Neutrophil count and infarct size in patients with acute myocardial infarction

Predictive value of elevated neutrophil-lymphocyte ratio for left ventricular systolic dysfunction in patients with non ST-elevated acute coronary syndrome

Objective:

We aimed to study the predictive value of the neutrophil-lymphocyte ratio (NLR) for left ventricular systolic dysfunction (LVSD) in patients with non ST-elevated acute coronary syndrome (NST-ACS).

Methods:

A total of 405 patients (mean age 62 years and 75% male) with NST-ACS were included in the study. The study population was divided into tertiles based on admission NLR values. The low, medium and high tertiles defined as NLR≤1.81 (n=135), 1.81<NLR≤3.2 (n=135) and NLR>3.2 (n=135), respectively.

Results:

The patients in the high NLR group were older (p<0.001), have higher rate of diabetes mellitus (p=0.028) and non-ST elevated myocardial infarction (NSTEMI) (p<0.001) and have lower left ventricular ejection fraction (LVEF) (p<0.001). Baseline WBC (p=0.02) and neutrophil (p<0.001) levels and NLR (p<0.001) were significantly higher, baseline hemoglobin (p=0.044), hematocrit (p=0.019) and lymphocyte (p<0.001) levels were significantly lower in the high NLR group. NLR was negatively correlated with LVEF in correlation analysis. An NLR >3.2 and age ≥70 were found to be an independent predictor of systolic dysfunction in multivariate analyses.

Conclusion:

An NLR >3.2 is a useful predictor for LVSD in patients with NST-ACS. The practice of using an NLR count on admission may be useful for identifying high-risk patients and their associated treatment methods.

The efficacy of tonsillectomy in chronic tonsillitis patients as demonstrated by the neutrophil-to-lymphocyte ratio

OBJECTIVES

Adenoidectomy and tonsillectomy are the oldest surgical procedures. The neutrophil-to-lymphocyte ratio is an inflammatory marker. This study aimed to investigate neutrophil-to-lymphocyte ratios in chronic tonsillitis patients and to determine whether this ratio reflects the pre- and post-operative inflammatory status in these patients.

METHODS

Patients and healthy individuals were assigned to four groups: the adenoid hypertrophy, adenotonsillar hypertrophy, chronic tonsillitis and control groups. The neutrophil-to-lymphocyte ratio was calculated for each patient before surgery and one month post-surgery. Pre- and post-operative white blood cell, neutrophil and lymphocyte counts and neutrophil-to-lymphocyte ratios were compared both within and between groups.

RESULTS

Pre- and post-operative neutrophil-to-lymphocyte ratios were significantly higher in the chronic tonsillitis group than in the adenoid hypertrophy and adenotonsillar hypertrophy groups (p < 0.01 and p < 0.05, respectively). In the chronic tonsillitis group, post-operative neutrophil-to-lymphocyte ratios were significantly lower than pre-operative ratios (p = 0.045). The pre-operative neutrophil-to-lymphocyte ratio was significantly higher in the chronic tonsillitis group than in the adenoid hypertrophy, adenotonsillar hypertrophy and control groups (p = 0.000). In contrast, there was no significant difference in post-operative neutrophil-to-lymphocyte ratios among all groups (p = 0.584).

CONCLUSION

The neutrophil-to-lymphocyte ratio measurement can be used in chronic tonsillitis patients as an effective auxiliary method for determining the necessity and timing of tonsillectomy and post-operative follow up, thereby helping prevent complications due to delayed or inadequate treatment.

Does neutrophil-to-lymphocyte ratio predict active ulcerative colitis?

BACKGROUND

Inflammatory markers have been studied in ulcerative colitis (UC) for diagnosis, disease activity, and prediction of relapse. Blood neutrophil-to-lymphocyte (N/L) ratio has been used to determine outcomes of some malignancies and coronary artery disease. Blood N/L ratio is a simple sign of clinical inflammation. In this study, we examined N/L ratio in recurrent patients suffering from UC.

METHODS

The aim of the present study was to analyze N/L ratios in serum samples of UC patients in remission and active phases. Patients' age, extend of the disease, disease duration, disease activity, drug, and other medical history were all noted for patients. C-reactive protein, erythrocyte sedimentation rate, and complete blood count were determined for patients.

RESULTS

Forty-nine UC patients were admitted into the present study. The blood N/L ratios were significantly increased in active phase compared with inactive UC patients (p < 0.05). The cut-off value for N/L ratio for the detection of active UC patients was calculated as ≥ 2.3 using receiver operating characteristic analysis [sensitivity: 61.2 %, specificity: 66.7 %, AUC: 0.650 (0.540-0.760), p = 0.01].

CONCLUSIONS

Present study shows that in patients with UC, the blood N/L ratio is associated with active disease. N/L ratio may be used as an activity parameter in UC.

Relationship between neutrophil-to-lymphocyte ratio and electrocardiographic ischemia grade in STEMI

Background

Neutrophil-to-lymphocyte ratio (NLR) has been found to be a good predictor of future adverse cardiovascular outcomes in patients with ST-segment elevation myocardial infarction (STEMI). Changes in the QRS terminal portion have also been associated with adverse outcomes following STEMI.

Objective

To investigate the relationship between ECG ischemia grade and NLR in patients presenting with STEMI, in order to determine additional conventional risk factors for early risk stratification.

Methods

Patients with STEMI were investigated. The grade of ischemia was analyzed from the ECG performed on admission. White blood cells and subtypes were measured as part of the automated complete blood count (CBC) analysis. Patients were classified into two groups according to the ischemia grade presented on the admission ECG, as grade 2 ischemia (G2I) and grade 3 ischemia (G3I).

Results

Patients with G3I had significantly lower mean left ventricular ejection fraction than those in G2I (44.58 ± 7.23 vs. 48.44 ± 7.61, p = 0.001). As expected, in-hospital mortality rate increased proportionally with the increase in ischemia grade (p = 0.036). There were significant differences in percentage of lymphocytes (p = 0.010) and percentage of neutrophils (p = 0.004), and therefore, NLR was significantly different between G2I and G3I patients (p < 0.001). Multivariate logistic regression analysis revealed that only NLR was the independent variable with a significant effect on ECG ischemia grade (odds ratio = 1.254, 95% confidence interval 1.120–1.403, p < 0.001).

Conclusion

We found an association between G3I and elevated NLR in patients with STEMI. We believe that such an association might provide an additional prognostic value for risk stratification in patients with STEMI when combined with standardized risk scores.

Neutrophil–Lymphocyte Ratio and Platelet–Lymphocyte Ratio Combination Can Predict Prognosis in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

We assessed the effect of combination of neutrophil–lymphocyte ratio (NLR) and platelet–lymphocyte ratio (PLR) in predicting in-hospital and long-term mortality in patients (n = 2518) undergoing primary percutaneous coronary intervention (pPCI). Cutoff values for NLR and PLR were calculated with receiver–operating characteristic (ROC) curves. If both PLR and NLR were above the threshold, patients were classified as “high risk.” If either PLR or NLR was above the threshold individually, patients were classified as “intermediate risk.” High-risk (n = 693) and intermediate-risk (n = 545) groups had higher in-hospital and long-term mortality (7.2 4% vs 0.7%, P < .001; 14.1, 9.5% vs 4.5%, P < .001, respectively). Classifying patients into intermediate-risk group (hazards ratio [HR]: 1.492, 95% confidence interval [CI]: 1.022-2.178, P = .038) and high-risk group (HR: 1.845, 95% CI: 1.313-2.594, P < .001) was an independent predictor of in-hospital and long-term mortality. The combination of PLR and NLR can be useful for the prediction of in-hospital and long-term mortality in patients undergoing pPCI.

Relationship Between Hematologic Indices and Global Registry of Acute Coronary Events Risk Score in Patients With ST-Segment Elevation Myocardial Infarction

The aim of this study was to evaluate the relationship between hematologic indices and the Global Registry of Acute Coronary Events (GRACE) score in patients with ST-segment elevation myocardial infarction (STEMI). A total of 800 patients who consecutively and retrospectively presented with STEMI within 12 hours of symptom onset. After accounting for exclusion criteria, a total of 379 patients remained in the study. We enrolled 379 patients with STEMI (mean age 61.7 ± 13.6 years; men 73%). Neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), red cell distribution width (RDW), and monocyte count were associated with increased worse GRACE risk score (P = .008, P = .012, P = .005, P = .022, respectively). In multivariate linear regression analysis, NLR, PLR, RDW, and monocyte count were found to be independent predictors of GRACE risk score. We demonstrate for the first time that PLR, RDW, and monocyte were associated with the GRACE score in patients with STEMI.

White blood cell counts, leukocyte ratios, and eosinophils as inflammatory markers in patients with coronary artery disease

Inflammation is a key feature of atherosclerosis and its clinical manifestations. The leukocyte count has emerged as a marker of inflammation that is widely available in clinical practice. Since inflammation plays a key role in atherosclerosis and its end results, discovering new biomarkers of inflammation becomes important in order to help diagnostic accuracy and provide prognostic information about coronary cardiac disease. In acute coronary syndromes and percutaneous coronary intervention, elevated levels of almost all subtypes of white blood cell counts, including eosinophils, monocytes, neutrophils, and lymphocytes, and neutrophil-lymphocyte ratio and eosinophil-leukocyte ratio constitute independent predictors of adverse outcomes. Eosinophil count and eosinophil-leukocyte ratio, in particular, emerge as novel biomarkers for risk stratification in patients with coronary artery disease. Since the presence of eosinophils denotes hypersensitivity inflammation and hypersensitivity associated with Kounis syndrome, this reality is essential for elucidating the etiology of inflammation in order to consider predictive and preventive measures and to apply the appropriate therapeutic methods.

Calgranulins may contribute vascular protection in atherogenesis

S100A8, S100A9 and S100A12 are considered proinflammatory mediators of atherosclerosis. Known as calgranulins, they are major components of neutrophils and are upregulated in macrophages and foam cells. They influence leukocyte recruitment, and may propagate inflammation by binding TLR4 and/or receptor for advanced glycation endproducts (RAGE). However, the receptors for calgranulins remain an enigma; we have no evidence for TLR4 or RAGE activation by S100A8 or S100A12. Moreover, gene regulation studies suggest antiinflammatory functions for S100A8 and emerging reports indicate pleiotropic roles. Unlike S100A9, S100A8 effectively scavenges oxidants generated by the myeloperoxidase system in vivo, forming novel thiol modifications. S100A8 is also readily S-nitrosylated, stabilizing nitric oxide and transporting it to hemoglobin. S100A8-SNO reduces leukocyte transmigration in the vasculature. S-glutathionylation of S100A9 modifies its effects on leukocyte adhesion. Both S100A8 forms inhibit mast cell activation, at least partially by scavenging reactive oxygen species required for signaling. Conversely, S100A12 activates and sequesters mast cells. However S100A12 suppresses proinflammatory cytokine induction by SAA-activated monocytes and macrophages, and inhibits matrix metalloprotease activity. We propose that the abundance and types of cells expressing calgranulins in particular microenvironments, their relative concentrations and post-translational modifications may have distinct functional outcomes, including those that are protective, at different stages of atherogenesis.  

White Blood Cell Subtypes and Neutrophil-Lymphocyte Ratio in Prediction of Coronary Thrombus Formation in Non-ST-Segment Elevated Acute Coronary Syndrome

Leukocytes are reported as crucial not only for plaque activation but also in thrombus formation in acute coronary syndromes (ACSs). Among the markers of inflammation, in coronary artery disease neutrophil-lymphocyte ratio (NLR) has been reported to have the greatest predictive power of poor outcomes. Our aim was to evaluate the association of NLR with coronary thrombus in patients with non-ST-segment elevated ACSs (NST-ACSs). A total of 251 patients were hospitalized with a diagnosis of NST-ACS including non-ST-segment elevated myocardial infarction and unstable angina pectoris. Coronary angiographies were performed. In 167 patients, coronary thrombus was detected. Between the patient groups with and without coronary thrombus, neutrophil count, platelet count, and NLR are significantly increased, and lymphocyte count is significantly decreased in the group with coronary thrombus as compared to patient group without coronary thrombus. Leukocyte count and NLR may give an indication about the presence of coronary thrombus. In NST-ACS, blood parameters may give valuable information about the status of the coronary arteries.

Blood neutrophil-to-lymphocyte ratio independently predicts survival in patients with liver cirrhosis

OBJECTIVES

Neutrophil-to-lymphocyte ratio (NLR) is a novel inflammation index that has been shown to independently predict poor clinical outcomes. We aimed to evaluate the role of NLR in the prediction of long-term mortality in patients with stable liver cirrhosis.

MATERIALS AND METHODS

This is a retrospective observational cohort study in which 145 stable cirrhotic patients without infection, hepatocellular carcinoma, and ongoing steroid therapy were enrolled between January 2009 and December 2011. The primary end point was survival during follow-up. NLR along with Child-Turcotte-Pugh (CTP), Model for End-Stage Liver Disease (MELD) scores, and Charlson comorbidity index were assessed for the prediction of mortality.

RESULTS

There were 86 men and 59 women, mean age 58.9±13.4 years. The etiologies of liver cirrhosis included viral hepatitis (n=73), cryptogenic (50), alcoholic (12), and other (10). The mean follow-up duration was 27.8±6.8 months, during which 40 patients died. The mean NLRs were 2.08±0.99 and 4.39±3.0 in surviving and nonsurviving patients, respectively (P<0.001). Kaplan-Meier survival analysis was carried out according to the median NLR above and below 2.72. Patients with NLR of at least 2.72 had a significantly lower survival (log rank, P<0.001). NLR was found to be an independent predictor of mortality in all Cox Regression models (odds ratio 1.2; 95% confidence interval 1.2-1.3; P<0.001). Receiver operating characteristic analysis showed that cut-off values of 4.22, 3.07, and 2.96 for NLR predicted 12, 24, and 36-month mortality, respectively (AUC: 0.806, P=0.0029; 0.841, P<0.0001 and 0.783, P<0.0001, respectively).

CONCLUSION

NLR is a predictor of mortality independent of CTP and MELD scores in patients with liver cirrhosis. NLR could predict mortality in the subgroup of patients with low MELD scores as well.

The neutrophil to lymphocyte ratio was associated with impaired myocardial perfusion and long term adverse outcome in patients with ST-elevated myocardial infarction undergoing primary coronary intervention

OBJECTIVES

In the present study we aimed to reveal any probable correlation between neutrophil-to-lymphocyte ratio (N/L ratio) and the occurrence of no-reflow, along with assessment of the prognostic value of N/L ratio in patients with ST-segment elevation myocardial infarction (STEMI).

BACKGROUND

The N/L ratio stands practically for the balance between neutrophil and lymphocyte counts in the body, which can also be utilized as an index for systemic inflammatory status.

METHODS

In our study, we included 204 consecutive patients suffering from STEMI who underwent primary percutaneous coronary intervention (PCI). Patients with STEMI were assigned into distinct tertiles based on their N/L ratios on admission. No-reflow encountered following PCI was evaluated through both angiography [Thrombolysis in Myocardial Infarction (TIMI) flow and myocardial blush grade (MBG)] and electrocardiography (as ST-segment resolution).

RESULTS

Patients featured with no ST-resolution were documented to have displayed significantly higher N/L ratio on admission compared to those with intermediate or complete ST-segment resolution. The number of the patients characterized with no-reflow, evident both angiographically (TIMI flow ≤ 2 or TIMI flow 3 with final myocardial bush grade ≤ 2 after PCI) and electrocardiographically (ST-resolution <30%), was encountered to depict increments throughout successive N/L ratio tertiles. Moreover, the same also held true for three-year mortality rates across the tertile groups (9% vs. 15% vs. 35%, p < 0.01). Multivariable logistic regression analysis disclosed that N/L ratio on admission stood for a significant indicator for long-term mortality in patients with no-reflow phenomenon detected with MBG. Elevated N/L ratio on admission was also found to be a significant indicator for three-year mortality and major adverse cardiac events.

CONCLUSIONS

In patients with STEMI who underwent primary PCI, elevated N/L ratios on admission were revealed to be correlated with both no-reflow phenomenon and long-term prognosis.

Predictive value of elevated neutrophil to lymphocyte ratio in patients undergoing primary angioplasty for ST-segment elevation myocardial infarction

OBJECTIVES

The neutrophil to lymphocyte ratio (NLR) has been investigated as a new predictor for cardiovascular risk. Admission NLR would be predictive of adverse outcomes after primary angioplasty for ST-segment elevation myocardial infarction (STEMI).

METHODS

A total of 2410 patients with STEMI undergoing primary angioplasty were retrospectively enrolled. The study population was divided into tertiles based on the NLR values. A high NLR (n = 803) was defined as a value in the third tertile (>6.97), and a low NLR (n = 1607) was defined as a value in the lower 2 tertiles (≤6.97).

RESULTS

High NLR group had higher incidence of inhospital and long-term cardiovascular mortality (5% vs 1.4%, P < .001; 7% vs 4.8%, P = .02, respectively). High NLR (>6.97) was found as an independent predictor of inhospital cardiovascular mortality (odds ratio: 2.8, 95% confidence interval: 1.37-5.74, P = .005).

CONCLUSIONS

High NLR level is associated with increased inhospital and long-term cardiovascular mortality in patients with STEMI undergoing primary angioplasty.

Neutrophil-lymphocyte ratio as a predictor of disease severity in ulcerative colitis

BACKGROUND

Blood neutrophil-to-lymphocyte (N/L) ratio is an indicator of the overall inflammatory status of the body, and an alteration in N/L ratio may be found in ulcerative colitis (UC) patients. The aims of this study were to investigate the utility of N/L ratio as a simple and readily available predictor for clinical disease activity in UC.

METHODS

Twenty-six patients and 28 healthy controls were enrolled in the study. The neutrophil and lymphocyte counts were recorded, and the N/L ratio was calculated from these parameters. The extent of disease classified according to the Montreal classification, clinical disease activity was evaluated using a modified Truelove-Witts severity index, and endoscopic disease activities were classified according to Schroder et al.

RESULTS

The serum N/L ratios of active patients were significantly higher than those of inactive UC and controls (P < 0.001). The optimum N/L ratio cut-off point for active UC was 2.47. There was no significant difference between inflammation parameters, disease extension, and disease activity.

CONCLUSION

Our results demonstrate that N/L ratio is higher in patients with active UC compared with controls and UC patients in remission and a cut-off value of 2.47 can be used to identify patients with active ulcerative colitis.

Prognostic value of neutrophil/lymphocyte ratio in patients with ST-elevated myocardial infarction undergoing primary coronary intervention: a prospective, multicenter study

OBJECTIVE

The pre-procedural neutrophil to lymphocyte ratio (N/L) is associated with adverse outcomes among patients with coronary artery disease but its prognostic value in ST-segment elevation myocardial infarction (STEMI) has not been fully investigated. This study evaluated the relations between pre-procedural N/L ratio and the in-hospital and long-term outcomes in STEMI patients undergoing primary percutaneous coronary intervention (PCI).

METHODS

A total of 682 STEMI patients presented within the first 6h of symptom onset were enrolled and stratified according to tertiles of N/L ratio based on the blood samples obtained in the emergency room upon admission.

RESULTS

The mean follow-up period was 43.3 months (1-131 months). In-hospital in-stent thrombosis, non-fatal myocardial infarction, and cardiovascular mortality increased as the N/L tertile ratio increased (p<0.001, p<0.001, p=0.003, respectively). Long-term in-stent thrombosis, non-fatal myocardial infarction and cardiovascular mortality also increased as the N/L ratio increased (p<0.001, p<0.001, p=0.002, respectively). On multivariate analysis, N/L ratio remained an independent predictor for both in-hospital (OR 1.189, 95% CI 1.000-1.339; p<0.001) and long-term major (OR 1.228, 95% CI 1.136-1.328; p<0.001) adverse cardiac events.

CONCLUSION

The N/L ratio was an independent predictor of both in-hospital and long-term adverse outcomes among STEMI patients undergoing primary PCI. Our findings suggest that this inexpensive, universally available hematological marker may be incorporated into the current established risk assessment model for STEMI.

The long-term predictive value of the neutrophil-to-lymphocyte ratio in Type 2 diabetic patients presenting with acute myocardial infarction

BACKGROUND

Patients with diabetes mellitus have worse long-term outcomes after acute myocardial infarction (AMI) than non-diabetics. This may be related to differential contribution of neutrophil and lymphocyte to inflammation during AMI in diabetics vs. non-diabetics. We aim to determine the predictive value of neutrophil-to-lymphocyte ratio (NLR) for major adverse events post-AMI in Type 2 diabetics vs. non-diabetics.

METHODS AND RESULTS

A total of 2559 consecutive patients admitted for AMI (61 ± 14 years, 73% male and 43% diabetic) were analyzed. A complete blood count was obtained and the NLR computed for each patient on admission. Across the cohort, the 1-year reinfarction rate was 8.4% (n = 214) and 1-year mortality was 14.5% (n = 370). Univariate determinants of the composite endpoint included age, hypertension, hyperlipidemia, smoking, revascularization and NLR (P < 0.001 for all). The cohort was divided into NLR quartiles. Admission NLR was significantly higher in the diabetic group, 5.2 ± 5.8 vs. 4.6 ± 5.4 (P = 0.007). A step-wise increase in the incidence of the composite endpoint was noted across NLR quartiles for diabetic subjects; hazard ratio (HR) was 2.41 for fourth vs. first quartile (95% confidence interval = 1.63-3.53, P < 0.001). Multivariate analysis of the diabetic group showed that NLR remains as an independent predictor of the composite endpoint (adjusted HR = 1.53, 95% confidence interval = 1.00-2.33, P = 0.048). However, in non-diabetics, HR for NLR was not significant (P = 0.35).

CONCLUSION

Increased NLR post-AMI is an independent predictor of major adverse cardiac events in diabetics. Monitoring this easily obtainable new index allows prognostication and risk stratification.

Neutrophil to lymphocyte ratio is associated with the severity of coronary artery disease in patients with ST-segment elevation myocardial infarction

We assessed the relationship between the severity of coronary artery disease assessed by SYNTAX score (SS) and neutrophil to lymphocyte ratio (N:L ratio) in patients with ST elevation myocardial infarction (STEMI). In total, 840 patients with STEMI in whom primary percutaneous coronary intervention was performed were prospectively included (622 male, 218 female; mean age 58.6 ± 12.4 years). Total and differential leukocyte counts and other biochemical markers were measured at admission. Patients were categorized into tertiles on the basis of SS. The N:L ratio of SShigh group was higher compared with SSlow and SSmid groups (P < .001 for all). Multivariate regression analysis showed that N:L ratio (β = .277, P < .001), ejection fraction (β = -.086, P = .012), age (β = .104, P = .004), and diabetes (β = .152, P < .001) were the independent predictors for SS in patients with STEMI.

Neutrophil to lymphocyte ratio: a new marker for predicting steatohepatitis and fibrosis in patients with nonalcoholic fatty liver disease

BACKGROUND

Nonalcoholic steatohepatitis (NASH), the most severe form of nonalcoholic fatty liver disease (NAFLD), is associated with inflammation and increased oxidative stress. The neutrophil/lymphocyte ratio (N/L) integrates information on the inflammatory milieu and physiological stress.

AIMS

The aim of this study was to determine the utility of N/L ratio to predict the presence of NASH in patients with NAFLD.

METHODS

Our cohort consisted of 101 consecutive patients undergoing liver biopsy for clinical suspicion of NAFLD. Patients were divided into two groups: NASH group (n = 50) and not NASH group (n = 51). The stage of fibrosis was measured using a 4-point scale. The total white cell count, neutrophil and lymphocyte counts were recorded, and the N/L ratio was calculated.

RESULTS

The mean age was 49.5 (± 10.8) years and the mean BMI was 31.4 (± 4.9) kg/m(2) . Patients with NASH had a higher N/L ratio compared with patients with not NASH [2.5 (1.9-3.3) and 1.6 (1.2-2.0), respectively, P < 0.001]. The N/L ratio correlated with the NAFLD activity score and its individual components (steatosis, inflammation and ballooning P < 0.001). Patients with advanced fibrosis (F3-4) had an elevated N/L ratio [2.9 (2.0-3.9)] compared with patients with fibrosis stage 1-2 [1.8 (1.2-2.2)], P < 0.001. For each one-unit increase in N/L ratio, the likelihood of having NASH increased by 70% and the likelihood of having fibrosis increased by 50%.

CONCLUSION

The N/L ratio is higher in patients with NASH and advanced fibrosis. This ratio can be used as a novel noninvasive marker to predict advanced disease.

Usefulness of neutrophil to lymphocyte ratio in predicting short- and long-term mortality after non-ST-elevation myocardial infarction

Neutrophil/lymphocyte ratio (NLR) is the strongest white blood cell predictor of adverse outcomes in stable and unstable coronary artery syndromes. The aim of our study was to explore the utility of NLR in predicting long-term mortality in patients with non-ST-segment elevation myocardial infarction (NSTEMI). Consecutive patients with NSTEMI at Staten Island University Hospital were evaluated for study inclusion. Of the 1,345 patients with NSTEMI admitted from September 2004 to September 2006, 619 qualified for study inclusion. Survival analysis, stratified by NLR tertiles, was used to evaluate the predictive value of average inpatient NLR levels. Four-year vital status was accessed with electronic medical records and Social Security Death Index. Patients in the highest NLR tertile (NLR >4.7) had a higher 4-year mortality rate (29.8% vs 8.4%) compared to those in the lowest tertile (NLR <3, Wilcoxon chi-square 34.64, p <0.0001). After controlling for Global Registry of Acute Coronary Events risk profile scores, average NLR level remained a significant predictor of inpatient and 4-year mortality. Hazard ratios per unit increase of average NLR (log) increased by 1.06 (p = 0.0133) and 1.09 (p = 0.0006), respectively. In conclusion, NLR is an independent predictor of short-term and long-term mortalities in patients with NSTEMI with an average NLR >4.7. We strongly suggest the use of NLR rather than other leukocyte parameters (e.g., total white blood cell count) in risk stratification of the NSTEMI population.

Emerging hematological targets and therapy for cardiovascular disease: From bench to bedside

Atherosclerotic cardiovascular disease is the leading cause of death and a major part of its pathophysiology remains obscure. Some hematological targets have been related to the development and clinical outcome of this disease, especially soluble cytokines, leukocytes, red blood cells, hemostatic factors and platelets, and bone-marrow vascular progenitors. These emerging factors may be modulated by current antiatherosclerotic pharmacotherapy, target-designed novel drugs or progenitor cell therapy. The aim of current review article is to comprehensively review the role of these antiatherosclerotic targets and therapy.

Association of leukocyte and neutrophil counts with infarct size, left ventricular function and outcomes after percutaneous coronary intervention for ST-elevation myocardial infarction

Elevated leukocyte count during ST-segment elevation myocardial infarction is associated with adverse clinical outcomes. Whether increased leukocyte count after primary percutaneous coronary intervention (PCI) directly reflects larger infarct size and left ventricular impairment is not known. The aim of this study was to assess the relation between leukocyte and neutrophil counts with infarct size and the left ventricular ejection fraction (LVEF) after primary PCI. Three hundred sixty-three patients from the Evaluation of MCC-135 for Left Ventricular Salvage in Acute Myocardial Infarction (EVOLVE) study, a randomized, double-blind, placebo-controlled trial assessing the efficacy of intracellular calcium modulator as an adjunct to primary PCI in patients with first ST-segment elevation myocardial infarctions, were evaluated. Total and differential leukocyte counts were measured before and serially after PCI. Infarct size and the LVEF were assessed using single-photon emission computed tomography after 5 and 30 days, and patients were followed up to 180 days. Total leukocyte and neutrophil counts obtained 24 hours after PCI were significantly correlated with infarct size (r = 0.34 and 0.37, respectively, p <0.001) and inversely correlated with the LVEF (r = -0.20 and -0.22, respectively, p <0.001). Patients with elevated leukocyte and neutrophil counts had larger infarct sizes (12.5% vs 5% and 13.5% vs 5%, respectively, p <0.001). The highest neutrophil quartile was associated with increased 180-day composite cardiac events (19% vs 20% vs 23% vs 45%, log-rank p <0.001). Elevated leukocyte and neutrophil counts independently predicted adverse cardiac events (hazard ratios 2.5 and 2.2, respectively, p = 0.001). In conclusion, elevated leukocyte and neutrophil counts after primary PCI in patients with ST-segment elevation myocardial infarctions are directly related to myocardial infarct size and the LVEF and are independent predictors of cardiovascular outcomes.

Association between admission neutrophil to lymphocyte ratio and outcomes in patients with acute coronary syndrome

The neutrophil/lymphocyte ratio (NLR) has recently been described as a predictor of mortality in patients who undergo percutaneous coronary intervention. The aim of this study was to investigate the utility of admission NLRs in predicting outcomes in patients with acute coronary syndromes (ACS). A total of 2,833 patients admitted to the University of Michigan Health System with diagnoses of ACS from December 1998 to October 2004 were followed. Patients were divided into tertiles according to NLR. The primary end point was all-cause in-hospital and 6-month mortality. The ACS cohort comprised 564 patients with ST-segment elevation myocardial infarctions and 2,269 patients with non-ST-segment elevation ACS. Patients in tertile 3 had higher in-hospital (8.5% vs 1.8%) and 6-month (11.5% vs 2.5%) mortality compared with those in tertile 1 (p <0.001). After adjusting for Global Registry of Acute Coronary Events risk profile, patients in the highest tertile were at an exaggerated risk for in-hospital (odds ratio 2.04, p = 0.013) and 6-month (odds ratio 3.88, p <0.001) mortality. Admission NLR is an independent predictor of in-hospital and 6-month mortality in patients with ACS. This relatively inexpensive marker of inflammation can aid in the risk stratification and prognosis of patients diagnosed with ACS.

Usefulness of the neutrophil to lymphocyte ratio in predicting long-term mortality in ST segment elevation myocardial infarction

Neutrophil to lymphocyte ratio (N/L) has been associated with poor outcomes in patients who underwent cardiac angiography. Nevertheless, its role for risk stratification in acute coronary syndromes, specifically in patients with ST-segment elevation myocardial infarction (STEMI), has not been elucidated. We sought to determine the association of N/L maximum value (N/L max) with mortality in the setting of STEMI and to compare its predictive ability with total white blood cell maximum count (WBC max). We analyzed 515 consecutive patients admitted with STEMI to a single university center. White blood cells (WBC) and differential count were measured at admission and daily for the first 96 hours afterward. Patients with cancer, inflammatory diseases, or premature death were excluded, and 470 patients were included in the final analysis. The association between N/L max and WBC max with mortality was assessed by Cox regression analysis. During follow-up, we registered 106 deaths (22.6%). A positive trend between mortality and N/L max quintiles was observed; 6.4%, 12.4%, 11.7%, 34%, and 47.9% of deaths occurred from quintiles 1 to 5 (p <0.001), respectively. In a multivariable setting, after adjusting for standard risk factors, patients in the fourth (Q4 vs Q1) and fifth quintile (Q5 vs Q1) showed the highest mortality risk (hazard ratio 2.58, 95% confidence interal 1.06 to 6.32, p = 0.038 and hazard ratio 4.20, 95% confidence interal 1.73 to 10.21, p = 0.001, respectively). When WBC max and cells subtypes were entered together, N/L max remained as the only WBC parameter; furthermore, the model with N/L max showed the most discriminative ability. In conclusion, N/L max is a useful marker to predict subsequent mortality in patients admitted for STEMI, with a superior discriminative ability than total WBC max.