Neutrophil-to-Lymphocyte Ratio and Outcomes in Patients Admitted for Acute Heart Failure (As Seen in the BLAST-AHF, Pre-RELAX-AHF, and RELAX-AHF Studies)

Acute-on-chronic inflammation in acute myocardial infarction

PURPOSE OF REVIEW

Acute myocardial infarction (AMI) is heralded by chronic inflammation and entails an excessive burst of acute-on-chronic inflammation (AoCI). This review describes the evolution from understanding atherosclerosis as a chronic inflammatory disease, to recent efforts in optimizing anti-inflammatory therapy to patients with AMI. It highlights the challenges and opportunities in selecting the optimal patient with AMI to derive maximal benefit from early anti-inflammatory therapy.

RECENT FINDINGS

The causal role of inflammation in atherosclerosis has been proven in large outcome trials. Since then, several smaller trials have sought to translate the concept of anti-inflammatory therapy targeting residual inflammatory risk to the dynamic early phase of AoCI after AMI. Current evidence highlights the importance of selecting patients with a high inflammatory burden. Surrogate criteria for large AMI (e.g., angiographic or electrocardiographic), as well as novel point-of-care biomarker testing may aid in selecting patients with particularly elevated AoCI. Additionally, patients presenting with AMI complicated by pro-inflammatory sequelae (e.g., atrial fibrillation, acute heart failure, left ventricular thrombosis) may dually profit from anti-inflammatory therapy.

SUMMARY

Improved understanding of the mechanisms and dynamics of acute and chronic inflammatory processes after AMI may aid the strive to optimize early anti-inflammatory therapy to patients with AMI.

Association of innate versus specific immunity with heart failure incidence: a prospective study

BACKGROUND

Immune disorders are key heart failure (HF) triggers, but little is known about whether the status of immunity affects the incidence of HF. To explore this, we used blood cell counts and derived ratios to investigate the association between immunity status markers and HF incidence.

METHODS

The number and proportion of peripheral blood leucocytes in a physiological state are related to the body's immune status. Neutrophils, monocytes, SII (systemic immune-inflammatory index), NLR (neutrophil-to-lymphocyte ratio), and PLR (platelet-to-lymphocyte ratio) serve as innate immunity status markers, while lymphocytes and LMR (lymphocyte-to-monocyte ratio) serve as specific immunity status markers. 330 362 UK Biobank (UKB) participants were finally examined. Cox proportional hazard models were used to explore the relationship between immunity status markers and HF incidence. Flexible parametric survival models were used to capture time-varying relationships between blood cell ratios and HRs for HF. Subgroup analyses were conducted by age, sex, and body mass index. Finally, sensitivity analyses were performed to validate the results.

RESULTS

During a median follow-up of 14.1 years, 9611 (2.9%) participants developed HF. Neutrophils, monocytes, SII, and NLR were positively associated with HF incidence, with fully adjusted per SD increment HR (95% CI) of 1.20 (1.17 to 1.22), 1.09 (1.07 to 1.12), 1.12 (1.10 to 1.14), and 1.16 (1.14 to 1.18), respectively. Platelets, lymphocytes, and LMR were inversely correlated with HF incidence, with fully adjusted per SD increment HR (95% CI) of 0.97 (0.95 to 1.00), 0.97 (0.95 to 0.99), and 0.90 (0.88 to 0.92), respectively.

CONCLUSIONS

The innate immunity status markers were positively associated with HF incidence, while specific immunity status markers exhibited an inverse association, offering novel insights for HF prediction and intervention.

Relative Values of Hematological Indices for Prognosis of Heart Failure: A Mini-Review

Owing to the augmented perception of heart failure (HF) pathophysiology, management of the affected patients has been improved dramatically; as with the identification of the inflammatory background of HF, new avenues of HF prognosis research have been opened up. In this regard, relative values of hematologic indices were demonstrated by a growing body of evidence to successfully predict HF outcomes. Cost-effectiveness, accessibility, and easy obtainability of these relative values make them a precious option for the determination of HF prognosis; particularly in low-income developing countries. In this short review, we aimed to present the current literature on the predictability of these hematologic parameters for HF outcomes.

Corticosteroid burst therapy in patients with acute heart failure: Design of the CORTAHF pilot study

AIMS

Inflammation has emerged as a potential key pathophysiological mechanism in heart failure (HF) in general and acute HF (AHF) specifically, with inflammatory biomarkers shown to be highly predictive of adverse outcomes in these patients. The CORTAHF study builds on both these data and the fact that steroid burst therapy has been shown to be effective in the treatment of respiratory diseases and COVID-19. Our hypothesis is that in patients with AHF and elevated C-reactive protein (CRP) levels without symptoms or signs of infection, a 7-day course of steroid therapy will lead to reduced inflammation and short-term improvement in quality of life and a reduced risk of worsening HF (WHF) events.

METHODS AND RESULTS

The study, which is currently ongoing, will include 100 patients with AHF ages 18-85, regardless of ejection fraction, screened within 12 h of presentation. Patients will be included who have NT-proBNP > 1500 pg/mL and CRP > 20 mg/L at screening. Exclusion criteria include haemodynamic instability and symptoms and signs of infection. After signed consent, eligible patients will be randomized according to a central randomization scheme stratified by centre 1:1 to either treatment once daily for 7 days with 40 mg prednisone orally or to standard care. Patients will be assessed at study day 2, day 4 or at discharge if earlier, and at days 7 and 31 at the hospital; and at day 91 through a telephone follow-up. The primary endpoint is the change in CRP level from baseline to day 7, estimated from a mixed model for repeated measures (MMRM) including all measured timepoints, in patients without a major protocol violation. Secondary endpoints include the time to the first event of WHF adverse event, readmission for HF, or death through day 91; and changes to day 7 in EQ-5D visual analogue scale score and utility index. Additional clinical and laboratory measures will be assessed.

CONCLUSIONS

The results of the study will add to the knowledge of the role of inflammation in AHF and potentially inform the design of larger studies with possibly longer duration of anti-inflammatory therapies in AHF.

Prognostic roles of neutrophil-lymphocyte, monocyte-lymphocyte and platelet-lymphocyte ratios for long-term all-cause mortality in heart failure

Background

Heart failure (HF) and inflammation have a bidirectional relation leading to activation and adaptation of multiple cellular lines, including leucocyte subtypes and platelets. We aimed to assess and compare the predictive value of the neutrophil-lymphocyte (NLR), monocyte-lymphocyte (MLR) and platelet-lymphocyte (PLR) ratios for all-cause long-term mortality in HF.

Methods

This is an observational retrospective cohort study that included patients from the HI-HF cohort that survived the initial hospitalization. Vital status and survival time were assessed in June 2020.

Results

We analyzed 1018 HF patients with a mean age of 72.32 ± 10.29 years and 53.54 % women. All-cause long-term mortality was 38.21 % after a median follow-up time of 68 [38 - 82] months. NLR (AUC 0.667, 95 %CI 0.637 - 0.697), MLR (AUC 0.670, 95 %CI 0.640 - 0.700) and PLR (AUC 0.606, 95 %CI 0.574 - 0.636) were predictors of all-cause mortality. In multivariable Cox proportional hazards analysis, NLR≥3.56 was the only hematological index independent predictor of fatality (HR 1.36, 95 %CI 1.05 - 1.76).

Conclusions

Of the three hematological indices, NLR was the only independent predictor of all-cause long-term mortality of HF patients. We suggest NLR≥3.56 as an auxiliary prognostic biomarker for the evaluation of HF patients.

The Prognostic Role of the Neutrophil-to-Lymphocytes Ratio in the Most Frequent Cardiovascular Diseases: An Update

Given the continuous changes in the world, with an increasing trend of unhealthy lifestyles, metabolic comorbidities, and increased susceptibility to cardiovascular diseases (CVDs), researchers change their attention to improve not only the therapeutic platform but also current CVD predictive and prognostic tools to improve disease outcomes. As CVD is characterized by an inflammatory paradigm involving, to some degree, the innate and adaptative immune systems, the neutrophil-to-lymphocyte ratio (NLR) emerged as a potential low-cost, rapidly available, and reliable inflammatory marker, with substantial recent evidence showing its potential utility in clinical practice. Thus, in this literature review, we will present an up-to-date discussion of the prognostic role of NLR in the most frequent CVDs, such as acute and chronic coronary disease, atherosclerotic disease, heart failure, cardiac valvopathies, and cardiac arrhythmias with predilection to atrial fibrillation.

Soluble ST2 as a possible biomarker for inflammation in patients with acute heart failure

AIM

The aim of this study was to explore the relationship between peripheral circulating serum soluble suppression of tumorigenicity-2 (sST2) levels and inflammatory biomarkers in patients with acute heart failure (AHF).

METHODS

One hundred and eleven consecutive AHF patients with NYHA class II-IV were enrolled, and peripheral blood was collected within 24 h of admission for the detection of NT-ProBNP, sST2, hypersensitive troponin I, cytokines, precalcitoninogen, C-reactive protein, in addition to routine standard of care blood tests.

RESULTS

The median sST2 of 111 patients was 47.50 ng/ml (24.25-86.15 IQR), of whom 43 patients (38.7%) had sST2 35 ng/ml or less; linear correlation analysis showed that serum sST2 correlated with NT-ProBNP ( r2  = 0.32), NEU% ( r2  = 0.41), NLR ( r2  = 0.36), CRP ( r2  = 0.50), IL-18 ( r2  = 0.43) ( P  < 0.001), and correlated with Hs-cTnI ( r2  = 0.19), NUE ( r2  = 0.25), LYM ( r2  = -0.23), IL-2RA ( r2  = 0.29) ( P  < 0.05). Multiple linear regression analysis depicted that CRP (β = 0.318), IL-18 (β = 0.368), NEU% (β = 0.346), NLR (β = -0.304), and NT-ProBNP (β = 0.324) significantly correlated with sST2 values, respectively ( P  < 0.05). ST2 levels have a linear association with length of hospitalization.

CONCLUSION

Peripheral blood inflammatory markers (CRP, IL-18, NEU%, NLR) in patients with AHF had a close relationship with sST2 levels, and the mechanism of action of sST2 may be related to the inflammatory response.

Causal effects between circulating immune cells and heart failure: evidence from a bidirectional Mendelian randomization study

BACKGROUND

Heart failure (HF) is a prevalent cardiac condition characterized by high mortality and morbidity rates. Immune cells play a pivotal role as crucial biomarkers in assessing the overall immune status of individuals. However, the causal relationship between circulating immune cells and the pathogenesis of HF remains an area requiring further investigation.

OBJECTIVES

The aim of this study was to investigate the genetic interactions between circulating immune cells and HF, and to further elucidate the genetic associations between different lymphocyte subsets and HF.

METHODS

We obtained genetic variants associated with circulating immune cells as instrumental variables (IVs) from the Blood Cell Consortium and publicly available HF summary data. We conducted additional subsets analyses on lymphocyte counts. Our study utilized two-sample and multivariate Mendelian randomization (MVMR) analysis to investigate the causal effect of immune cells on HF. The primary analysis employed inverse variance weighting (IVW) and was complemented by a series of sensitivity analyses.

RESULTS

The findings of the study showed that the IVW model demonstrated a significant correlation between an elevation in lymphocyte count and a decreased risk of HF (OR = 0.97, 95% CI, 0.94 - 1.00, P = 0.032). However, no such correlation was evident in the MVMR analysis for lymphocytes and HF. Furthermore, the examination of the lymphocyte subsets indicated that an increase in CD39+ CD4+ T-cell counts was notably linked to a reduced risk of HF (OR = 0.96, 95% CI, 0.95 - 0.98, P = 0.0002). The MVMR results confirmed that the association between CD39+ CD4+ T-cell counts and HF remained significant. There was no substantial evidence of reverse causality observed between circulating immune cells and HF.

CONCLUSION

Our MR research provided evidence for a causal relationship between lymphocyte cell and HF. Subsets analyses revealed a causal relationship between CD39+ CD4+ T lymphocytes and HF. These findings will facilitate a future understanding of the mechanisms underlying HF.

Neutrophil to lymphocyte ratio (NLR) prognostic effects on heart failure; a systematic review and meta-analysis

BACKGROUND

Neutrophil to lymphocyte ratio (NLR), as a recent inflammatory index, has been reported to be a prognostic tool in different diseases. However, implication of this ratio in heart failure (HF) is less investigated. In this systematic review and meta-analysis, we aimed to assess the potential impact of NLR on HF clinical outcomes.

METHODS

Relevant English published records in PubMed, Scopus, Embase, and Web of Science were screened up to July 2023. Articles reporting clinical outcomes (follow-up or in-hospital mortality, readmission, HF prediction, extended hospital stay length, pulmonary vascular resistance, atrial fibrillation, renal disease and functional capacity) in HF sufferers were collected for further analysis with addition of NLR difference stratified by death/survived and HF status.

RESULTS

Thirty-six articles (n = 18231) were finally selected which reported NLR in HF sufferers (mean: 4.38, 95% confidence interval (CI): 4.02-4.73). We found 25 articles reported NLR and total mortality (either follow-up death (N = 19): 4.52 (95% CI: 4.03-5.01) or in-hospital death (N = 10): 5.33 (95% CI: 4.08-6.57)) with mean NLR of 4.74 (95% CI: 4.28-5.20). NLR was higher among deceased patients compared to survived ones (standard mean difference: 0.67 (95% CI: 0.48-0.87), P < 0.001)). NLR was found to be related with higher mortality risk (continuous variable: hazard ratio (HR): 1.12, 95% CI: 1.02-1.23, P = 0.013), categorical variable: HR: 1.77, 95% CI: 1.27-2.46, P = 0.001, T2 vs. T1: HR:1.56, 95%CI: 1.21-2.00, P = 0.001, T3 vs. T1: HR:2.49, 95%CI: 1.85-3.35, P < 0.001). Other aforementioned variables were not feasible to analyze due to presence of few studies.

CONCLUSIONS

NLR is a simple and acceptable prognostic tool for risk stratification and prioritizing high risk patients in clinical settings, especially in resource limited nations.

Association between the neutrophil-to-lymphocyte ratio and risk of in-hospital heart failure and arrhythmia in patients with acute myocardial infarction

Background

This study was to probe into the relationship between the neutrophil-to-lymphocyte ratio (NLR) and both in-hospital and long-term heart failure risk in patients with acute myocardial infarction (AMI).

Methods

990 patients with AMI, including 386 with non-ST-segment elevation myocardial infarction (NSTEMI) and 604 with segment elevation myocardial infarction (STEMI) were recruited between January 2019 and March 2022. The in-hospital acute heart failure (AHF) and arrhythmia events were recorded.

Results

The NLR was significantly greater in the AHF group in STEMI and NSTEMI patients, with a higher frequency of arrhythmia in comparison to the non-AHF group. A high NLR was related to a high level of myocardial injury markers, accompanied with more AHF and arrhythmia events. Multivariate logistic regression analyses revealed that high NLR is independently linked with increased in-hospital AHF and arrhythmia risk. Receiver operating characteristic curve analyses revealed that the prognostic value of NLR for in-hospital AHF was 0.704 in STEMI patients and 0.766 in NSTEMI patients. However, during a median follow-up of 28 months with 32 heart failure patients, there was no significant difference between the low NLR group (n = 18) and the high NLR group (n = 14). Further analysis showed that the two groups did not significantly differ in the occurrence of heart failure within 12 months of discharge.

Conclusion

Our results indicate that NLR is an independent risk factor of in-hospital AHF in AMI patients. However, NLR has no value in predicting long-term heart failure.

The Value of Neutrophil-to-Lymphocyte Ratio and Epicardial Adipose Tissue Thickness in Heart Failure With Preserved Ejection Fraction

Background Using epicardial adipose tissue thickness (EATt) and neutrophil-to-lymphocyte ratio (NLR) as individual indicators provides beneficial insight into the prognosis of patients suffering from heart failure with preserved ejection fraction (HFpEF). Aim In our study, we aimed to evaluate whether the combined evaluation of NLR and EATt would provide an advantage for identifying high-risk HFpEF patients according to hospitalization for heart failure (HHF) and left ventricular diastolic dysfunction (LVDD). Method A total of 168 outpatients with HFpEF were retrospectively analyzed. The predictive performance of two inflammatory variables was assessed by the receiver operating characteristic curve and a one-way analysis of variance (ANOVA) test. The patients were stratified into three distinct risk categories based on the established cut-off values for EATt and NLR as follows: Group I, high risk; Group II, middle risk; and Group III, low risk. Results Patients in Group I had the highest risk for HHF and the presence of LVDD (p=0.001 for HHF, p=0.011 for LVDD). Patients in Group I also exhibited more symptomatic and a greater number of comorbidities. In Group I, more structural remodeling (enlarged left ventricular end-systolic volume index (LVESVI) and left atrial volume index (LAVI)) and associated signs of increased intracardiac pressure (elevated E/A ratio, medial E/e') were observed. Conclusion The results of our study indicate that the use of both EATt and NLR among patients with HFpEF may provide better accuracy in predicting HHF and LVDD compared to the use of either EATt or NLR alone.

Correlation analysis between the static and the changed neutrophil-to-lymphocyte ratio and in-hospital mortality in critical patients with acute heart failure

OBJECTIVE

Association between neutrophil-to-lymphocyte ratio (NLR) on admission and poor prognosis in patients with acute heart failure (AHF) has been well established. However, the relationship between dynamic changes in NLR and in-hospital mortality in AHF patients has not been studied. Our purpose was to determine if an early change in NLR within the first week after AHF patients was admitted to intensive care unit (ICU) was associated with in-hospital mortality.

METHODS

Data from the medical information mart for intensive care IV (the MIMIC-IV) database was analyzed. The effect of baseline NLR on in-hospital mortality in critical patients with AHF was evaluated utilizing smooth curve fitting and multivariable logistic regression analysis. Moreover, comparison of the dynamic change in NLR among survivors and non-survivors was performed using the generalized additive mixed model (GAMM).

RESULTS

There were 1169 participants who took part in the present study, 986 of whom were in-hospital survivors and 183 of whom were in-hospital non-survivors. The smooth curve fitting revealed a positive relationship between baseline NLR and in-hospital mortality, and multivariable logistic regression analysis indicated that baseline NLR was an independent risk factor for in-hospital mortality (OR 1.04, 95% CI 1.02,1.07, P-value = 0.001). After adjusting for confounders, GAMM showed that the difference in NLR between survivors and non-survivors grew gradually during the first week after ICU admission, and the difference grew by an average of 0.51 per day (β = 0.51, 95% CI 0.45-0.56, P-value <0.001).

CONCLUSIONS

Baseline NLR was associated with poor prognosis in critical patients with AHF. Early rises in NLR were linked to higher in-hospital mortality, which suggests that keeping track of how NLR early changes might help identify short-term prognosis of critical patients with AHF.