Usefulness of the neutrophil-to-lymphocyte ratio to predict bare-metal stent restenosis

Regulation of vascular remodeling by immune microenvironment after the establishment of autologous arteriovenous fistula in ESRD patients

Autogenous arteriovenous fistula (AVF) is the preferred dialysis access for receiving hemodialysis treatment in end-stage renal disease patients. After AVF is established, vascular remodeling occurs in order to adapt to hemodynamic changes. Uremia toxins, surgical injury, blood flow changes and other factors can induce inflammatory response, immune microenvironment changes, and play an important role in the maintenance of AVF vascular remodeling. This process involves the infiltration of pro-inflammatory and anti-inflammatory immune cells and the secretion of cytokines. Pro-inflammatory and anti-inflammatory immune cells include neutrophil (NEUT), dendritic cell (DC), T lymphocyte, macrophage (Mφ), etc. This article reviews the latest research progress and focuses on the role of immune microenvironment changes in vascular remodeling of AVF, in order to provide a new theoretical basis for the prevention and treatment of AVF failure.

Systemic immune inflammation index and its implication on in-stent restenosis among patients with acute coronary syndrome

OBJECTIVE

This study aims to assess the predictive value of the Systemic Immune Inflammation Index (SII) in determining in-stent restenosis (ISR) likelihood in patients with acute coronary syndrome (ACS) who have undergone percutaneous coronary intervention (PCI).

METHODS

The study enrolled 903 ACS patients undergoing PCI, categorized into ISR (+) and ISR (-) groups based on control coronary angiography results. Demographic, clinical, laboratory, and angiographic-procedural characteristics were systematically compared.

RESULTS

The ISR (+) group encompassed 264 individuals (29.2%), while the ISR (-) group comprised 639 individuals (70.8%). Patients had a mean age of 55.8 ± 10.2 years, with 69% being male. The ISR (+) group had higher diabetes and smoking prevalence and notably larger stent dimensions. Lab parameters showed significantly elevated creatinine, total cholesterol, red cell distribution width, white blood cell and neutrophil counts, SII index and C-reactive protein (CRP) in the ISR (+) group, while lymphocyte levels were lower. Binary logistic regression identified stent diameter (odds ratio [OR]: 0.598, 95% confidence interval [CI]: 0.383-0.935; P  = 0.024), stent length (OR: 1.166, 95% CI: 1.132-1.200; P  < 0.001), creatinine (OR: 0.366, 95% CI: 0.166-0.771; P  = 0.003), CRP (OR: 1.075, 95% CI: 1.042-1.110; P  = 0.031), and SII index (OR: 1.014, 95% CI: 1.001-1.023; P  < 0.001) as independent ISR predictors.

CONCLUSION

The SII index exhibits potential as a predictive marker for ISR in ACS patients post-PCI, indicating systemic inflammation and heightened restenosis risk. Integrating the SII index into risk models could identify high-risk patients for targeted interventions.

Risk factors for instent restenosis of sirolimus-coated stents in coronary intervention for patients with unstable angina

To investigate the instent restenosis rate of sirolimus-coated stents in percutaneous coronary intervention (PCI) and risk factors for in-stent restenosis, patients with unstable angina (UA) caused by coronary artery stenosis were enrolled, and all clinical and imaging data were analyzed. Among 143 enrolled patients with UA aged 35-83 (mean 60.9 ± 10.0) years enrolled, there were 114 (79.7%) male and 29 (20.3%) female patients. Arterial stenosis was present in one coronary artery in 6 (4.2%) patients, in two coronary arteries in 20 (14.0%) patients, in three arteries in 116 (81.1%), and in four coronary arteries in 1 (0.7%) patient. Stenting was successfully performed in all (100%) patients, and 181 stents were deployed. The quantitative flow ratio (QFR) was 0.92 ± 0.03 (range 0.84-0.96) immediately after stenting, and the TIMI was grade 3 in all patients. The diameter of the stents deployed ranged 2.25-4 mm (mean 3.04 ± 0.44) with a length ranging 10 mm to 104 mm (mean 32.73 ± 15.5). Follow-up angiography was performed in all patients with a duration of 1-92 (mean 15.0 ± 18.8) months. Instent restenosis ≥ 50% occurred in 25 (17.5%) patients. In univariate logistic regression analysis, significant (P < 0.05) risk factors for instent restenosis ≥ 50% were QFR (OR 0.036, 95% CI 0.13-0.97), stent diameter (OR 0.43, 95% CI 0.18-0.92), hypertension (OR 3.16, 95% CI 1.02-9.82), smoking (OR 0.31, 95% CI 0.11-0.89), and neutrophil count (OR 2.22, 95% CI 1.10-5.44). In multivariate analysis, QFR (OR 0.02, 95% CI 0.002-0.19), stent diameter (OR 0.06, 95% CI 0.005-0.59), hypertension (OR 6.75, 95% CI 1.83-35.72) and neutrophil count (OR 276.07, 95% CI 12.32-10,959.95) were significant (P < 0.05) independent risk factors for instent restenosis ≥ 50%. In conclusion, certain instent restenosis rates occurs after the sirolimus-eluted coronary stent deployment for the treatment of coronary artery stenosis in patients with UA, and quantitative flow ratio after stenting, stent diameter, hypertension, and neutrophil count are significant risk factors for instent restenosis of the sirolimus-coated stents in coronary intervention.

Multilevel Assessment of Stent-Induced Inflammation in the Adjacent Vascular Tissue

A recent U.S. Food and Drug Administration report presented the currently available scientific information related to biological response to metal implants. In this work, a multilevel approach was employed to assess the implant-induced and biocorrosion-related inflammation in the adjacent vascular tissue using a mouse stent implantation model. The implications of biocorrosion on peri-implant tissue were assessed at the macroscopic level via in vivo imaging and histomorphology. Elevated matrix metalloproteinase activity, colocalized with the site of implantation, and histological staining indicated that stent surface condition and implantation time affect the inflammatory response and subsequent formation and extent of neointima. Hematological measurements also demonstrated that accumulated metal particle contamination in blood samples from corroded-stetted mice causes a stronger immune response. At the cellular level, the stent-induced alterations in the nanostructure, cytoskeleton, and mechanical properties of circulating lymphocytes were investigated. It was found that cells from corroded-stented samples exhibited higher stiffness, in terms of Young's modulus values, compared to noncorroded and sham-stented samples. Nanomechanical modifications were also accompanied by cellular remodeling, through alterations in cell morphology and stress (F-actin) fiber characteristics. Our analysis indicates that surface wear and elevated metal particle contamination, prompted by corroded stents, may contribute to the inflammatory response and the multifactorial process of in-stent restenosis. The results also suggest that circulating lymphocytes could be a novel nanomechanical biomarker for peri-implant tissue inflammation and possibly the early stage of in-stent restenosis. Large-scale studies are warranted to further investigate these findings.

Markers of Restenosis after Percutaneous Transluminal Balloon Angioplasty in Patients with Critical Limb Ischemia

Among cardiovascular diseases, chronic obliterating lesions of the arteries of lower extremities, which are one of the important problems of modern healthcare, are distinguished. In most cases, the cause of damage to the arteries of lower extremities is atherosclerosis. The most severe form is chronic ischemia, characterized by pain at rest and ischemic ulcers, ultimately increasing the risk of limb loss and cardiovascular mortality. Therefore, patients with critical limb ischemia need limb revascularization. Percutaneous transluminal balloon angioplasty is one of the least invasive and safe approaches, with advantages for patients with comorbidities. However, after this procedure, restenosis is still possible. Early detection of changes in the composition of some molecules as markers of restenosis will help screen patients at the risk of restenosis, as well as find ways to apply efforts for further directions of inhibition of this process. The purpose of this review is to provide the most important and up-to-date information on the mechanisms of restenosis development, as well as possible predictors of their occurrence. The information collected in this publication may be useful in predicting outcomes after surgical treatment and will also find new ways for the target implication to the mechanisms of development of restenosis and atherosclerosis.

Relationship Between Neutrophil-Lymphocyte Ratio and Drug-Coated Balloon Restenosis in Patients With Femoropopliteal Arterial Disease

We investigated the relationship between neutrophil-lymphocyte ratio (NLR) and restenosis in patients with femoropopliteal arterial disease following drug-coated balloon (DCB) angioplasty. Patients (n = 120) were divided into 3 groups according to the development of restenosis and the time of restenosis occurrence. The postoperative NLR was higher in the late-restenosis group than that in the no-restenosis group (3.53 vs 2.70; p = .011). In multivariate logistic analysis, postoperative NLR was an independent predictor of late restenosis (odds ratio: 1.404, 95% confidence interval: 1.073-1.839; p = .014). The postoperative NLR cutoff value for predicting late restenosis was 2.78 with a sensitivity of 80.8% and a specificity of 53.2% (area under the ROC curve was .666 (95% CI: .541-.791, p = .010). The incidence of late restenosis in the NLR ≥2.78 group was higher than that in the NLR <2.78 group (32.3 vs 9.1%; p = .002). Postoperative NLR is independently associated with late restenosis in patients treated with DCB for femoropopliteal arterial disease.

Neutrophil-to-Lymphocyte Ratio and Systemic Inflammation Index as Predictors of Poor Outcome in Patients with Critical Limb Ischemia Treated with Remote Endarterectomy

Introduction: Severe ischemia occurring in the lower limbs represents the advanced stage of peripheral artery disease (PAD). Atherosclerosis and inflammatory markers have been intensively studied to identify prognostic tools with a role in the evolution of patients with PAD. The aim of this study is to demonstrate the predictive value of systemic inflammatory markers such as the neutrophil-to-lymphocyte ratio (NLR) and the systemic inflammation index (SII) in the prognosis of patients diagnosed with critical leg ischemia (CLI) undergoing infrainguinal surgical revascularization with remote endarterectomy.

Materials and methods: This retrospective study included all patients admitted to the Vascular Surgery Clinic of the County Emergency Clinical Hospital of Târgu Mureș, Romania between January 2018 and December 2021, who had critical limb ischemia Leriche-Fontaine stage III and were treated with endarterectomy. Patients were divided into two groups based on the presence or absence of patency in the lower limbs at 12 months.

Results: There was a higher baseline value of neutrophil count (p <0.0001), platelet count (p = 0.006), NLR and SII value (p <0.0001), as well as a lower value of lymphocyte count (p = 0.001) in the group without patency at 12 months. The ROC curve analysis showed that the NLR and SII were associated with the risk of major amputation and primary patency failure at 12 months, while multivariate analysis has shown that arterial hypertension (OR 3.63, p = 0.04), history of myocardial infarction (OR 2.93, p = 0.009), diabetes mellitus (OR 2.20; p = 0.04) and smoking (OR 3.48, p <0.0001) were also predictors of primary patency failure.

Conclusions: The results of this study demonstrated the predictive role of NLR and SII regarding poor outcomes among patients with CLI Leriche-Fontaine stage III undergoing infrainguinal surgical revascularization with remote endarterectomy.

The Role of Systemic Immune Inflammation Index for Predicting Saphenous Vein Graft Disease in Patients with Coronary Artery Bypass Grafting

As inflammation plays a significant role in the development of coronary artery disease, we hypothesized that there may be a relation between the systemic immune inflammation index (SII) and saphenous vein graft disease (SVGD). The study population consisted of 716 consecutive patients who underwent elective coronary angiography (CAG) >1 year after bypass grafting. The patients were divided into 2 groups depending on the extent of SVG patency. SII value was significantly higher in the SVGD(+) group compared with the SVGD(-) group (P < .001). In multivariate logistic regression analysis, SII (P < .001, odds ratio (OR) = 3.27, 95% CI = 1.94-5.65) and neutrophil-to-lymphocyte ratio (NLR) (P < .001, OR = 2.08, 95% CI = 1.59-3.11) were found to be independent predictors of SVGD. An SII value of >935 (x10³/ml) has 89.2% sensitivity and 70.6% specificity for the prediction of the SVGD, and an NLR value of >4.15 has 54.6% sensitivity and 68.5% specificity for the prediction of the SVGD. The AUC of SII was found to be greater than the AUC of NLR (P = .002), platelet-to-lymphocyte ratio (PLR) (P = .009), lymphocyte-to-monocyte ratio (LMR) (P = .013), MPV (P = .011), and C-reactive protein (CRP) (P = .034) in predicting SVGD. In conclusion, we demonstrated that SII, which is among the new inflammation indexes, is a more reliable predictor in determining SVGD than the NLR, PLR, and LMR.

Neutrophil-to-Lymphocyte Ratio Predicts Restenosis After Drug-Coated Balloon Therapy for Femoropopliteal Artery Lesions: A Retrospective Study

Background

Peripheral artery disease (PAD) is a common atherosclerotic vascular disease. The use of drug-coated balloon (DCB) for the treatment of femoropopliteal artery disease has gradually increased. A certain percentage of patients developed target lesion restenosis after DCB treatment of the femoral popliteal artery. The neutrophil-to-lymphocyte ratio (NLR) is closely related to the level of inflammatory activity and has predictive value for atherosclerotic vascular disease. This study aimed to analyze the relationship between NLR and 1-year restenosis after DCB for femoropopliteal artery disease.

Methods

Patients with femoropopliteal artery disease who were treated with DCBs at our hospital from May 2016 to December 2020 were retrospectively included. Baseline data during the patient’s first hospital stay and data during follow-up were collected. Demographic data, laboratory test results, lesion examination results, and major adverse events during the follow-up period were collected. Logistic regression was used to analyze the factors associated with restenosis after DCB.

Results

A total of 117 patients were included. During 1-year follow-up, 19 cases (16.2%) of restenosis were detected. Five of these patients (4.3% of total included patients) were readmitted for symptomatic ischemia. No deaths or amputations occurred. Baseline NLR in patients with restenosis was higher than that in patients without restenosis (2.4 (2.1, 3.4) vs. 1.8 (1.3, 2.3), P &lt; 0.001). Logistic univariate and multivariate analysis showed that baseline hs-CRP level (OR = 1.10, 95%CI: 1.05–1.34), lesion length (OR = 1.04, 95%CI: 1.02–1.27), use of rivaroxaban (OR = 1.08, 95%CI: 1.05–1.39), NLR (OR = 1.47, 95%CI: 1.13–2.48), LDL-C level (OR = 1.25, 95%CI: 1.05–1.52), and diabetes (OR = 1.25, 95%CI: 1.05–1.52) = 1.18, 95%CI: 1.06–1.66) were predictors of restenosis.

Conclusion

Baseline NLR before DCB can predict the risk of restenosis after surgery.

Neutrophil-to-Lymphocyte Ratio Is Not Associated with Severity of Coronary Artery Disease and Is Not Correlated with Vitamin D Level in Patients with a History of an Acute Coronary Syndrome

Coronary artery disease (CAD), the leading cause of death worldwide, has an underlying cause in atherosclerosis. The activity of this inflammatory process can be measured with neutrophil-to-lymphocyte ratio (NLR). The anti-inflammatory and anti-atherogenic properties of vitamin D affect many mechanisms involved in CAD. In this study, we investigated the association between NLR, vitamin D concentration, and severity of CAD in a group of patients with a history of myocardial infarction (MI). NLR was higher in patients with acute coronary syndrome (ACS) in comparison to those with stable CAD (median: 2.8, range: 0.96−24.3 vs. median: 2.3, range: 0.03−31.6; p < 0.05). No associations between NLR and severity of CAD (p = 0.14) in the cohort and in the subgroups with stable CAD (p = 0.40) and ACS (p = 0.34) were observed. We found no correlation between vitamin D level and NLR neither in the whole study group (p = 0.29) nor in subgroups of patients with stable CAD (p = 0.84) and ACS (p = 0.30). NLR could be used as prognostic biomarker of consecutive MI in patients with CAD and a history of MI.

The prognostic value of neutrophil-to-lymphocyte ratio across all stages of coronary artery disease

The natural history of coronary heart disease (CAD) commonly begins with atherosclerosis, progressing to chronic coronary syndrome (CCS), acute coronary syndrome (ACS), and eventually, heart failure. Despite advancements in preventive and therapeutic strategies, there is room for further cardiovascular risk reduction. Recently, inflammation has emerged as a potential therapeutic target. The neutrophil-to-lymphocyte ratio (NLR) is a novel inflammatory biomarker which predicts poor prognosis in several conditions such as metabolic syndrome, sepsis, malignancy and CAD. In atherosclerosis, a high NLR predicts plaque vulnerability and severe stenosis. This is consistent with observations in CCS, where an elevated NLR predicts long-term major adverse cardiac events (MACEs). In ACS patients, high NLR levels are associated with larger infarct sizes and poor long-term outcomes. Possible reasons for this include failure of fibrinolysis, ischemia-reperfusion injury and in-stent restenosis, all of which are associated with raised NLR levels. Following myocardial infarction, an elevated NLR correlates with pathological cardiac remodeling which propagates chronic heart failure. Finally, in heart failure patients, an elevated NLR predicts long-term MACEs, mortality, and poor left ventricular assist device and transplant outcomes. Further studies must evaluate whether the addition of NLR to current risk-stratification models can better identify high-risk CAD patients.

What is the Role of the Preoperative Blood-Based Inflammation Biomarkers in the Prognosis of Upper Tract Urothelial Carcinoma With Radical Nephroureterectomy? A Single-Centre Retrospective Study

Objective: To assess the prognostic value of preoperative blood-based inflammation biomarkers, including the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and lymphocyte-monocyte ratio (LMR), on the survival outcomes of patients with upper tract urothelial carcinoma (UTUC) following radical nephroureterectomy (RNU). Methods: We retrospectively studied the data of 172 patients who were diagnosed with UTUC after RNU during 2008 to 2018. We determined the cut-off value by using X-tile software. The area under the curve (AUC) and concordance index (C-index) were utilized to compare the predictive accuracy between subgroups. We also performed decision curve analysis (DCA) to evaluate the clinical net benefit of prognostic models. The Kaplan-Meier method and Cox proportional hazards regression models were performed to evaluate the association between these inflammation biomarkers and survival outcomes. Results: The median follow-up period was 45.5 (range: 1-143; interquartile range, IQR: 27-77) months. Kaplan-Meier analyses showed that a high NLR or PLR significantly reduced overall survival (OS), cancer-specific survival (CSS), recurrence-free survival (RFS) and metastasis-free survival (MFS), and a low LMR markedly decreased RFS and MFS. The multivariate Cox proportional hazards model revealed that the NLR plus PLR was an independent predictor of worse survival (all P < .05). Additionally, the AUC and C-index of the new prognostic models were the largest for the 1- to 5-year OS, CSS, RFS, and MFS were the largest. Conclusion: Our study confirms that the combination of preoperative NLR and PLR could be an independent risk factor for UTUC patients who have undergone RNU. The addition of NLR and PLR may improve the accuracy of current prognostic models and help guide clinical strategies in the treatment of UTUC.

The Value of Inflammation Indexes in Predicting Patency of Saphenous Vein Grafts in Patients With Coronary Artery Bypass Graft Surgery

Aim:Our study aimed to investigate the predictive values of inflammation markers in predicting postoperative saphenous vein graft patency in patients who underwent coronary artery bypass grafting (CABG).

Method: We retrospectively analyzed 89 patients who undergone CABG, and 49 patients diagnosed with non-critical coronary artery disease (less than ≤50% stenosis) on coronary angiography were included in the study as a control group. Eighty-nine patients who underwent CABG were divided into two groups according to the presence of 50% or more stenosis in saphenous vein grafts. In these three groups of patients, neutrophil to lymphocyte ratio (NLR), derived NLR (dNLR; neutrophils/white blood cells-neutrophils), platelet to lymphocyte ratio (PLR), lymphocyte to monocyte ratio (LMR), systemic inflammation response index (SIRI; neutrophils × monocytes/lymphocytes), systemic inflammation index (SII; platelet × neutrophil/lymphocyte), and the aggregate index of systemic inflammation (AISI; neutrophil × platelet × monocyte/lymphocyte ratio) were calculated from blood tests. The primary endpoint was more than 50% of saphenous vein stenosis or occlusion, and the aim is to predict this saphenous vein graft disease by inflammation indexes.

Results: The groups were similar in terms of the frequency of stroke, diabetes mellitus, and chronic obstructive pulmonary disease. The frequency of heart failure and hypertension was higher in group 2 (p=0.045, p=0.005), respectively. Multivariate logistic regression analysis showed that LMR and NLR levels were independent predictors of saphenous vein graft disease (SVGD; OR: 0.896; 95%CI: 0.465-0.957; P<0.001) , (OR: 0.592; 95%CI: 0.450-0.875; P=0.034, respectively).The cut-off value of the LMR <2.625 was associated with 78.4% sensitivity and 78% specificity to predict saphenous vein graft disease in patients with CABG.

Conclusion: LMR and NLR may be useful predictors for SVGD.

Predictive value of neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio for primary patency of percutaneous transluminal angioplasty in hemodialysis arteriovenous fistula stenosis

OBJECTIVE

The aim of this study is to investigate the potential association of the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) with the primary patency of percutaneous transluminal angioplasty (PTA) in hemodialysis arteriovenous fistula (AVF) stenosis.

METHODS

This study conducted a retrospective review of patients with end-stage renal disease referred for hemodialysis AVF stenosis in one center. The study consisted of 114 patients with significant (significant stenosis was defined as a reduction in the caliber of the fistula vein of > 50% with respect to the non-aneurysmal venous segment). AVF stenosis patients were treated with PTA, with conventional balloon angioplasty. The NLR and PLR were calculated from the pre-interventional blood samples. The patients were classified into two groups: group A, primary patency < 12 months (n = 35) and group B, and primary patency ≥ 12 months (n = 79). Comparisons between the groups were performed using the Mann-Whitney U test. Kaplan-Meier analysis was performed to compare the factors, NLR and PLR, for association with primary patency AVFs. A receiver-operating characteristic curve analysis was performed to identify the sensitivity and specificity of the NLR and PLR cut-off values in the prediction of primary patency time.

RESULTS

There was no difference in gender; age; side of AVF; AVF type; comorbid diseases such as diabetes mellitus and hypertension; or blood parameters such as white cell count, erythrocytes, hemoglobin, neutrophils, lymphocytes, monocytes, eosinophils, basophils, C-reactive protein, NLR, or PLR between the two groups (p > 0.05). There was also no significant difference in the patency rate between the NLR < 4.13 and NLR ≥ 4.13 groups at 12 months (NLR cut-off point = 4.13, p = 0.273). There were statistically significant differences between the primary patency rates of the PLR < 187.86 and PLR ≥ 187.86 groups at 12 months (PLR cut-off point = 187.86, p = 0.023). The cut-off value for PLR for the determination of primary patency was 187.86, with a sensitivity of 57.0% and specificity of 34.4%.

CONCLUSION

An increased level of PLR may be a risk factor for the development of early AVF restenosis after successful PTA. However, more studies are needed to validate this finding.

Current Smoking is a Risk Factor for the Irregular Surface and Calcification of Carotid Plaque in Men

Objective

To explore whether current smoking could influence plaque characteristics and determine its correlation to the irregular surface and calcification of carotid plaque.

Methods

Three hundred and seventeen patients with severe carotid atherosclerosis stenosis (SCAS) detected by color duplex flow imaging (CDFI) and confirmed by CT angiography (CTA) were recruited. The results of laboratory parameters were collected by using electronic database of the hospital. Computerized tomography (CT) scanning and high-resolution ultrasonography were performed for assessment of plaque morphology, respectively.

Results

All enrolled smokers and non-smokers had no significant difference among all characteristics not related to smoking. CT scanning could efficiently identify the difference among enrolled smokers and non-smokers not only for the characteristics related to smoking but also the onsets of carotid plaque. Surface morphology was also efficiently detected by ultrasonography. Further ridge trace analysis showed that ultrasonography is efficient for diagnosis of calcified plaque compared with gold standard for plaque diagnosis. Further correlation analysis showed that ultrasonography parameters could offer reliable evidence for plaque scores, which was associated with age index. Ultrasonography parameters could efficiently differentiate plaque morphologies among enrolled smokers and never-smokers.

Conclusion

Current smoking was positively associated with plaque calcification onsets, and smoking cessation could efficiently attenuate such injury. High-frequency ultrasound can clearly distinguish the details of calcification with promising clinical significance for current smoking patients.

Neutrophil-lymphocyte ratio as a link between complex pedal ulcers and poor clinical results after infrainguinal surgical revascularization

BACKGROUND

Our aim was to evaluate the influence of preoperative neutrophil-lymphocyte ratio (NLR) on patency and clinical results after infrainguinal surgical revascularization for chronic limb ischemia.

METHODS

Retrospective analysis of 150 infrainguinal autologous bypasses performed to infragenicular popliteal artery or tibial vessels in 140 (93%) patients with chronic limb-threatening ischemia (CLTI) and in 10 (7%) with disabling claudication. NLR was calculated using blood samples obtained 24 hours preoperatively. The cohort was stratified into 2 groups according to interquartile ranges of NLR: "ELEVATED-NLR" (Quartile 4 N.=37) and "LOW-NLR" (Quartile 1-2-3 N.=113). Reperfused ulcers were described using the WIfI classification. Patency, freedom from MALE and amputation-free survival at 24 months were calculated using the Kaplan-Meier method. Univariate comparisons between NLR groups were performed using the Log-Rank test. Statistical differences on univariate analysis were adjusted in a multivariate model (Cox regression).

RESULTS

NLR values were similar between CLTI and claudication. Ischemic ulcers were more frequent, (83.4% vs. 59.3% P<0.01), more severe (W2-3: 37.8% vs. 22.1% P=0.01) and pedal infection was deeper (fI 2-3: 40.5% vs. 18.6% P=0.003) in "ELEVATED-NLR" group. Severe ischemia (I3) was similar between groups. High NLR values were independent predictors of patency loss (HR: 1.77 CI95% [1.01-3.10] P=0.04), MALE (HR: 2.04 CI95% [1.03-4.04] P=0.04) and worse amputation-free survival (HR:2.10 CI95% [1.06-4.14] P=0.03) rates at 24 months.

CONCLUSIONS

High preoperative NLR values are associated with severe and deep infected ulcers and predicts primary patency loss, higher major adverse limb events and worse amputation-free survival rates on long-term follow-up after infrainguinal surgical revascularization.

Risk factors of contrast-induced nephropathy in patients with STEMI and pump failure undergoing percutaneous coronary intervention

Risk factors associated with the development of contrast-induced nephropathy (CIN) remain poorly defined in patients with ST-elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI). The present study was designed to assess the association between the Killip grade and the development of CIN in patients with STEMI and pump failure undergoing PCI. Data were retrospectively collected from the records of patients with STEMI and pump failure from the Chinese Society of Cardiology and American Heart Association database. A total of 7,471 patients were analyzed, including 5,521 patients with Killip grade II, 878 with Killip III and 1,072 with Killip IV pump failure. Patients were classified into two groups: Those undergoing primary PCI (PPCI; n=5,063) and those undergoing elective PCI (EPCI; n=2,408). Patients in the PPCI group had higher cardiac arrest rates, lower blood pressure and higher cholesterol levels as compared to the EPCI group. There was a statistically significant difference in the rates of CIN with Killip II pump failure in the PPCI group as compared to the EPCI group, but not in those with Killip III and VI pump failure. Logistic regression analysis indicated that the Killip classification is a risk predictor for post-PCI CIN. The present results indicated a positive association between the Killip grade and post-PCI CIN in patients with STEMI and pump failure. In addition, patients with STEMI and Killip grade II pump failure were at a higher risk of PCI after PPCI as compared to EPCI. Further prospective studies are required to confirm the present results.

The relationship between neutrophil-lymphocyte ratio and in-stent restenosis in superficial femoral artery

The present study aimed to investigate the relationship between an increase in the pre- and post-operative neutrophil–lymphocyte ratio (NLR) and superficial femoral artery in-stent restenosis (ISR) rate. We recruited 199 patients that underwent superficial femoral artery stenting for lower extremity arteriosclerosis obliterans at our hospital from March 2015 to July 2018. Patients were divided into two groups according to the occurrence of ISR within 1 year (group 1, ISR and group 2, Non-ISR). The after NLR (NLR_after) and NLR change ratio (NLR_ratio) (P<0.001) were significantly higher in group 1. A NLR_after > 4.3 was associated with an odds ratio of 1.946 (95% CI [1.51–2.50]; P<0.001) for the presence of ISR. A NLR_ratio > 37.5% was associated with an odds ratio of 3.6 (95% CI [2.03–6.36]; P<0.001) for occurrence of ISR. A NLR_after level > 4.3 had 75% sensitivity and 76% specificity for the prediction of ISR, as identified by the ROC curve. A NLR_ratio level > 37.5% predicted ISR with 77% sensitivity and 60% specificity. Multivariate logistic regression analysis demonstrated that NLR_ratio was the strongest independent predictor of ISR (P<0.001). In conclusions, NLR_ratio could be used as a prognostic marker in superficial femoral artery stents.

Monocyte counts are negatively associated with ankle-brachial index values in non-dialysis-dependent chronic kidney disease patients

Our aim was to determine which leukocyte subtypes are most relevant to ankle-brachial index (ABI) values in patients with non-dialysis-dependent chronic kidney disease (NDD-CKD). The study included 79 NDD-CKD patients aged 62.84 ± 12.09 years (63.33% men; 26.67% patients with diabetes) and 21 age-matched normal controls. According to the estimated glomerular filtration rate (eGFR) calculated by the CKD-Epidemiology Collaboration equation (CKD-EPI), we classified the study population into 2 groups (21 subjects with NDD-CKD with an eGFR 60–89 mL/min/1.73m², 58 subjects with NDD-CKD with eGFR <60 mL/min/1.73 m²). ABI was calculated as the ratio of the ankle systolic BP divided by the arm systolic BP using an ABI-form device. An automated hematologic analyzer was used to measure total and differential leukocyte counts. Monocyte counts and monocyte-to-total leukocyte count ratios (MTR) in patients with an ABI value <1.10 were significantly higher than those in patients with an ABI value ≥1.10, respectively. Univariate analyses revealed that mean ABI values were negatively correlated with monocyte count (r= −0.341; p = 0.044), MTR (r= −0.346, p = 0.031). Multivariate linear regression analyses showed that monocyte count was negatively associated with ABI values (β ± SE = −1.825 ± 0.341, p = 0.013). The area under the curve of monocyte counts was 0.695 (95% confidence interval 0.586–0.804, p = 0.002) in predicting an ABI value <1.10. Monocyte counts are negatively associated with ABI values in patients with NDD-CKD without apparent peripheral arterial occlusive disorder (PAOD).

Platelet-to-lymphocyte and Neutrophil-to-lymphocyte Ratios Predict Target Vessel Restenosis after Infrainguinal Angioplasty with Stent Implantation

Platelet-to-lymphocyte (PLR), neutrophil-to-lymphocyte (NLR) and lymphocyte-to-monocyte (LMR) ratios are associated with the occurrence of critical limb ischemia in peripheral artery disease (PAD). We therefore investigated whether PLR, NLR or LMR are linked to target vessel restenosis (TVR) following infrainguinal angioplasty and stenting. Moreover, we studied on-treatment platelet reactivity and neutrophil-platelet aggregate (NPA) formation as potential underlying mechanisms. Platelet, neutrophil, lymphocyte and monocyte counts were determined one day after angioplasty and stenting in 95 stable PAD patients. Platelet reactivity and NPA formation in response to protease-activated receptor−1 stimulation were measured by light transmission aggregometry (LTA) and flow cytometry, respectively. PLR and NLR were significantly higher in patients who subsequently developed TVR (both p < 0.05). In contrast, LMR did not differ significantly between patients without and with TVR (p = 0.28). A PLR ≥ 91 and NLR ≥2.75 were identified as the best thresholds to predict TVR, providing sensitivities of 87.5% and 81.3%, and specificities of 34.9% and 50.8%, respectively, and were therefore defined as high PLR and high NLR. TVR occurred significantly more often in patients with high PLR and high NLR than in those with lower ratios (both p < 0.05). Patients with high PLR and high NLR exhibited significantly increased on-treatment platelet aggregation compared to those with lower ratios, and patients with high PLR had higher levels of NPA formation (all p < 0.01). In conclusion, PLR and NLR predict TVR after infrainguinal angioplasty with stent implantation. Platelet activation and neutrophil-platelet interaction may be involved in the underlying pathomechanisms

Inflammatory Markers and Plasma Fatty Acids in Predicting WBC Level Alterations in Association With Glucose-Related Markers: A Cross-Sectional Study

Aging leads to immune function changes which contribute to occurrence of chronic conditions. White blood cell (WBC) level is a marker widely known to reflect the immune function, thus, prediction of WBC level changes by using certain biomarkers is needed to prevent chronic conditions and to decrease the burdens of aging. In this respect, the present study aimed to explore the relationships between inflammatory markers and plasma fatty acid (FA) composition according to WBC levels for verifying potential predictors of WBC levels. Study subjects were divided into three groups according to their WBC count: moderate-low WBC (MLW), normal WBC, and moderate-high WBC (MHW). Inflammatory markers were measured, and plasma FA profiles were constructed via gas chromatography-mass spectrometry (GC-MS). In the MHW group, insulin, homeostatic model assessment of insulin resistance (HOMA-IR), γ-glutamyltransferase (GGT), high-sensitivity C-reactive protein (hs-CRP), and interferon (IFN)-γ showed significant increases compared to those in the other groups. In addition, the granulocyte-to-lymphocyte ratio (GLR) significantly increased according to the WBC levels, whereas the platelet-to-lymphocyte ratio (PLR) showed the opposite result. Total ω-3 polyunsaturated fatty acids (PUFAs) showed significant differences among the groups. Regarding ω-6 PUFAs, dihomo-γ-linolenic acid and docosatetraenoic acid levels were significantly increased in the MHW group compared to the other groups. Finally, multivariate linear regression analysis revealed that GGT, hs-CRP, IFN-γ, ω-3 PUFAs, and dihomo-γ-linolenic acid were independent factors for altering WBC levels. In conclusion, elevated WBC levels accompanied by an increased GLR and a decreased PLR were associated with the risk of type 2 diabetes based on increased insulin and HOMA-IR levels and decreased adiponectin levels. Additionally, GGT, hs-CRP, IFN-γ, ω-3 PUFAs, and dihomo-γ-linolenic acid levels emerged as independent biomarkers for predicting WBC level alterations. Therefore, this study showed that these inflammatory markers and plasma FAs not only affect WBC level alterations but also may play roles in the risk of type 2 diabetes as one of the chronic conditions by certain mechanisms, which should be further studied. Finally, checking these biomarkers along with WBC levels can be helpful to prevent the chronic conditions.

NLR-A Simple Indicator of Inflammation for the Diagnosis of Left Ventricular Hypertrophy in Patients with Hypertension

We aimed to investigate the relationship between neutrophil-to-lymphocyte ratio (NLR), C-reactive protein (CRP), brain natriuretic peptide (BNP), and left ventricular hypertrophy (LVH) in hypertension.

METHODS

This study included 386 patients with hypertension. Mann-Whitney U test and multivariate binary logistic regression analysis were used to investigate the relationship between NLR, CRP, BNP, and LVH in patients with hypertension, as well as compare the levels of NLR, CRP, and BNP in the four configurations. Receiver operator characteristic (ROC) curve was used to compare the diagnostic efficacy of NLR, CRP, and BNP on LVH.

RESULTS

The NLR and CRP and BNP levels of the LVH group were significantly higher than those of the non-LVH group. In the multivariate logistic regression analysis, NLR as well as age, BMI, and SBP were associated with LVH. In addition, in patients with eccentric and concentric hypertrophy, the NLR and CRP and BNP levels were higher than those of the normal left ventricular geometry and concentric remodeling groups. The cutoff values of NLR, CRP, and BNP obtained by ROC curve were 2.185, 2.205, and 283.45, respectively, for the prediction of LVH.

CONCLUSIONS

NLR is independently associated with LVH in patients with hypertension, and this is consistent with the diagnostic efficacy of CRP and BNP, which may be a simple and convenient indicator for judging LVH.

Neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio: novel markers for the diagnosis and prognosis in patients with restenosis following CAS

Aim: In this study, we investigated the effect of neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio on restenosis status in patients undergoing carotid angioplasty stenting (CAS). Methodology & results: Clinical imageology and receiver operating characteristic analysis were utilized to study the prognostic significance of NLRs/platelet-to-lymphocyte ratios and their correlation with survival. NLR of restenosis (+) patients was evidently increased after the CAS procedures, while the NLR of restenosis (-) patients before the CAS procedures being the lowest. Area under the curve of pre-CAS NLR or/and post-CAS NLR were all evidently higher than 50%. Also, restenosis incidence was the highest in patients with both high pre-CAS and high post-CAS values. Conclusion: Therefore, NLR can be utilized as an independent prognostic indicator to predict the incidence of restenosis after CAS procedures.

Association of monocyte to high-density lipoprotein ratio with bare-metal stent restenosis in STEMI patients treated with primary PCI

OBJECTIVE

Monocyte to high-density lipoprotein ratio (MHR) has recently been postulated as a novel parameter related to adverse cardiovascular outcomes. In this study, we aimed to investigate the correlation of MHR with stent restenosis (SR) rates after the primary percutaneous coronary intervention (PCI) and bare-metal stent (BMS) implantation.

METHODS

In this study, patients who had undergone primary PCI for STEMI and had a control angiogram during follow-up were retrospectively recruited. Patients were categorized according to admission MHR tertiles, clinical and angiographic data were compared. In addition, predictors of SR were evaluated with logistic regression analysis.

RESULTS

A total number of 448 patients (240 patients with SR and 208 patients without SR) were included in this study. Patients were categorized into three groups according to tertiles of admission MHR. During a follow-up period of median 12 months, the rate of SR was significantly higher in patients with higher MHR levels (45% in tertile 1, 54% in tertile 2 and 62% in tertile 3, p<0.01). In multivariate Cox regression analysis, male gender, stent length, admission NLR levels and MHR levels (HR 1.03, 95% CI 1.02-1.06, p<0.01) remained as the independent predictors of SR in the study population.

CONCLUSION

Gender, stent length, higher MHR and NLR levels are correlated to SR after primary PCI.

Association of Platelet to Lymphocyte and Neutrophil to Lymphocyte Ratios with In-Hospital Mortality in Patients with Type A Acute Aortic Dissection

OBJECTIVE

To evaluate the relationship between neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) with in-hospital mortality in type A acute aortic dissection (AAD).

METHODS

A total of 96 patients who presented to the emergency department between January 2013 and June 2018 with a diagnosis of type A AAD were enrolled in this study. White blood cell count subtypes such as NLR and PLR were calculated at the time of admission. The end point was in-hospital mortality.

RESULTS

Of the 96 type A AAD patients included in this analysis, 17 patients (17.7%) died during hospitalization. NLR and PLR were significantly elevated in patients with type A AAD (P<0.001 and <0.001, respectively). Based on the receiver operating characteristic curve, the best NLR cut-off value to predict in-hospital mortality was 9.74, with 70.6% sensitivity and 76.8% specificity, whereas the best PLR cut-off value was 195.8, with 76.5% sensitivity and 78.1% specificity.

CONCLUSION

Admission NLR and PLR levels were important risk factors and independently associated with in-hospital mortality of type A AAD patients.

Association of Platelet to Lymphocyte and Neutrophil to Lymphocyte Ratios with In-Hospital Mortality in Patients with Type A Acute Aortic Dissection

Objective

To evaluate the relationship between neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) with in-hospital mortality in type A acute aortic dissection (AAD).

Methods

A total of 96 patients who presented to the emergency department between January 2013 and June 2018 with a diagnosis of type A AAD were enrolled in this study. White blood cell count subtypes such as NLR and PLR were calculated at the time of admission. The end point was in-hospital mortality.

Results

Of the 96 type A AAD patients included in this analysis, 17 patients (17.7%) died during hospitalization. NLR and PLR were significantly elevated in patients with type A AAD (P<0.001 and <0.001, respectively). Based on the receiver operating characteristic curve, the best NLR cut-off value to predict in-hospital mortality was 9.74, with 70.6% sensitivity and 76.8% specificity, whereas the best PLR cut-off value was 195.8, with 76.5% sensitivity and 78.1% specificity.

Conclusion

Admission NLR and PLR levels were important risk factors and independently associated with in-hospital mortality of type A AAD patients.

Neutrophil count as the centerpiece in the joined association networks of inflammatory and cell damage markers, and neuroendocrine stress markers in patients with stable angina pectoris following stenting

Objective

The primary aim of this study was to examine whether markers of cell damage and of the psycho-neuroendocrino-inflammatory/immune (PNI) system could be associated in patients with stable coronary artery disease (CAD) on the next day following percutaneous coronary intervention (PCI).

Materials and methods

Blood samples of 23 patients (18 men and five women, mean age 62.9 ± 10.6 years), were collected immediately before (pre-PCI), immediately after (post-PCI), and on the day following PCI (1d-PCI). Lactoferrin, LL-37 and interleukin-6 (IL-6) were assayed in plasma, in addition to cortisol and chromogranin A (CgA), as well as CK, ASAT and ALAT. Total and differential leukocyte counts were also analysed.

Results

At all the three time points, the monocyte fractions, the monocyte-to-lymphocyte and the neutrophil-to-lymphocyte ratios and CgA levels were elevated. We detected significant peri-procedural changes in the plasma levels of our PNI markers: IL-6 (p<0.05), lactoferrin, LL-37 (both: p <0.0001), CgA, (p<0.05), and cortisol (p<0.01). On the first day after PCI, highly significant associations were found of ASAT with IL-6 and neutrophil count (both: r>0.75, p<0.0001), and of CgA with neutrophil count and monocyte count (both: r>0.79, p<0.0001); furthermore, cortisol was also associated with neutrophil count (r>0.7, p<0.0001).

Conclusions

The findings suggest that myocardial damage could correlate not only with an inflammatory reaction but, via neutrophil count, also with increased level of stress in stable CAD after PCI. Furthermore, 1d-PCI neutrophil count may serve as an easy-to-obtain integrative PNI measure in stable CAD.

Blood Cell Parameters and Predicting Coronary In-Stent Restenosis

Major advances in coronary interventional techniques and pharmacotherapy as well as the use of drug-eluting stents (DESs) have considerably reduced the risk of in-stent restenosis (ISR). However, ISR remains a major clinical challenge. Inflammation and platelet activation are important processes that underlie the pathophysiology of ISR. Parameters related to blood cells, entailing both cell count and morphology, are useful markers of the inflammatory response and platelet activation in clinical practice. Recent studies have highlighted several new combined or derived parameters related to blood cells that independently predict ISR after DES implantation. The neutrophil/lymphocyte ratio, an inflammatory marker, is regarded as a predictor of the risk of ISR and the stability of atherosclerotic plaques. The mean platelet volume, a widely used platelet activation parameter, has been shown to be a predictor of the risk of ISR and the efficacy of antiplatelet therapy. Other markers considered include the platelet/lymphocyte ratio, red blood cell distribution width, and platelet distribution width. This review provides an overview of these parameters that may help stratify the risk of coronary angiographic and clinical outcomes related to ISR.

Evaluation of endothelial function and arterial stiffness in obese individuals with insulin resistance

BACKGROUND

Obesity is associated with metabolic imbalance, including insulin resistance and endothelial dysfunction.

AIM

We aimed to evaluate clinical and vascular parameters in obese with or without insulin resistance.

METHODS

Participants ( n=39) were divided into two groups according to Homeostasis Model Assessment - Insulin Resistance lower (group 1) or higher (group 2) than 2.7. All patients were submitted to clinical, anthropometric, biochemical, vascular structure and endothelial function assessment.

RESULTS

The mean age (53±9 vs. 52±7 years, p=0.784) and body mass index (34.3±4.1 vs. 35.2±3.9 kg/m², p=0.464) were similar in both groups, and 74.4% were treated hypertensive subjects. Fasting glucose (84±7 vs. 97±18 mg/dl, p=0.004) and insulin (9.32±2.48 vs. 22.74±7.49 μU/ml, p<0.001) were higher in group 2. Group 2 presented lower HDL-cholesterol (59±14 vs. 42±12 mg/dl, p<0.001) and higher triglycerides (122±87 vs. 191±112 mg/dl, p=0.042) levels compared with group 1. HOMA-IR was correlated with abdominal circumference ( r=0.51, p=0.001), abdominal/hip ratio ( r=0.57, p<0.001) and triglycerides/HDL ratio ( r=0.53, p=0.001). Differences in brachial flow-mediated dilation did not reach statistical significance (10.2±6.2 vs. 7.9±4.7%, p=0.245). Carotid intima-media thickness, carotid-femoral pulse wave velocity (8.5±1.9 vs. 9.1±1.5 m/s, p=0.334) and central hemodynamic parameters were also similar between groups.

CONCLUSION

Obese individuals with insulin resistance have higher visceral adiposity associated with impaired glucose and lipid metabolism. Endothelial function and arterial stiffness were similar between the groups, perhaps because of antihypertensive treatment in most of these subjects.

Relationship Between Postoperative Neutrophil-Lymphocyte Ratio and 6-Month Primary Patency of Percutaneous Transluminal Angioplasty in Femoropopliteal disease With Drug-Coated and Uncoated Balloons

We investigated the relationship of postoperative neutrophil-lymphocyte ratio (NLR) with 6-month primary patency of percutaneous transluminal angioplasty (PTA) in femoropopliteal disease using drug-coated balloon (DCB) or uncoated balloon (UCB). This retrospective study included 106 patients who received DCB (n = 44) or UCB (n = 62). The postoperative NLR was lower in the DCB group than that in the UCB group (2.60 vs 3.23; P = .004), and 6-month primary patency rate was significantly higher in DCB group than that in the UCB group (77.3% vs 53.2%; P = .011). Multivariate logistic analysis showed that the postoperative NLR was an independent predictor of 6-month primary patency after PTA in patients with femoropopliteal disease (odds ratio: 1.589, 95% confidence interval: 1.078-2.343; P = .019). The cutoff value of postoperative NLR was 3.05 for prediction of 6-month primary patency, with a sensitivity of 64.1% and specificity of 65.7%. The 6-month primary patency rate in the NLR ≤3.05 group was higher than that in the NLR >3.05 group (75.9% vs 47.9%; P = .003). In conclusion, DCB may improve early primary patency by inhibiting inflammation. A higher postoperative NLR was associated with early restenosis.

Association between blood neutrophil-to-lymphocyte ratio and severity of coronary artery disease: Evidence from 17 observational studies involving 7017 cases

This study aimed to evaluate the association between blood neutrophil-to-lymphocyte ratio (NLR) and severity of coronary artery disease (CAD), and investigate the diagnostic ability and optimal cut-off value of NLR in predicting severe stenosis in CAD.A systematic search was conducted in public databases to identify all relevant studies. Weighted mean difference (MD) and 95% confidence interval (CI) were pooled for continuous univariate data, and odds ratios (OR) and 95% CI were calculated for dichotomous multivariate data.Seventeen studies were included in this meta-analysis with a total of 7017 CAD cases. For continuous univariate data, the cases with the highest stenosis category had a significantly higher NLR level than those with lowest stenosis category (MD: 1.57, 95% CI: 1.06-2.09; n = 17). After further classification according to the Gensini or SYNTAX score, the cases with severe stenosis demonstrated a higher NLR than those with mild stenosis (MD: 2.33, 95% CI: 1.22-3.43; n = 6) and moderate stenosis (MD: 1.92, 95% CI: 0.80-3.04; n = 6). Compared with mild stenosis, NLR was also higher in those with moderate-to-severe stenosis (MD: 1.34, 95% CI: 0.77-1.92; n = 6) and moderate stenosis (MD: 0.52, 95% CI: 0.36-0.68; n = 6). For dichotomous multivariate data, high NLR levels were recognized as an independent predictor for severe stenosis in CAD (OR: 1.50, 95% CI: 1.32-1.72; n = 11). NLR showed a diagnostic ability in predicting severe stenosis in CAD (area under receiver operating characteristics [ROC] curve [AUC]: 0.66, 95% CI: 0.64-0.68; n = 8), with the cut-off ranging from 1.95 to 3.97. Subgroup analysis and sensitivity analysis showed the results were robust. Begg's test detected no significant publication biases.This study suggested that high blood NLR was associated with the severity of CAD, and it might be useful for predicting severe stenosis in CAD.

Neutrophil to Lymphocyte Ratio as a Predictor of Restenosis After Angioplasty and Stenting for Asymptomatic Carotid Stenosis

The inflammatory response plays a vital role in the development of in-stent restenosis (ISR) after carotid angioplasty and stenting (CAS). The neutrophil to lymphocyte ratio (NLR) has been suggested as a sensitive inflammatory marker. We explored the association between NLR and ISR in CAS patients. A total of 427 patients who underwent CAS were enrolled. Neutrophil to lymphocyte ratio was measured before the procedure. Clinical examination and radiographic evaluation were performed at 6 months and annually after the procedure. In-stent restenosis was defined as ≥50% stenosis in the treated lesion. Cox regression was used to identify predictors of ISR after CAS. Of the 459 arteries (in 427 patients) with CAS, 72 (15.7%) were identified with ISR during a mean follow-up of 14.6 (19.1) months (range, 0.7-120.7 months). Increased NLR (≥2.13) was significantly related to ISR in patients with asymptomatic stenosis ( P = .001). However, significance was not observed in symptomatic stenosis. On multivariate analysis, baseline NLR ≥ 2.13 (hazard ratio [HR], 2.74; 95% confidence interval [CI], 1.46-5.14), smoking (HR, 1.99; 95% CI, 1.11-3.58), residual stenosis (HR, 1.12; 95% CI, 1.09-1.15), and baseline glucose level (HR, 1.01; 95% CI, 1.01-1.02) were associated with ISR. Elevated NLR may be a predictor of ISR after CAS for asymptomatic stenosis.

Novel Biomarkers for Coronary Restenosis Occurrence After Drug-Eluting Stent Implantation in Patients With Diabetes Having Stable Coronary Artery Disease

The purpose of the study was to assess whether the occurrence of restenosis is associated with CD45+ platelet count and neutrophil to lymphocyte ratio in patients with type 2 diabetes mellitus (DM) after drug-eluting stent (DES) implantation for stable coronary artery disease (CAD). The study comprised 126 patients, including 55 patients with type 2 DM and stable CAD who underwent elective coronary artery stenting with DES and follow-up angiography within 6 to 12 months. Blood samples were collected from each patient on the morning of the coronary angiography procedure. The variables related to in-stent restenosis were selected by logistic regression analysis. The logistic regression analysis showed that 2 inflammatory factors, CD45+ platelet count (odds ratio [OR] = 4.51, 95% confidence interval [CI]: 1.50-13.50, P = .007) and neutrophil to lymphocyte ratio (OR = 3.09, 95% CI: 1.05-9.10, P = .04), were significantly associated with the risk of in-stent restenosis after stenting with DES in patients with stable CAD and type 2 DM. A receiver operator characteristic curve analysis indicated that the area under the curve was 0.83% (0.05%; P < .001), which showed that the logistic model had good predictive accuracy (based on CD45+ platelet count and neutrophil to lymphocyte ratio) for the risk of in-stent restenosis development in DES in patients with CAD and type 2 DM. Two novel biomarkers of restenosis, CD45+ platelet count and neutrophil to lymphocyte ratio, may be effectively used to predict in-stent restenosis after DES implantation in patients with CAD and type 2 DM.

Usefulness of Platelet-to-Lymphocyte Ratio to Predict Long-Term All-Cause Mortality in Patients at High Risk of Coronary Artery Disease Who Underwent Coronary Angiography

Platelet-to-lymphocyte ratio (PLR) has recently been studied as a biomarker in patients with established coronary artery disease (CAD). The association between PLR and long-term all-cause mortality is unclear in patients at high risk of CAD who undergo coronary angiography for various indications. Follow-up was completed for 514 patients who underwent coronary angiography in a prospective study cohort. The primary end point was all-cause mortality. Patients were classified into tertiles based on preangiography PLR and also dichotomized based on the optimal cutoff at a PLR of 137, determined from the receiver operating characteristic curve analysis. The mean follow-up period was 5.0 ± 1.3 years, with 50 all-cause deaths. On the Kaplan-Meier analysis, patients in Tertile 3 (PLR > 145) had worse prognosis than patients in Tertiles 1 (PLR ≤ 106) and 2 (PLR 106.1 to 145) (p = 0.0075), and patients with PLR ≥ 137 had a significantly higher rate of all-cause mortality than those with PLR < 137 (p = 0.0006). On multivariate Cox regression adjusting for known cardiovascular risk factors, PLR was a strong, independent predictor of long-term all-cause mortality on the tertile analysis (Tertile 3 vs Tertile 1: hazard ratio 2.52, 95% confidence interval 1.18 to 5.39, p = 0.017) and based on the cutoff at a PLR of 137 (PLR ≥ 137 vs <137: hazard ratio 2.25, 95% confidence interval 1.21 to 4.20, p = 0.011). In conclusion, elevated PLR is associated with long-term all-cause mortality in patients at high risk of CAD who undergo coronary angiography, and PLR may be a useful prognostic biomarker in this population.

Association of serum procalcitonin level with in-stent restenosis in patients undergoing bare-metal stent implantation

AIM

Procalcitonin (PCT) is an inflammatory marker and elevated PCT levels are associated with cardiovascular events. We assessed whether PCT level is an independent predictor of bare-metal stent (BMS) in-stent restenosis (ISR).

PATIENTS & METHODS

We evaluated 240 patients undergoing BMS implantation. Serum PCT levels were measured before procedure. Patients were classified as ISR(-) group (n = 120) and ISR(+) group (n = 120).

RESULTS

Serum PCT levels were higher in the ISR (+) group (p < 0.001). At multivariate analysis, PCT (odds ratio [OR] 1.561; p = 0.012), stent length (OR: 1.089), stent diameter (OR: 0.141) and uric acid (OR: 1.465) were independent predictors of ISR.

CONCLUSION

Serum PCT is independently associated with ISR and increased PCT levels may provide useful information for the risk of BMS-ISR.

Increased neutrophil to lymphocyte ratio predicts myocardial injury in patients undergoing non-cardiac surgery

BACKGROUND

The neutrophil to lymphocyte ratio (NLR), has been proposed as potential indicator of cardiovascular events. Our aim was to determine the relationship between NLR and development of myocardial injury after non-cardiac surgery (MINS).

METHODS

This observational cohort study included 255 consecutive noncardiac surgery patients aged ≥45 years. Electrocardiography recordings and high sensitivity cardiac troponin T (hscTnT) levels of the patients were obtained for a period of 3 days postoperatively.

RESULTS

MINS was detected in 30 (11.8%) patients using the cut-off level of ≥14 ng/L for hscTnT. In the MINS group NLR (3.79 ± 0.7 vs. 2.69 ± 0.6, p < 0.000) values were higher than non-NLR group. The NLR to be independently associated with the development of MINS (OR: 11.690; CI: 4.619-29.585, p < 0.000).

CONCLUSIONS

NLR seems to be a simple, easy and cheap tool to predict the development of MINS in patient undergoing non-cardiac surgery.

Opposite impact of Methylene tetrahydrofolate reductase C677T and Methylene tetrahydrofolate reductase A1298C gene polymorphisms on systemic inflammation

BACKGROUND

Methylenetetrahydrofolate reductase (MTHFR) gene polymorphisms have been found to be related with many diseases. Systemic inflammation is now considered as a major predisposition factor for diseases including diabetes mellitus (DM), coronary arterial disease (CAD), stroke, and cancer. This study aimed to investigate whether systemic inflammation is a possible underlying pathogenesis for MTHFR gene polymorphism-related disease.

METHODS

A total of 292 patients were enrolled, and single nucleotide polymorphisms for MTHFR C667T and A1298C were genotyped. Systemic inflammation markers, neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) were collected.

RESULTS

In our study population, MTHFR 677 variants had significant higher NLR level than MTHFR 677 wild type (3.77 ± 0.26 vs 3.06 ± 0.18, P = .028). Logistic regression analysis showed that MTHFR 677 variants were significantly associated with increased NLR level. MTHFR 1298 variants showed the opposite effects which tended to have lower level of NLR (3.21 ± 0.16 vs 3.79 ± 0.34, P = .087) and PLR (137.0 ± 4.8 vs 157.7 ± 9.4, P = .052) than MTHFR 1298 wild type. General linear model showed that there was no statistically significant interaction between MTHFR C667T and A1298C gene polymorphism on NLR or PLR.

CONCLUSIONS

This study indicates that MTHFR C677T and MTHFR A1298C gene polymorphisms have opposite effect on systemic inflammation, and systemic inflammation may contribute to the pathogenesis for diseases associated with MTHFR C667T gene polymorphism.

Evaluation of Preprocedural Laboratory Parameters as Predictors of Drug-Eluting Stent Restenosis in Coronary Chronic Total Occlusion Lesions

This retrospective, single-center study assessed the prognostic value of several emerging inflammatory markers as predictors of in-stent restenosis (ISR) after drug-eluting stent implantation for coronary chronic total occlusion (CTO) lesions. Consecutive patients (n = 416) who underwent successful percutaneous coronary intervention (PCI) for documented CTO lesions and with follow-up angiography were enrolled. Preprocedural high-sensitivity C-reactive protein (hsCRP), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and red cell distribution width (RDW) were analyzed. At mean follow-up of 14.4 ± 3.3 months, ISR occurred in 72 patients. Compared with the non-ISR group, preprocedural hsCRP level, PLR, NLR, and RDW were significantly higher in the ISR group. The ISR group also had significantly greater proportions of patients with diabetes and smoking history, lower estimated glomerular filtration rate, higher low-density lipoprotein cholesterol (LDL-C) level and neutrophil count, longer stent length, and higher rate of severe dissection. In multivariate analysis, NLR (odds ratio [OR]: 3.110; 95% confidence interval [CI], 2.102-4.063; P < .001) and PLR (OR: 1.029; 95% CI, 1.016-1.143; P < .001) were independent predictors of ISR, along with LDL-C level and stent length. In conclusion, higher preprocedural NLR and PLR levels were independent risk factors for the development of ISR in patients who underwent PCI for CTO lesions.

CXCR2 Inhibition - a novel approach to treating CoronAry heart DiseAse (CICADA): study protocol for a randomised controlled trial

Background

There is emerging evidence of the central role of neutrophils in both atherosclerotic plaque formation and rupture. Patients with lower neutrophil counts following acute coronary syndromes tend to have a greater coronary flow reserve, which is a strong predictor of long-term cardiovascular health. But so far, no data are available regarding the impact of neutrophil inhibition on cardiovascular clinical or surrogate endpoints. Therefore, the aim of this study is to investigate the effects of AZD5069, a cysteine-X-cysteine chemokine receptor 2 (CXCR2) inhibitor, on coronary flow reserve and coronary structure and function in patients with coronary artery disease.

Methods/Design

Ninety subjects with coronary artery disease undergoing percutaneous coronary intervention will be included in this investigator-driven, randomised, placebo-controlled, double-blind, phase IIa, single-centre study. Participants will be randomised to receive either AZD5069 (40 mg) administered orally twice daily or placebo for 24 weeks. Change in coronary flow reserve as determined by ¹³N-ammonia positron emission tomography-computed tomography will be the primary outcome. Change in the inflammatory component of coronary plaque structure and the backward expansion wave, an invasive coronary physiological measure of diastolic function, will be assessed as secondary outcomes.

Discussion

Cardiovascular surrogate parameters, such as coronary flow reserve, may provide insights into the potential mechanisms of the cardiovascular effects of CXCR2 inhibitors. Currently, ongoing trials do not specifically focus on neutrophil function as a target of intervention, and we therefore believe that our study will contribute to a better understanding of the role of neutrophil-mediated inflammation in coronary artery disease.

Trial registration

EudraCT, 2016-000775-24. Registered on 22 July 2016.

International Standard Randomised Controlled Trial Number, ISRCTN48328178. Registered on 25 February 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2210-2) contains supplementary material, which is available to authorized users.

Usefulness of the CHA2DS2-VASc Score in Predicting In-Stent Restenosis Among Patients Undergoing Revascularization With Bare-Metal Stents

In-stent restenosis (ISR) is a limitation of percutaneous coronary intervention and has been linked to specific clinical and angiographic variables. The aim of the present study was to investigate the predictive value of preprocedural CHA2DS2-VASc score on ISR in patients undergoing revascularization with bare-metal stent (BMS) implantation for stable coronary artery disease or acute coronary syndrome. In the years 2012 to 2014, a total of 358 consecutive patients (mean age: 62.36 ± 11.28 years and 62.2% men) who had undergone successful BMS implantation were included in the study. All patients underwent stent implantation at admission to our center and had another coronary angiography performed due to recurrence of the symptoms consistent with myocardial ischemia and/or a stress test indicating ischemia. The patients were divided into 2 groups-ISR (n = 166) and non-ISR (n = 192). Angiographic ISR was defined as narrowing ≥50% in the stented coronary artery segment at follow-up angiography. The mean CHA2DS2-VASc score was 3.42 ± 1.35 (range 1-7). The CHA2DS2-VASc scores and high-sensitivity C-reactive protein (hs-CRP) levels were higher in the ISR group compared to the non-ISR group. At multivariable analysis, CHA2DS2-VASc score (odds ratio [OR]: 2.004, 95% confidence interval: 1.361-2.949, P < .001), total stent length (OR: 1.093, P = .001), stent diameter (OR: 0.129, P < .001), and hs-CRP (OR: 1.224, P < .001) emerged as independent risk factors for ISR. In conclusion, preprocedural CHA2DS2-VASc is an easily calculated score that provides an additional level of risk stratification beyond that provided by conventional risk factors. Thus, this score can be used as a simple and effective tool to predict ISR in patients undergoing BMS implantation.

Correlation and prognostic role of neutrophil to lymphocyte ratio and SYNTAX score in patients with acute myocardial infarction treated with percutaneous coronary intervention: A six-year experience

BACKGROUND/PURPOSE

The neutrophil/lymphocyte ratio (NLR) has been proposed as a prognostic marker in acute myocardial infarction (AMI). The aim of our study is to demonstrates the correlation between SYNTAX score (SXs) and NLR and its association with 1-year cardiovascular (CV) mortality in patients with ST-segment elevation myocardial infarction (STEMI) or non-ST-segment elevation myocardial infarction (NSTEMI) treated with percutaneous coronary intervention (PCI).

METHODS/MATERIALS

Over 6 consecutive years, (1st January 2010 and 1st January 2016) 6560 patients (4841 males and 1719 females, mean age 64.36±11.77years) were admitted for AMI and treated with PCI within 24-h. The study population was divided into tertiles based on the SXs.

RESULTS

Both in STEMI and NSTEMI groups, neutrophils and the SXs were significantly higher (p<0.0001) in upper versus lower among NLR tertiles and a significant correlation was found between the NLR and SXs (r=0.617, p<0.0001 and r=0.252, p<0.0001 for STEMI and NSTEMI groups, respectively). One-year CV mortality significantly raised up among the NLR tertiles in both STEMI and NSTEMI patients (p<0.0001). Multivariate analysis revealed that, after adjusting SXs and PAD, an NLR (≥3.9 and ≥2.7 for STEMI and NTEMI patients, respectively) was an independent significant predictor of 1-year CV mortality (OR 2.85, 95% CI 1.54-5.26, p=0.001 and OR 2.57, 95% CI 1.62-4.07, p<0.0001 for STEMI and NSTEMI respectively.) CONCLUSIONS: NLR significantly correlates with SXs and is associated with 1-year CV mortality in patients with STEMI or NSTEMI treated with PCI within 24-h.

Neutrophil to Lymphocyte Ratio as a predictor of early penile prosthesis implant infection

PURPOSE

To investigate the predictive value of preoperative serum neutrophil-to-lymphocyte ratio (NLR) on the development of postoperative infections in patients undergoing penile prosthesis implantation (PPI).

METHODS

We retrospectively analyzed the data of 361 patients who underwent PPI over a 4-year period with at least 1-year follow-up. Demographics, blood results, and postoperative 1-year complications were recorded. Recommended cutoff values of NLR for early postoperative infectious complications were determined using receiver operating characteristic analysis.

RESULTS

A total of 153 patients with the mean age of 56.4 ± 8 years were included in the study. Mean follow-up time was 56.7 ± 30.4 months (12-108 months). Early postoperative infectious complications were occured in 18 patients (11.8%). These infections were prosthesis infection in 8 patients (5.2%), wound infection in 6 patients (3.9%), and urinary tract infection in 4 patients (2.6%). All these complications were occured within the first year of the surgery. Mean NLR was statistically higher in patients with postoperative complications when compared with uncomplicated cases (7.2 ± 3.9 vs. 2.2 ± 1.4, p < 0.001, respectively) Using a cut point of 6.2, preoperative NLR predicted postoperative complications with a sensitivity of 67% and specificity of 99%.

CONCLUSIONS

This study is the first to investigate the relationship between NLR and early postoperative infection as a complication of PPI. The results demonstrated that the NLR value could be a potential laboratory parameter for predicting early postoperative infectious complications in patients undergoing PPI.

High Preoperative Neutrophil-Lymphocyte Ratio (NLR) and Red Blood Cell Distribution Width (RDW) as Independent Predictors of Native Arteriovenous Fistula Failure

Objective: To study the association between a high preoperative neutrophil lymphocyte ratio (NLR) and red cell distribution width (RDW) with arteriovenous fistula (AVF) failure, as well as to determine the cut-off values in a South Asian population.

Materials and Methods: A total of 150 consecutive patients with a failed fistula who presented in the Department of Vascular Surgery between January 2014 and January 2016. Patients fulfilling the inclusion criteria were selected as defined as Case. They were compared with 150 patients who had matured fistulae (Control).

Results: A significant difference was found between the Case and Control groups in mean preoperative NLR (3.3±0.5 versus 2.2±0.9, P value=0.011) and RDW (15.9±2.9 versus 13.6±1.1%, P value of 0.02), respectively. Multivariate analysis revealed that NLR (Odds Ratios (OR) 1.39; 95% Confidence Intervals (CI) 1.02 to 2.08; P<0.001) and RDW (OR 1.39; 95%CI 1.11 to 1.69; P<0.001) were strong independent predictors of AVF failure. A receiver operating characteristic curve analysis showed a cut-off value of 2.65 (specificity 80%, sensitivity 98%) and 15.1 (specificity 79%, sensitivity 98%) for NLR and RDW, respectively.

Conclusion: Increased preoperative NLR and RDW were associated with a high rate of AVF failure in a South Asian population.

Blood level of CD45+ platelets and development of restenosis after drug-eluting stent implantation in patients with stable coronary artery disease

OBJECTIVE

The aim of this study was to assess CD45-positive platelets (CD45+ platelets) involvement in restenosis development after drug-eluting stent (DES) implantation in patients with stable coronary artery disease (CAD).

METHODS

The study comprised 126 male and female patients with stable angina pectoris, who underwent elective coronary stenting with DES and follow-up angiography within 6-12 months. The patients were assigned to the group with restenosis (n = 53) or group without restenosis (n = 73) according to the follow-up angiograms. In both groups we compared the level in blood of CD45+ platelets, the clinical, laboratory and angiographic variables, which may affect the development of restenosis. We have also constructed a logit regression model for prognosis of restenosis occurrence after DES implantation.

RESULTS

The blood count of CD45+ platelets was higher in patients with restenosis than in patients without: 0.82 % (0.58; 1.12) vs. 0.34 % (0.20; 0.68), p < 0.001, data are expressed as median (lower quartile; upper quartile). By binary comparisons of more than 35 different clinical, laboratory and angiographic variables we identified 8 significant risk factors for the development of stent restenosis after DES. In order to define the risk of the development of restenosis, we have built a logit regression model. The resulting logit regression equation included the level of CD45+ platelets, the neutrophil to lymphocyte ratio (NLR), small diameter arteries stenting and the number of simultaneously implanted stents in one patient. Receiver operating characteristic (ROC) curve analysis has demonstrated the high prognostic value of the resulting logit regression equation with an area under the curve (AUC) of 0.91 % (p < 0.001).

CONCLUSIONS

The acquired data indicate the presence of a close relationship between circulating CD45+ platelets and restenosis development after DES implantation in patients with stable CAD.

Usefulness of the monocyte-to-high-density lipoprotein cholesterol ratio to predict bare metal stent restenosis

Aim: The aim of the present study was to investigate the predictive value of preprocedural monocyte count-to-high-density lipoprotein cholesterol ratio (MHR) on development of in-stent restenosis in patients undergoing coronary bare-metal stent (BMS) implantation. Patients & methods: Data from 705 patients who had undergone BMS implantation and additional control coronary angiography were analyzed. Results: Patients were divided into three tertiles based on preprocedural MHR. Restenosis occurred in 59 patients (25%) in the lowest tertile, 84 (35%) in the middle tertile and 117 (50%) in the highest MHR tertile (p < 0.001). Using multiple logistic regression analysis, smoking, diabetes mellitus, stent length, preprocedural MHR and C-reactive protein levels emerged as independent predictors of in-stent restenosis. Conclusion: High preprocedural MHR is related to BMS restenosis.