseases, including coronary heart

disease (CHD), congestive heart failure (CHF), ischemic and

hemorrhagic stroke, renal failure, and peripheral arterial disease2_.

27_{Although antihypertensive therapy reduces the risks of cardiovascular}

and renal disease, large segments of the hypertensive population are

12 EPIDEMIOLOGY

29_{Blood pressure is prevalent in both developing and industrialised}

country.Tracking of blood pressure is very important to know the

prevalence of hypertension even from young age. Hypertension is more

common in men in early adulthood whereas the incidence is more in

women in age more than 60 years.

28_{Family history, dietary intake and lifestyle influence the onset of}

hypertension. Hypertension is more common in obese individuals and is

also associated with high sodium intake. Urine sodium to potassium ratio

is more determinant of hypertension than potassium alone.

7Alcohol consumption, psychological stress, sedentary lifestyle

contributes to hypertension. The degree of acculturation is influencing

13

occur in patients with a positive family history.

GENETIC CONSIDERATION

8_{Recent studies consider that genes coding for renin angiotensin}

aldosterone system contributes for hypertension. Genetic associations of

diabetes, obesity and insulin resistance also contributes for hypertension.

Other genes include ANP( atrial natriuretic peptide) gene, AT1 receptor

gene also contributes to hypertension.

PATHOGENESIS

26_{Hypertension is mainly determined by cardiac output and}

peripheral resistance. Cardiac output is determined by stroke volume and

heart rate. So factors influencing these factors contribute to the

14

27 Stroke volume is determined by contractility of myocardium and

this is dependent on ventricular mass. Peripheral resistance is dependent

on the vascular diameter and it is also affected by autonomic nervous

system.

INTRAVASCULAR VOLUME

8_{Sodium being a predominant extracellular action ,is the primary}

determinant of the extracellular fluid volume. When intake of NaCl

increases the capacity of the kidney to excrete the same, vascular volume

expands initially and cardiac output also increases. 27_{But since certain}

vascular beds retain the capacity to auto-regulate the blood flow they

help in maintaining the blood flow by increasing the peripheral resistance

15 AUTONOMIC NERVOUS SYSTEM

The autonomic nervous system plays an important role in

maintaining hypertension. The main mediators are adrenaline,

noradrenaline and dopamine.

9_{The receptors are alpha1, alpha 2 , beta 1 and beta 2 receptors. The}

mediators act on different receptors and act via positive and negative feed

back mechanisms to regulate blood pressure.

24_{Many reflexes alter blood pressure on minute basis.Arterial}

baroreflex is mediated stretch receptors in the carotid sinuses and the

aortic arch. The blood pressure increases as rate of firing of these

baroreceptors increases and as a result, sympathetic outflow decreases

and results in reduced arterial blood pressure and heart rate. This is the

major mechanism which results in rapid buffering of sudden fluctuations

of arterial blood pressure that may occur during change of posture and

change in behaviour or physiologic stress, and also changes in volume

of blood.

23_{As the activity ofbaroreceptors is continued its threshold is set at}

higher pressures. Patients with abnormal autonomic nervous function and

defective baroreflex function have labile arterial blood pressures with

difficult-to-control episodic spikes of blood pressure associated with

16

RENIN ANGIOTENSIN ALDOSTERONE

10_{The renin-angiotensin-aldosterone system helps in regulating blood}

pressure mainly via the angiotensin II which is a vasoconstrictor and

aldosterone which retains sodium. Renin is synthesized from its precursor

which is inactive precursor prorenin. Renin is synthesized in the

circulation from renal afferent renal arteriole.

25_{The three primary stimuli for renin secretion:}

 Reduced NaCl transport in the thick ascending limb of the loop

(distal )that is present near the afferent arteriole (macula densa).

 Reduced pressure or stretch in the renal afferent arteriole

(baroreceptor mechanism)

 Autonomic nervous system stimulation of renin-secreting cells via

18

20 BRAIN

22_{Hypertension is the leading cause of stroke in the world.}

Hypertension increases the risk of stroke. Hypertension also increases the

risk of dementia and cognitive impairment . Blood flow to brain is auto

regulated between mean arterial pressure between 50-150mm hg. Patient

with malignant hypertension is due to failure of these auto regulatory

mechanisms . 11This results in vasodilatation and hyper perfusion leading

to hypertensive encephalopathy . The symptoms are headache, altered

sensorium, projectile vomiting. If hypertensive encephalopathy is not

treated patient may go for seizures, coma and death within hours. So

patient must be treated efficiently.

Treatment of hypertension decreases the risk of both ischemic and

22 KIDNEY

12_{Kidney is the organ which can be both a target organ for end organ}

damage due to hypertension and also a cause for hypertension.

Mechanisms of kidney failure induced hypertension are decreased

excretion of sodium chloride , and increased secretion of RAAS and

increased sympathetic activity leading to secondary hypertension .

Hypertension can cause ESRD. 21Atherosclerotic leisions affect afferent

24 HEART

20_{Hypertension is the most important risk factor for developing}

cardiac problems. Hypertension leads to structural and functional

problems and changes of cardiac tissue. This can be in the form of left

ventricular hypertrophy, arrhythmias, coronary vascular atherosclerosis.

13_{Left ventricular hypertrophy can in-turn lead to other}

complications like stroke, congestive heart failure and sudden cardiac

arrest so preventing and controlling hypertension can lead to prevention

of complications associated with hypertension. Hypertension should be

therefore diagnosed at an early stage and properly treated so that all these

complications can be prevented.

19_{Hypertension can be in the form of systolic or diastolic}

dysfunction. Diastolic dysfunction is the earliest consequence of

hypertensive heart disease. If the patient is having elevated diastolic

blood pressure they are more prone for developing hypertensive cardiac

disease. The diastolic dysfunction can be accurately assessed by cardiac

25

27 PERIPHERAL ARTERIES

14_{Peripheral arteries are one of the major site of developing}

atherosclerosis and hypertension.

Patient with peripheral arterial disease is at increased risk for

28

29

30

BLOOD PRESSURE CLASSIFICATION

31

32 MANAGEMENT OF HYPERTENSION

15_{Hypertension can be managed either pharmacologically or along}

with exercise and diet. If individuals prone for hypertension are closely

monitored they can be given life style modifications and the onset of

hypertension can be delayed to a certain extent. So screening the general

population for the onset of hypertension is very important. So the

preventive measures of hypertension should begin with simple

measurement of hypertension.

1) LIFESTYLE MODIFICATIONS

2) PHARMACOLOGICAL THERAPY

 Beta blockers

 Aldosterone antagonist

 ACE inhibitors

 Calcium channel blockers

 Diuretics

 Direct vasodilators

 Alpha antagonist

LIFESTYLE MODIFICATIONS

16_{Lifestyle modifications can effectively prevent hypertension. This}

includes weight reduction, salt restricted diet, DASH type diet plan,The

above table shows the various life style modifications. DASH diet is the

33

This includes incorporating fresh fruits and vegetables in the diet and

reduction of saturated fatty acid content in food.

Physical activity plays an important role in controlling

hypertension.Patient should be advised to engage in healthy lifestyle by

promoting walking, jogging, and other cardio exercises.

Alcohol consumption should be reduced as it is a very important

risk factor for hypertension. Alcohol along with smoking increases the

risk of hypertension and other cardiovascular diseases.

34 PHARMACOLOGICAL THERAPY

17_{Once hypertension is diagnosed it should be adequately}

controlled using various drugs specifically to control hypertension. Drugs

helps not only in controlling hypertension but also in preventing the

cardiovascular and other complications of hypertension.

The various drugs mentioned above known as antihypertensive

medicines are the ones with different mechanism of action which act at

different levels to control hypertension.

These can be action at the level of blood vessel, kidney, and

40

42

MATERIALS AND METHODS

This study was conducted at the Institute of Internal Medicine,

Rajiv Gandhi Government General Hospital (RGGGH), Madras Medical

College, Chennai 600003.

ETHICAL COMMITTEE APPROVAL

Obtained

STUDY DURATION

This study was conducted over a period of six months.

STUDY POPULATION

Patients having hypertension and undergoing treatment in medical

ward and hypertensive op

SAMPLE SIZE

100

TYPE OF STUDY

Observational study

INCLUSION CRITERIA

1) Age > 25 and <60 years

43 EXCLUSION CRITERIA

1) Patients with anaemia

2) Patients with dyslipidemia

3) Patients with CKD, CAD, CVA

4) Patients with diabetes mellitus

5) Sepsis

44

DATA COLLECTION AND METHODS

Patients selected for observational study as per inclusion /

exclusion criteria are subjected to detailed history taking, clinical

examination and relevant investigations.

Routine blood investigations- complete blood count [TC/RBS

/Hb/RDW /platelet]

Patients aged between 25 and 60 years, diagnosed with essential

hypertension of one year or more were enrolled in the study. Patients with

haematological disorder, chronic liver disease, chronic kidney disease,

any systemic disease including rheumatologic disorders that could affect

blood count, chronic hepatobiliary disease, peripheral artery disease,

stroke, inflammatory bowel disease or diseases of terminal ileum

malignant disorder and diabetes mellitus type 2 were excluded from the

study.

The characteristics of the patients including age, gender, duration

of hypertension and other medical conditions were recorded on a

standardized data collection form. Blood samples were drawn and the

complete blood count was determined by Beckman Coulter’s

AutomatedHaematology Analyzer .

RDW was recorded and compared in cases (hypertensives),

pre-hypertensives, and normotensives. The normal RDW range was taken

45

Pre-hypertensives were selected based on systolic blood pressure

between 120-139 mm Hg and diastolic blood pressure between 80-89 mm

Hg.

Normotensives are those with blood pressure less than 120/80 mm

Hg.

All the data obtained were entered in the proforma (enclosed).

46

. OBSERVATIONS AND RESULTS

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 20-30 YEARS 31-40YEARS 41-50 YEARS ABOVE 50 YEARS 0% 19% 38% 78% 0% 56% 41% 10% 100% 25% 21% 13% Per ce n tage

Comparison of age group

NORMAL PREHYPERTENSIVE HYPERTENSIVE AGE_GROUP Total 20-30 YEARS 31-40YEARS 41-50 YEARS ABOVE 50 YEARS GROUP HYPERTENSIVE

Count 0 3 16 31 50

% within

AGE_GROUP 0.0% 18.8% 38.1% 77.5% 50.0%

PREHYPERTENSIVE

Count 0 9 17 4 30

% within

AGE_GROUP 0.0% 56.2% 40.5% 10.0% 30.0%

NORMAL

Count 2 4 9 5 20

% within

AGE_GROUP 100.0% 25.0% 21.4% 12.5% 20.0%

Total

Count 2 16 42 40 100

% within

47 CROSS TAB

SEX Total

FEMALE MALE

GROUP

HYPERTENSIVE

Count 22 28 50

% within

SEX 50.0% 50.0% 50.0%

PREHYPERTENSIVE

Count 14 16 30

% within

SEX 31.8% 28.6% 30.0%

NORMAL

Count 8 12 20

% within

SEX 18.2% 21.4% 20.0%

Total

Count 44 56 100

% within

SEX 100.0% 100.0% 100.0%

0% 20% 40% 60% 80% 100% FEMALE MALE 50% 50% 32% _29% 18% _21% Per ce n tage

Comparison of age group

NORMAL

PREHYPERTENSIVE

48 GROUP

50%

30%

20%

Group

HYPERTENSIVE

PREHYPERTENSIV E

GROUP Frequency Percent

Valid

Percent

Cumulative

Percent

Valid

HYPERTENSIVE 50 50.0 50.0 50.0

PREHYPERTENSIVE 30 30.0 30.0 80.0

NORMAL 20 20.0 20.0 100.0

49 Descriptives

N Mean Std.

Deviation

Std. Error 95% Confidence

Interval for Mean

Minimum Maximum

Lower Bound

Upper Bound

WBC

HYPERTENSIVE 50 6504.0000 1346.94818 190.48724 6121.2016 6886.7984 4400.00 9900.00

PREHYPERTENSIVE 30 6256.6667 1314.03126 239.90819 5765.9993 6747.3340 4400.00 8900.00

NORMAL 20 6215.0000 1353.85415 302.73099 5581.3768 6848.6232 4500.00 8900.00

Total 100 6372.0000 1331.67169 133.16717 6107.7674 6636.2326 4400.00 9900.00

HBgdl

HYPERTENSIVE 50 12.9200 1.12122 .15856 12.6014 13.2386 11.00 15.50

PREHYPERTENSIVE 30 13.1367 1.09654 .20020 12.7272 13.5461 11.50 15.00

NORMAL 20 13.9900 1.35798 .30365 13.3544 14.6256 11.50 15.60

Total 100 13.1990 1.22280 .12228 12.9564 13.4416 11.00 15.60

RDWflSD

HYPERTENSIVE 50 47.9000 3.47293 .49115 46.9130 48.8870 39.20 55.20

PREHYPERTENSIVE 28 45.5464 2.23664 .42269 44.6791 46.4137 40.20 48.80

NORMAL 20 40.0550 1.40018 .31309 39.3997 40.7103 38.50 44.50

Total 98 45.6265 4.11531 .41571 44.8015 46.4516 38.50 55.20

RBSmg

HYPERTENSIVE 50 127.4000 11.22861 1.58796 124.2089 130.5911 110.00 150.00

PREHYPERTENSIVE 30 128.9333 8.84710 1.61525 125.6298 132.2369 120.00 150.00

NORMAL 20 128.0000 9.51453 2.12751 123.5471 132.4529 110.00 150.00

50 6050

6100 6150 6200 6250 6300 6350 6400 6450 6500 6550

HYPERTENSIVE PREHYPERTENSIVE NORMAL 6504

6257

6215

Comparison of WBC in groups

12.20 12.40 12.60 12.80 13.00 13.20 13.40 13.60 13.80 14.00

HYPERTENSIVE PREHYPERTENSIVE NORMAL 12.92

13.14

13.99

51 Correlations

WBC HBgdl RDWflSD RBSmg GROUP

GROUP

Correlation

Coefficient

-.086 .284** _0.676** _{.078 1.000}

Sig.

(2-tailed)

.397 .004 .000 .439 .

N 100 100 100 100 100

**. Correlation is significant at the 0.01 level (2-tailed).

36.00 38.00 40.00 42.00 44.00 46.00 48.00

HYPERTENSIVE PREHYPERTENSIVE NORMAL 47.90

45.55

40.06

52

GROUP * RDW_GROUP Crosstabulation

RDW_GROUP Total NORMAL (36-48) ABNORMAL (>48) GROUP HYPERTENSIVE

Count 11 39 50

% within

RDW_GROUP 24.4% 70.9% 50.0%

PRE

HYPERTENSIVE

Count 14 16 30

% within

RDW_GROUP 31.1% 29.1% 30.0%

NORMAL

Count 20 0 20

% within

RDW_GROUP 44.4% 0.0% 20.0%

Total

Count 45 55 87

% within

RDW_GROUP 100.0% 100.0%

100.0 % Pearson Chi-Square=35.165** P<0.001

53 Descriptives

N Mean

Std.

Deviation

Std.

Error

95% Confidence Interval

for Mean

Minimum Maximum Lower

Bound

Upper

Bound

RDWflSD

HYPERTENSIVE 50 47.9000 3.47293 .49115 46.9130 48.8870 39.20 55.20

PREHYPERTENSIVE 28 45.5464 2.23664 .42269 44.6791 46.4137 40.20 48.80

NORMAL 20 40.0550 1.40018 .31309 39.3997 40.7103 38.50 44.50

54

GROUP * RDW_GROUP Crosstabulation

RDW_GROUP

Total NORMAL(36-48) ABNORMAL(>48)

GROUP

HYPERTENSIVE Count 11 39 50

% within RDW_GROUP 24.4% 70.9% 50.0%

PREHYPERTENSIVE Count 14 16 30

% within RDW_GROUP 31.1% 29.1% 30.0%

NORMAL Count 20 0 20

% within RDW_GROUP 44.4% 0.0% 20.0%

Total

Count 45 55 87

55

MALE - GROUP * RDW_GROUP Crosstabulation

RDW_GROUP Total

NORMAL(36-48) ABNORMAL(>48)

GROUP

HYPERTENSIVE

Count 7 21 28

% within RDW_GROUP 30.4% 63.6% 50.0%

PREHYPERTENSIVE

Count 4 12 16

% within RDW_GROUP 17.4% 36.4% 28.6%

NORMAL

Count 12 0 12

% within RDW_GROUP 52.2% 0.0% 21.4%

Total

Count 23 33 56

56 Pearson Chi-Square=21.913** P<0.001

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

NORMAL(36-48) ABNORMAL(>48) 30%

64% 17%

36% 52%

0%

NORMAL

PREHYPERTENSIVE

57

FEMALE –GROUP * RDW_GROUP Crosstabulation

RDW_GROUP Total NORMAL (36-48) ABNORMA L(>48) GROUP Hypertensive

Count 4 18 22

% within

RDW_GROUP 18.2% 81.8% 50.0%

Prehypertensive

Count 10 4 14

% within

RDW_GROUP 45.5% 18.2% 31.8%

Normal

Count 8 0 8

% within

RDW_GROUP 36.4% 0.0% 18.2%

Total

Count 22 22 44

% within

RDW_GROUP 100.0% 100.0% 100.0%

Pearson Chi-Square=19.481** P<0.001

58

smokers GROUP * RDW_GROUP Crosstabulation

RDW_GROUP Total NORMAL (36-48) ABNORMAL (>48) GROUP HYPERTENSIVE

Count 5 13 18

% within

RDW_GROUP 38.5% 56.5% 50.0%

PREHYPERTENSIVE

Count 3 10 13

% within

RDW_GROUP 23.1% 43.5% 36.1%

NORMAL

Count 5 0 5

% within

RDW_GROUP 38.5% 0.0% 13.9%

Total

Count 13 23 36

% within

RDW_GROUP 100.0% 100.0% 100.0%

Pearson Chi-Square=10.345** P=0.006

59

Alcoholic GROUP * RDW_GROUP Crosstabulation

RDW_GROUP Total NORMAL (36-48) ABNORMAL (>48) GROUP HYPERTENSIVE

Count 5 17 22

% within

RDW_GROUP 33.3% 68.0% 55.0%

PREHYPERTENSIVE

Count 3 8 11

% within

RDW_GROUP 20.0% 32.0% 27.5%

NORMAL

Count 7 0 7

% within

RDW_GROUP 46.7% 0.0% 17.5%

Total

Count 15 25 40

% within

RDW_GROUP 100.0% 100.0% 100.0%

Pearson Chi-Square=14.206** P=0.001

60

AGE_GROUP * RDW_GROUP hypertensive Crosstabulation

RDW_GROUP Total

NORMAL(36-48) ABNORMAL(>48) AGE_GR OUP 31-40YEA RS

Count 1 2 3

% within

RDW_GROUP 9.1% 5.1% 6.0%

41-50

YEARS

Count 7 9 16

% within

RDW_GROUP 63.6% 23.1% 32.0%

ABOVE

50

YEARS

Count 3 28 31

% within

RDW_GROUP 27.3% 71.8% 62.0%

Total

Count 11 39 50

% within

RDW_GROUP 100.0% 100.0% 100.0%

Pearson Chi-Square=7.379* P=0.025

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% NORMAL(36-48) ABNORMAL(>48) 9% _5% 64% 23% 27% 72%

ABOVE 50 YEARS

41-50 YEARS

61

AGE_GROUP * RDW_GROUP Crosstabulation

RDW_GROUP Total

NORMAL (36-48) ABNORMAL (>48) AGE_GROUP 31-40YEARS

Count 1 1 2

% within

RDW_GROUP 14.3% 4.8% 7.1%

41-50

YEARS

Count 4 3 7

% within

RDW_GROUP 57.1% 14.3% 25.0%

ABOVE 50

YEARS

Count 2 17 19

% within

RDW_GROUP 28.6% 81.0% 67.9%

Total

Count%

within

RDW_GROUP

7 21 28

100.0% 100.0% 100.0%

Pearson Chi-Square=6.647* P=0.036

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% NORMAL(36-48) ABNORMAL(>48) 14% 5% 57% 14% 29%

81% ABOVE 50 YEARS 41-50 YEARS

62

AGE_GROUP * RDW_GROUP Crosstabulation

RDW_GROUP Total NORMAL (36-48) ABNORMAL (>48) AGE_GROUP 31-40YEARS

Count 3 2 5

% within

RDW_GROUP 30.0% 50.0% 35.7%

41-50

YEARS

Count 7 0 7

% within

RDW_GROUP 70.0% 0.0% 50.0%

ABOVE 50

YEARS

Count 0 2 2

% within

RDW_GROUP 0.0% 50.0% 14.3%

Total

Count 10 4 14

% within

RDW_GROUP 100.0% 100.0% 100.0%

Pearson Chi-Square=8.120* p=0.017

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% NORMAL(36-48) ABNORMAL(>48) 30% 50% 70% 0% 0% 50%

ABOVE 50 YEARS

41-50 YEARS

63

AGE_GROUP * RDW_GROUP Crosstabulation{ RDW AND HYPERTENSION} FEMALES

RDW_GROUP

Total NORMAL

(36-48)

ABNORMAL

(>48)

AGE_GROUP

31-40YEARS

Count 0 1 1

% within

RDW_GROUP 0.0% 5.6% 4.5%

41-50

YEARS

Count 3 6 9

% within

RDW_GROUP 75.0% 33.3% 40.9%

ABOVE 50

YEARS

Count 1 11 12

% within

RDW_GROUP 25.0% 61.1% 54.5%

Total

Count

% within

RDW_GROUP

4 18 22

100.0% 100.0% 100.0%

64

PREHYPERTENSIVE MALES

RDW_GROUP

Total NORMAL

(36-48)

ABNORMAL

(>48)

AGE_GROUP

31-40YEARS

Count 2 2 4

% within

RDW_GROUP 50.0% 16.7% 25.0%

41-50

YEARS

Count 2 8 10

% within

RDW_GROUP 50.0% 66.7% 62.5%

ABOVE 50

YEARS

Count 0 2 2

% within

RDW_GROUP 0.0% 16.7% 12.5%

Total

Count 4 12 16

% within

RDW_GROUP 100.0% 100.0% 100.0%

65

AGE_GROUP * RDW_ pre hypertensive GROUP Crosstabulation

RDW_GROUP Total

NORMAL

(36-48)

ABNORMAL

(>48)

AGE_GROUP

31-40YEARS

Count 5 4 9

% within

RDW_GROUP 35.7% 25.0% 30.0%

41-50

YEARS

Count 9 8 17

% within

RDW_GROUP 64.3% 50.0% 56.7%

ABOVE 50

YEARS

Count 0 4 4

% within

RDW_GROUP 0.0% 25.0% 13.3%

Total

Count 14 16 30

% within

RDW_GROUP 100.0% 100.0% 100.0%

66

NORMOTENSIVE MALES

RDW_GROU

P

Total NORMAL

(36-48)

AGE_GROUP

20-30 YEARS

Count 2 2

% within

RDW_GROUP 16.7% 16.7%

31-40YEARS

Count 2 2

% within

RDW_GROUP 16.7% 16.7%

41-50 YEARS

Count 4 4

% within

RDW_GROUP 33.3% 33.3%

ABOVE 50

YEARS

Count 4 4

% within

RDW_GROUP 33.3% 33.3%

Total

Count 12 12

% within

67

NORMOTENSIVE FEMALES

RDW_

GROUP

Total

NORMAL

(36-48)

AGE_

GROUP

31-40YEARS

Count 2 2

% within

RDW_GROUP 25.0% 25.0%

41-50 YEARS

Count 5 5

% within

RDW_GROUP 62.5% 62.5%

ABOVE 50

YEARS

Count 1 1

% within

RDW_GROUP 12.5% 12.5%

Total

Count 8 8

% within

68

AGE_GROUP * RDW_GROUP Crosstabulation

RDW_GROU

P

Total

NORMAL

(36-48)

AGE_GROU

P

20-30 YEARS

Count 2 2

% within

RDW_GROUP 16.7% 16.7%

31-40YEARS

Count 2 2

% within

RDW_GROUP 16.7% 16.7%

41-50 YEARS

Count 4 4

% within

RDW_GROUP 33.3% 33.3%

ABOVE 50

YEARS

Count 4 4

% within

RDW_GROUP 33.3% 33.3%

Total

Count 12 12

% within

69

RESULTS

AGE DISTRIBUTION

 The number of people who are hypertensive are more in the age group >50yrs by about 77.5%

 In the age group between 40-50 yrs the number of pre-hypertensives are more by 40.5%

 In the age group between 30-40 yrs also, number of pre- hypertensives are more

SEX DISTRIBUTION

 The distribution of hypertension is more in both males and females in the age group more than 50 yrs

 Pre-hypertensives are equal in both males and females in the age group 30-50 years

RDW AND HYPERTENSION

 RDW is more in the hypertensive group i.e.70.9% of the individuals enrolled for the study had increased RDW

 RDW is in borderline elevation in pre-hypertensive group .i.e. 29.9% has borderline elevation of RDW.

70

RDW AND HYPERTENSION IN MALES

 RDW is more in hypertensive males

 63.6% of hypertensive males enrolled for the study had increased RDW when compared to the remaining hypertensive individuals

 Pearson Chi-Square=21.913** P<0.001

RDW AND PRE-HYPERTENSION

 RDW is more in pre-hypertensive individuals with hypertension

 That is 36.4% of pre-hypertensive males had increased RDW as compared to others

 Pearson Chi-Square=21.913** P<0.001

RDW AND HYPERTENSION IN FEMALES

 RDW was increased in females with hypertension 81.8% of females with hypertension who were enrolled in to study had increased RDW

 Pearson Chi-Square=19.481** P<0.001

RDW AND PRE-HYPERTENSION IN FEMALES

 RDW was normal in majority of the pre-hypertensive individuals who were enrolled in to the study 18.2% of the pre-hypertensive females had increased RDW

71

 But the overall significance was greater when the study was considered as a whole

 Thus RDW was found to be significantly higher in hypertensive and pre- hypertensive individuals

RDW AND HYPERTENSIVES WHO ARE ALCOHOLICS

 68% of the alcoholics who are hypertensives who were enrolled in to the study was found to have increased RDW

 Pearson Chi-Square=14.206** P=0.001

RDW AND PRE-HYPERTENSIVES WHO ARE ALCOHOLICS

 32%ofalcoholics who were pre-hypertensives who were enrolled in to thestudy was found to have increased RDW

 Pearson Chi-Square=14.206** P=0.001

RDW AND HYPERTENSIVES WHO ARE SMOKERS

 56.5%who are smokers and hypertensives had increased RDW who were enrolled into the study.

72

RDWAND PRE-HYPERTENSIVESWHOARE SMOKERS

 43.5% of pre-hypertensive individuals who are smokers had increased RDW who were enrolled in to the study

73

DISCUSSION

In this study, 50 hypertensive individuals, 30 pre-hypertensive

individuals and 20 controls were analysed in RGGGH hypertensive and

medical out patient department foraperiodof6 months.

These cases and controls were analysed and they were examined in

detail and were selected based on inclusion and exclusion criteria.

They were assigned to 3 groups. Patients with hypertension were

assigned as cases and those with blood pressure between 120/80 to

139/89 and with a family history of hypertension were assigned in

pre-hypertensive group. And a set of 20 normal individuals were included as

controls.

They were advised to do complete blood count, RBS, Hb, and were

asked about history of smoking and hypertension.

The results were analysed and comparative study was done. The

results obtained were analysed using various statistical tests like

chi-square, ANOVA and p value were obtained.

In a study conducted by Tanindi A, Topal FE,TopalF,Celik B

aimed to search to know if RDW values are different in the healthy

population and the patients with pre-hypertension and hypertension who

are otherwise healthy, based on the widely accepted theory of RDW as a

74

In this study, One-hundred and twenty-eight patients with

hypertension, 74 patients with pre-hypertension and 36 healthy controls

were enrolled in the study. And these cases and controls were analysed

for complete blood count, random blood sugar and were analysed after

adjusting for age, hb, cbc and RDW, SD whose normal value is between

36-46 femtolitre (FL),was analysed and it was found out in this study

that RDW was found to be higher in hypertensive and pre-hypertensive

75

CONCLUSION

After this study we have come to the conclusion that in patients with hypertension and those who are prone for hypertension .i.e. pre- hypertensives had significantly elevated RDW compared to normal controls. Thus this study can be used for giving primordial prevention in those patients who are in the pre-hypertensive stage and life-style modifications can be advised.

RDW being a simple parameter which is easily available in a simple routine CBC can thus be used as a novel predictor of hypertension.

76

LIMITATIONS

 One of the limitations is sample size which is less and this study

should be tested in large number of patients.

77

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88

PROFOMA

RED CELL DISTRIBUTION WIDTH AS A PREDICTOR OF SYSTEMIC

HYPERTENSION

NAME

AGE SEX

IP NUMBER ADDRESS

OCCUPATION

SOCIOECONOMIC STATUS

PRESENTING COMPLAINTS

 HEADACHE

 BLURRING OF VISION

 CHEST PAIN

 PALPITATION

 GIDDINESS

89

PAST HISTORY

 HYPERTENSION

 TYPE 2 DIABETES MELLITUS

 PULMONARY TB

 THYROID DISORDERS

 CKD

 CVA

 ISHEMIC HEART DISEASE

FAMILY HISTORY

TREATMENT HISTORY

GENERAL EXAMINATION  CONSCIOUS

 ORIENTED

 AFEBRILE

 ICTERUS

 CLUBBING

90

 PEDAL EDEMA

 LYMPHADENOPATHY

 JVP

VITAL SIGNS  PULSE RATE

 BLOOD PRESSURE

 RESPIRATORY RATE

SYSTEMIC EXAMINATION

RS: CVS: P/A:

CNS:

INVESTIGATIONS

TOTAL COUNT HB

RDW RBC

PLATELET MCV

95

INFORMATION SHEET

We are conducting a study on “RED CELL DISTRIBUTION WIDTH AS

A PREDICTOR OF SYSTEMIC HYPERTENSION” among patients attending Rajiv Gandhi Government General Hospital, Chennai and for that your co-operation to undergo relevant investigations as per need may be valuable to us. The purpose of this study is to find the occurrence of systemic hypertension in prehypertensive and normal individuals with increased red cell distribution width..

We are selecting certain cases and if you are found eligible, we would like to perform extra tests and you will be subjected to a routine complete blood count examination which in any way do not affect your final report or management.

The privacy of the patients in the research will be maintained throughout the study. In the event of any publication or presentation resulting from the research, no personally identifiable information will be shared.

Taking part in this study is voluntary. You are free to decide whether to participate in this study or to withdraw at any time; your decision will not result in any loss of benefits to which you are otherwise entitled.

The results of the special study may be intimated to you at the end of the study period or during the study if anything is found abnormal which may aid in the management or treatment.

Signature of Investigator Signature / left thumb impression of Participant

96

PATIENT CONSENT FORM

Patient may check (√) these circles

a) I confirm that I have understood the purpose of procedure for the above study. I have the opportunity to ask question and all my questions and doubts have been answered to my complete

satisfaction. o ❏

b) I understand that my participation in the study is voluntary and that I am free to withdraw at any time without giving reason, without

my legal rights being affected. o ❏

c) I understand that sponsor of the clinical study, others working on the sponsor’s behalf, the ethical committee and the regulatory authorities will not need my permission to look at my health records, both in respect of current study and any further research

o ❏

Study Detail : “RED CELL DISTRIBUTION WIDTH AS A

PREDICTOR OF SYSTEMIC HYPERTENSION.”

Study Centre : Rajiv Gandhi Government General Hospital, Chennai.

Patient’s Name :

Patient’s Age :

97

that may be conducted in relation to it, even if I withdraw from the study I agree to this access. However, I understand that my identity will not be revealed in any information released to third parties or published, unless as required under the law. I agree not to restrict the use of any data or results that arise from this study.

d) I agree to take part in the above study and to comply with the instructions given during the study and faithfully cooperate with the study team and to immediately inform the study staff if I suffer from any deterioration in my health or well being or any

unexpected or unusual symptoms. o ❏

e) I hereby consent to participate in this study. o ❏

f) I hereby give permission to undergo detailed clinical examination

and relevant investigations as required. o ❏

Signature/thumb impression Patient’s Name and Address:

Signature of Investigator

Study Investigator’s Name: