Is elevated triglyceride/high-density lipoprotein cholesterol ratio associated with poor prognosis of coronary heart disease? A meta-analysis of prospective studies

BACKGROUND

Elevated triglycerides (TG) and reduced high-density lipoprotein cholesterol (HDL-C) are recognized as essential and independent hazard factors for total death and major adverse cardiovascular events (MACE) in patients with coronary heart disease (CHD). However, whether the increased TG/HDL-C forecasted the prognosis of CHD is still unknown. Therefore, we performed a meta-analysis to investigate the relationship between the elevated TG/HDL-C ratio and poor prognosis of CHD.

METHODS

A systematic literature search was conducted in PubMed, Web of Science, EMBASE, and The Cochrane Library, until August 30, 2021. Prospective observational studies regarding the association between TG/HDL-C and long-term mortality/MACEs in CHD patients were included.

RESULTS

In total, 6 independent prospective studies of 10,222 participants with CHD were enrolled in the systematic and meta-analysis. Our outcomes of the meta-analysis indicated that the elevated TG/HDL-C group had a significantly increased risk of long-term all-cause mortality (hazard ratio [HR] = 2.92, 95% confidence interval [CI]: 1.75-4.86, P < .05) and long-term MACEs (HR = 1.56, 95%CI 1.11-2.18, P < .05).

CONCLUSION

In patients with CHD, the present study showed that the high TG/HDL-C was associated with increased risk of long-term all-cause mortality and MACE.

Effects of neutrophil-lymphocyte ratio on renal function and histologic lesions in patients with diabetic nephropathy

AIM

Chronic low-grade inflammation related to diabetic nephropathy (DN) may affect the serum neutrophil-lymphocyte ratio (NLR). We aimed to examine the cross-sectional relationships of NLR with renal function and structural lesions of DN in patients with type 2 diabetes mellitus (T2DM).

METHODS

The study retrospectively included 247 patients with T2DM and biopsy-proven DN. The severity of different pathological lesions was evaluated based on the criteria of Renal Pathology Society. The patients were divided into two groups based on the median (2.42) of NLR level, group 1: NLR < 2.42 (n = 122) and group 2: NLR ≥ 2.42 (n = 125). Renal dysfunction was defined by estimated glomerular filtration rate less than 60 mL/min per 1.73 m² . The influence of NLR on renal dysfunction was evaluated using logistic regression analysis.

RESULTS

The spearman's rank-correlation test indicted that NLR was positively correlated with interstitial fibrosis and tubular atrophy (r = 0.170, P = 0.007) and serum fibrinogen (r = 0.261, P < 0.001), whereas negatively related with estimated glomerular filtration rate (r = -0.233, P < 0.001). However, the NLR level demonstrated no association with glomerular lesions, interstitial inflammation and arteriolar hyalinosis. A multivariate logistic regression analysis showed that higher level of NLR (≥2.42) was significantly associated with renal dysfunction when adjusting for some important baseline clinical and pathological variables (odds ratio, 2.46; 95% confidence interval, 1.21-4.97; P = 0.012).

CONCLUSION

Increased NLR affects renal function and histologic lesions in patients with T2DM and may be an important factor for the progression of DN.

Mid-arm muscle circumference: A significant factor of all-cause and cancer mortalities in individuals with elevated platelet-to-lymphocyte ratio

Platelet-to-lymphocyte ratio (PLR) is an inflammatory maker, and high PLR is associated with mortality in several diseases. The predictors of mortality in individuals with high PLR is still lacking. Our aims were to assess if mid-arm muscle circumference (MAMC) can predict all-cause mortality, cancer mortality, and cardiovascular mortality in individuals with high PLR. Adult participants from the National Health and Nutrition Examination Survey III (1988–1994) were included. All participants were divided into low PLR and high PLR groups with the cut-off point being the median PLR level, and each group was evaluated for risk factors of mortality. MAMC was divided into tertiles and the general characteristics of the study population related to MAMC were evaluated. The study included 14,221 adults with 6,701 (47.1%) male and 7,520 (52.9%) female participants. The median PLR ratio was 122. Higher levels of systolic blood pressure, total triglycerides, total cholesterol, low-density lipoprotein, C-reactive protein, uric acid, and glucose, as well as a higher age, were associated with increased risk of mortality in both groups. After adjusting for all the covariates, in the higher PLR group, the highest MAMC tertile was significantly associated with lower hazard ratios for all-cause and cancer mortalities compared with the lowest MAMC tertile. However, this association was not observed in the low PLR group. The highest MAMC tertile showed protective effects from all-cause and cancer mortalities compared with the lowest MAMC tertile in individuals with PLR ≥ 122. In conclusion, the highest MAMC tertile was significantly associated with decreasing HRs for all-cause and cancer mortalities compared with the lowest MAMC tertile in individuals with elevated PLR.

Relation of baseline neutrophil-to-lymphocyte ratio to survival and toxicity in head and neck cancer patients treated with (chemo-) radiation

Background

A high neutrophil-to-lymphocyte ratio (NLR) is a marker of systemic inflammation and together with the platelet-to-lymphocyte ratio (PLR) is associated with worse outcomes in several solid tumors. We investigated the prognostic value of NLR and PLR in patients with head and neck squamous cell carcinoma (HNSCC) treated with primary or adjuvant (chemo)radiotherapy ((C)RT).

Methods

A retrospective chart review of consecutive patients with HNSCC was performed. Neutrophil-to-lymphocyte ratio and PLR were computed using complete blood counts (CBCs) performed within 10 days before treatment start. The prognostic role of NLR and PLR was evaluated with univariable and multivariable Cox regression analyses adjusting for disease-specific prognostic factors. NLR and PLR were assessed as log-transformed continuous variables (log NLR and log PLR). Endpoints of interest were overall survival (OS), locoregional recurrence-free survival (LRFS), distant recurrence-free survival (DRFS), and acute toxicity.

Results

We analyzed 186 patients treated from 2007 to 2010. Primary sites were oropharynx (45%), oral cavity (28%), hypopharynx (14%), and larynx (13%). Median follow-up was 49 months. Higher NLR was associated with OS (adjusted HR per 1 unit higher log NLR = 1.81 (1.16–2.81), p = 0.012), whereas no association could be shown with LRFS (HR = 1.49 (0,83-2,68), p = 0.182), DRFS (HR = 1.38 (0.65–3.22), p = 0.4), or acute toxicity grade ≥ 2. PLR was not associated with outcome, nor with toxicity.

Conclusion

Our data suggest that in HNSCC patients treated with primary or adjuvant (C)RT, NLR is an independent predictor of mortality, but not disease-specific outcomes or toxicity. Neutrophil-to-lymphocyte ratio is a readily available biomarker that could improve pre-treatment prognostication and may be used for risk-stratification.

Usefulness of the delta neutrophil index to predict 30-day mortality in patients with ST segment elevation myocardial infarction

This study aimed to evaluate the association between the delta neutrophil index (DNI), which reflects immature granulocytes, and the severity of ST-elevation myocardial infarction (STEMI), as well as to determine the significance of the DNI as a prognostic marker for early mortality and other clinical outcomes in patients with STEMI who underwent reperfusion. This retrospective, observational cohort study was conducted using patients prospectively integrated in a critical pathway program for STEMI. We included 842 patients diagnosed with STEMI who underwent primary percutaneous coronary intervention (pPCI). Higher DNI values at time-I (within 2 h of pPCI; hazard ratio [HR], 1.075; 95% confidence interval [CI]: 1.046–1.108; p < 0.001) and time-24 (24 h after admission; HR, 1.066; 95% CI: 1.045–1.086; p < 0.001) were significant independent risk factors for 30-day mortality. Specifically, DNI values >2.5% at time-I (HR, 13.643; 95% CI: 8.13–22.897; p < 0.001) and > 2.9% at time-24 (HR, 12.752; 95% CI: 7.308–22.252; p < 0.001) associated with increased risks of 30-day mortality. In conclusion, an increased DNI value, which reflects the proportion of circulating immature granulocytes in the blood, was found to be an independent predictor of 30-day mortality and poor clinical outcomes in patients with acute STEMI post-pPCI.

Neutrophil to lymphocyte ratio predict mortality and major adverse cardiac events in acute coronary syndrome: A systematic review and meta-analysis

OBJECTIVES

Neutrophil to lymphocyte ratio (NLR) might be associated with the mortality or major adverse cardiac events (MACEs) in acute coronary syndrome (ACS) patients. We performed a meta-analysis to evaluate the correlation between NLR and mortality/MACEs in ACS.

METHODS

We assessed clinical trials through Pubmed, EMBASE, the Cochrane Library and Web of science in investigating the association between NLR and mortality/MACEs in ACS patients up to August 15, 2017. The primary outcome was mortality or recurrent MACEs.

RESULTS

In total, 8 studies of 9406 patients were included in the systematic and meta-analysis. Our analysis indicated that elevated pretreatment NLR was a poor prognostic marker for patients with recent ACS in predicting medium to long-term mortality/MACEs (OR 1.26, 95%CI 1.13-1.41). And the analysis indicated that higher pretreatment NLR value was associated with higher in-hospital mortality in ACS patients (OR 6.39, 95%CI 1.49-27.38, p<0.001). The NLR value of 5.0 maybe a cut-off value for ACS risk.

CONCLUSIONS

In patients with a recent ACS, an elevated pretreatment NLR value is effective in predicting the risk of mortality/MACEs.

Relation of Neutrophil to Lymphocyte Ratio With Periprocedural Myocardial Damage in Patients Undergoing Elective Percutaneous Coronary Intervention

Neutrophil to lymphocyte ratio (NLR) has been proposed as a marker of cardiovascular risk. The potential relation between NLR and periprocedural myocardial damage after percutaneous coronary intervention (PCI) is unclear. We enrolled 502 consecutive patients with stable coronary artery disease undergoing elective PCI. Blood samples were drawn in all patients at baseline, 6 hours, and 24 hours after PCI for complete blood cell count and cardiac biomarkers (creatine kinase-MB and troponin T [Tn-T]) assessment. NLR was calculated as the ratio between the absolute number of neutrophil over the absolute number of lymphocyte. Periprocedural myocardial infarction (PMI) was defined according to the 2012 universal definition of myocardial infarction. In the overall population, a significant postprocedural increase in NLR was observed (3.255 [2.763 to 3.995] at baseline, 4.430 [3.390 to 6.020] at 6 hours, 4.720 [3.940 to 5.750] at 24 hours, p <0.0001). PMI occurred in 33 patients (6.6%). Baseline NLR was similar in patients with and without PMI (3.250 [2.820 to 3.885] vs 3.260 [2.750 to 4.000], p = 0.898); however, patients who developed PMI showed significantly higher NLR both at 6 hours (5.750 [4.360 to 9.095] vs 4.370 [3.370 to 5.950], p <0.001) and 24 hours (5.180 [4.440 to 8.065] vs 4.670 [3.920 to 5.710], p = 0.003). Among patients who developed PMI, periprocedural NLR increase showed a moderate positive correlation with both creatine kinase-MB (rho = 0.377, p = 0.031) and troponin T increase (rho = 0.506, p = 0.003). In conclusion, preprocedural NLR values do not impact on the occurrence of PMI during elective PCI; however, PCI procedures induce a significant increase in NLR that seems to be proportional to the magnitude of periprocedural myocardial damage.

Neutrophil-to-lymphocyte ratio in occlusive vascular diseases: the literature review of the past 10 years

BACKGROUND

This study aims to evaluate the results of studies investigating neutrophil-to-lymphocyte ratio (NLR) and to identify the prognostic and diagnostic value of NLR in occlusive vascular diseases.

METHODS

With the aim of identifying the studies related to NLR, a search was performed on http://www.ncbi.nlm.nih.gov/pubmed by using the key words "neutrophil lymphocyte ratio" between January 2005 and December 2014. All of the original articles were evaluated according to date of publications, countries, clinics and topics. Studies about occlusive vascular diseases were evaluated according to their qualifications, review methods and results. SPSS for Windows 16.0 was used in data analysis and data were expressed as mean, standard deviation and percentage.

RESULTS

A total of 735 original research articles were investigated. The number of publications have shown a regular logarithmic increase over the years. Thirty-two percent of all publications were performed by clinics in Turkey and 56.4% were performed by general-oncological surgery and cardiology clinics. A total of 107 publications were identified to be about occlusive vascular diseases, 80.3% of these publications were found to be prognostic and 19.6% to be diagnostic, 82.2% of them were found to be planned as retrospective and 17.7% as prospective. In 95.3% of prognostic publications, there was a positive correlation between high NLR values at admission and poor prognosis. In 95.3% of diagnostic publications high NLR values at admission were identified to be significant diagnostically.

CONCLUSION

Elevated neutrophil-to-lymphocyte ratio at admission, could be used as a diagnostic and/or prognostic parameter in occlusive vascular diseases.

Multiple biomarkers for mortality prediction in peripheral arterial disease

Few studies have assessed which biomarkers influence mortality risk among those with peripheral arterial disease (PAD). We analyzed data from 556 individuals identified to have PAD (i.e. ankle–brachial index ⩽0.9) with available measurements of C-reactive protein, the neutrophil-to-lymphocyte ratio (NLR), homocysteine, and the urinary albumin-to-creatinine ratio (UACR) in the 1999–2004 National Health and Nutrition Examination Survey. We investigated whether a combination of these biomarkers improved the prediction of all-cause and cardiovascular mortality beyond conventional risk factors. During follow-up (median, 8.1 years), 277 of 556 participants died; 63 deaths were attributed to cardiovascular disease. After adjusting for conventional risk factors, Cox proportional-hazards models showed the following to be most strongly associated with all-cause mortality (each is followed by the adjusted hazard ratio [HR] per 1 standard deviation increment in the log values): homocysteine (1.31), UACR (1.21), and NLR (1.20). UACR alone significantly predicted cardiovascular mortality (1.53). Persons in the highest quintile of multimarker scores derived from regression coefficients of significant biomarkers had elevated risks of all-cause mortality (adjusted HR, 2.45; 95% CI, 1.66–3.62; p for trend, <0.001) and cardiovascular mortality (adjusted HR, 2.20; 95% CI, 1.02–4.71; p for trend, 0.053) compared to those in the lowest two quintiles. The addition of continuous multimarker scores to conventional risk factors improved risk stratification of all-cause mortality (integrated discrimination improvement [IDI], 0.162; p<0.00001) and cardiovascular mortality (IDI, 0.058; p<0.00001). In conclusion, the addition of a continuous multimarker score to conventional risk factors improved mortality prediction among patients with PAD.

Increased Neutrophil/Lymphocyte Ratio in Patients with Depression is Correlated with the Severity of Depression and Cardiovascular Risk Factors

OBJECTIVE

Chronic inflammation is associated with cardiovascular (CV) risk factors and psychiatric disorders. The neutrophil to lymphocyte ratio (NLR) has been investigated as a new biomarker for systemic inflammatory response. The aim of the study is to investigate the relation of NLR with severity of depression and CV risk factors.

METHODS

The study population consisted of 256 patients with depressive disorder. Patients were evaluated with the Hamilton Rating Scale for Depression (HAM-D). Patients were classified into four groups according to their HAM-D score such as mild, moderate, severe, and very severe depression. Patients were also evaluated in terms of CV risk factors.

RESULTS

Patients with higher HAM-D score had significantly higher NLR levels compared to patients with lower HAM-D score. Correlation analysis revealed that severity of depression was associated with NLR in depressive patients (r=0.333, p<0.001). Patients with one or more CV risk factors have significantly higher NLR levels. Correlation analysis revealed that CV risk factors were associated with NLR in depressive patients (r=0.132, p=0.034). In logistic regression analyses, NLR levels were an independent predictor of severe or very severe depression (odds ratio: 3.02, 95% confidence interval: 1.867-4.884, p<0.001). A NLR of 1.57 or higher predicted severe or very severe depression with a sensitivity of 61.4% and specificity of 61.2%.

CONCLUSION

Higher HAM-D scores are associated with higher NLR levels in depressive patients. NLR more than 1.57 was an independent predictor of severe or very severe depression. A simple, cheap white blood cell count may give an idea about the severity of depression.

Neutrophil-to-Lymphocyte Ratio and Platelet-to-Lymphocyte Ratio are Predictors of Heart Failure

BACKGROUND

Neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) are inflammatory markers used as prognostic factors in various diseases. The aims of this study were to compare the PLR and the NLR of heart failure (HF) patients with those of age-sex matched controls, to evaluate the predictive value of those markers in detecting HF, and to demonstrate the effect of NLR and PLR on mortality in HF patients during follow-up.

METHODS

This study included 56 HF patients and 40 controls without HF. All subjects underwent transthoracic echocardiography to evaluate cardiac functions. The NLR and the PLR were calculated as the ratio of neutrophil count to lymphocyte count and as the ratio of platelet count to lymphocyte count, respectively. All HF patients were followed after their discharge from the hospital to evaluate mortality, cerebrovascular events, and re-hospitalization.

RESULTS

The NLR and the PLR of HF patients were significantly higher compared to those of the controls (p < 0.01). There was an inverse correlation between the NLR and the left ventricular ejection fraction of the study population (r: -0.409, p < 0.001). The best cut-off value of NLR to predict HF was 3.0, with 86.3% sensitivity and 77.5% specificity, and the best cut-off value of PLR to predict HF was 137.3, with 70% sensitivity and 60% specificity. Only NLR was an independent predictor of mortality in HF patients. A cut-off value of 5.1 for NLR can predict death in HF patients with 75% sensitivity and 62% specificity during a 12.8-month follow-up period on average.

CONCLUSION

NLR and PLR were higher in HF patients than in age-sex matched controls. However, NLR and PLR were not sufficient to establish a diagnosis of HF. NLR can be used to predict mortality during the follow-up of HF patients.

High-sensitivity C-reactive protein as a predictor of cardiovascular events after ST-elevation myocardial infarction

Background

The association between high-sensitivity C-reactive protein and recurrent major adverse cardiovascular events (MACE) in patients with ST-elevation myocardial infarction who undergo primary percutaneous coronary intervention remains controversial.

Objective

To investigate the potential association between high-sensitivity C-reactive protein and an increased risk of MACE such as death, heart failure, reinfarction, and new revascularization in patients with ST-elevation myocardial infarction treated with primary percutaneous coronary intervention.

Methods

This prospective cohort study included 300 individuals aged >18 years who were diagnosed with ST-elevation myocardial infarction and underwent primary percutaneous coronary intervention at a tertiary health center. An instrument evaluating clinical variables and the Thrombolysis in Myocardial Infarction (TIMI) and Global Registry of Acute Coronary Events (GRACE) risk scores was used. High-sensitivity C-reactive protein was determined by nephelometry. The patients were followed-up during hospitalization and up to 30 days after infarction for the occurrence of MACE. Student's t, Mann-Whitney, chi-square, and logistic regression tests were used for statistical analyses. P values of ≤0.05 were considered statistically significant.

Results

The mean age was 59.76 years, and 69.3% of patients were male. No statistically significant association was observed between high-sensitivity C-reactive protein and recurrent MACE (p = 0.11). However, high-sensitivity C-reactive protein was independently associated with 30-day mortality when adjusted for TIMI [odds ratio (OR), 1.27; 95% confidence interval (CI), 1.07-1.51; p = 0.005] and GRACE (OR, 1.26; 95% CI, 1.06-1.49; p = 0.007) risk scores.

Conclusion

Although high-sensitivity C-reactive protein was not predictive of combined major cardiovascular events within 30 days after ST-elevation myocardial infarction in patients who underwent primary angioplasty and stent implantation, it was an independent predictor of 30-day mortality.

Application of neutrophil/lymphocyte ratio in predicting coronary blood flow and mortality in patients with ST-elevation myocardial infarction undergoing percutaneous coronary intervention

BACKGROUND

To investigate the potential correlation of neutrophil/lymphocyte ratio (NLR) to coronary blood flow and in-hospital along with long-term mortality in patients with ST-elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI).

METHODS

In the current study, 636 consecutive patients with STEMI were recruited and stratified into three tertiles by NLRs upon admission (tertile I<3.0, tertile II 3.0-6.40, tertile III>6.40). The coronary blood flow was expressed by corrected TIMI frame count (CTFC). The in-hospital mortality and 12-month long follow-up data were collected. Receiver operating characteristic (ROC) curves were also constructed.

RESULTS

Our analysis demonstrated that NLR was positively correlated to CTFC and in-hospital mortality (r=0.517, p<0.001; r=0.439, p<0.001). In the multiple logistic regression analysis, NLR was testified as an independent risk factor for coronary blood flow after PCI and in-hospital mortality [odds ratio (OR)=2.031, 95% confidence interval (CI): 1.627-2.435, p<0.001; OR=1.176, 95% CI: 1.025-1.351, p=0.021]. During the 12-month follow-up, there were a total of 43 deaths and statistically significant increase in long-term mortality was observed in patients from tertile I to III (p=0.005). In the ROC curves analysis, the area under the curve (AUC=0.607, 95% CI: 0.475-0.739, p=0.253), with threshold value of 5.9 (sensitivity: 63.7%, specificity: 61.1%) for predicting in-hospital mortality.

CONCLUSIONS

NLR, an indicator that can be tested in the laboratory with low cost and time consumption, is independently correlated to coronary blood flow and acts as an independent risk factor for in-hospital mortality in patients with STEMI undergoing PCI.

Systemic inflammation in patients with chronic obstructive pulmonary disease undergoing percutaneous coronary intervention

BACKGROUND AND OBJECTIVE

Systemic inflammation plays an important role in both chronic obstructive pulmonary disease (COPD) and coronary artery disease (CAD). The purpose of the present study was to assess the association of high-sensitivity C-reactive protein (hs-CRP), a biomarker of systemic inflammation, with in-hospital outcomes in patients with COPD undergoing percutaneous coronary intervention (PCI).

METHODS

A total of 378 patients with COPD who were treated with PCI from January 2007 through January 2012, were divided into two groups according to hs-CRP level at admission. Demographics, clinical, angiographic data and in-hospital outcomes were compared.

RESULTS

Patients with elevated hs-CRP (≥3 mg/L) were more likely to be female and current smokers, had more severe airflow limitation, more hypertension, diabetes and cardiac dysfunction and had increased incidence of three-vessel disease and more type C lesions. Subjects with elevated hs-CRP were also less likely to have been prescribed with statins and B-blockers, perhaps. Rate of in-hospital composite major adverse cardiovascular events (MACEs) was higher (15.5% vs. 8.2%, P = 0.041) and hospital stay was longer (8.2 ± 2.0 vs. 7.5 ± 1.7 days, P < 0. 001) in patients with elevated hs-CRP. A combined analysis of MACE on the basis of airflow limitation and hs-CRP showed an exaggerated hazard ratio in the presence of both severe airflow limitation and elevated hs-CRP. In a multivariate analysis, elevated periprocedural hs-CRP was independently related with MACEs and hospital stay.

CONCLUSIONS

Elevated periprocedural hs-CRP is independently and additively related with increased incidence of in-hospital adverse outcomes in COPD patients undergoing PCI.

Neutrophil lymphocyte ratio significantly improves the Framingham risk score in prediction of coronary heart disease mortality: insights from the National Health and Nutrition Examination Survey-III

BACKGROUND

Neutrophil lymphocyte ratio (NLR) has been shown to predict cardiovascular events in several studies. We sought to study if NLR predicts coronary heart disease (CHD) in a healthy US cohort and if it reclassifies the traditional Framingham risk score (FRS) model.

METHODS

We performed post hoc analysis of National Health and Nutrition Examination Survey-III (1998-94) including subjects aged 30-79 years free from CHD or CHD equivalent at baseline. Primary endpoint was death from ischemic heart disease. NLR was divided into four categories: <1.5, ≥1.5 to <3.0, 3.0-4.5 and >4.5. Statistical analyses involved multivariate Cox proportional hazards models as well as discrimination, calibration and reclassification.

RESULTS

We included 7363 subjects with a mean follow up of 14.1 years. There were 231 (3.1%) CHD deaths, more in those with NLR>4.5 (11%) compared to NLR<1.5 (2.4%), p<0.001. Adjusted hazard ratio of NLR>4.5 was 2.68 (95% CI 1.07-6.72, p=0.035). There was no significant improvement in C-index (0.8709 to 0.8713) or area under curve (0.8520 to 0.8531) with addition of NLR to FRS model. Model with NLR was well calibrated with Hosmer-Lemeshow chi-square of 8.57 (p=0.38). Overall net reclassification index (NRI) was 6.6% (p=0.003) with intermediate NRI of 10.1% (p<0.001) and net upward reclassification of 5.6%. Absolute integrated discrimination index (IDI) was 0.003 (p=0.039) with relative IDI of 4.3%.

CONCLUSIONS

NLR can independently predict CHD mortality in an asymptomatic general population cohort. It reclassifies intermediate risk category of FRS, with significant upward reclassification. NLR should be considered as an inflammatory biomarker of CHD.

Neutrophil to lymphocyte and platelet to lymphocyte ratio in patients with dipper versus non-dipper hypertension

BACKGROUND

Neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) are associated with worse outcome in various diseases. Non-dipping blood pressure pattern is associated with higher cardiovascular mortality. The aim of this study was to explore the association between NLR and PLR in patients with dipper versus non-dipper hypertension.

METHODS

The study included 166 patients with hypertension. Eighty-three patients (40 male, mean age: 49.1 ± 10.5 years) had dipper hypertension, while 83 patients (41 male, mean age: 52.3 ± 12.7 years) had non-dipper hypertension.

RESULTS

Baseline demographic characteristics were similar in both groups. Patients with non-dipper hypertension had significantly higher NLR compared to dipper hypertension (2.3 ± 0.9 versus 1.8 ± 0.5, p < 0.001). Patients with non-dipper hypertension had significantly higher PLR compared to dipper hypertension (117.7 ± 35.2 versus 100.9 ± 30.5, p = 0.001). In univariate analysis, hyperlipidemia, smoking, presence of diabetes, PLR more than 107 and NLR more than 1.89 were among predictors of dipper and non-dipper status. In logistic regression analyses, only hyperlipidemia (odds ratio: 2.96, CI: 1.22-7.13) and PLR more than 107 (odds ratio: 2.62, CI: 1.13-6.06) were independent predictors of dipper and non-dipper status. A PLR of 107 or higher predicted non-dipper status with a sensitivity of 66.3% and specificity of 68.7%.

CONCLUSION

We demonstrated that patients with non-dipper hypertension had significantly higher NLR and PLR compared to dipper hypertension, which has not been reported previously. Moreover PLR more than 107 but not NLR was independent predictor of non-dipper status.

Neutrophil to lymphocyte ratio and cardiovascular diseases: a review

The role of inflammatory markers in cardiovascular diseases has been studied extensively and a consistent relationship between various inflammatory markers and cardiovascular diseases has been established in the past. Neutrophil to lymphocyte ratio (NLR) is a new addition to the long list of these inflammatory markers. NLR, which is calculated from complete blood count with differential, is an inexpensive, easy to obtain, widely available marker of inflammation, which can aid in the risk stratification of patients with various cardiovascular diseases in addition to the traditionally used markers. It has been associated with arterial stiffness and high coronary calcium score, which are themselves significant markers of cardiovascular disease. NLR is reported as an independent predictor of outcome in stable coronary artery disease, as well as a predictor of short- and long-term mortality in patients with acute coronary syndromes. It is linked with increased risk of ventricular arrhythmias during percutaneous coronary intervention (PCI) and higher long-term mortality in patients undergoing PCI irrespective of indications of PCI. In patients admitted with advanced heart failure, high NLR was reported with higher inpatient mortality. Recently, NLR has been reported as a prognostic marker for outcome from coronary artery bypass grafting and postcoronary artery bypass grafting atrial fibrillation.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

High-throughput 13-parameter immunophenotyping identifies shifts in the circulating T-cell compartment following reperfusion in patients with acute myocardial infarction

Rationale

With the advent of primary PCI (PPCI), reperfusion is achieved in almost all patients presenting with acute myocardial infarction. However, despite multiple trials, reperfusion injury has not been successfully dealt with so far. In mouse models, CD4⁺ T lymphocytes (T cells) have been shown to be crucial instigators of reperfusion injury.

Objective

Our goal was to investigate the role of CD4⁺ T cells during myocardial reperfusion following PPCI by developing a protocol for high-throughput multiplexed flow cytometric analysis and multivariate flow clustering.

Methods and Results

13-parameter immunophenotyping and hierarchical cluster analysis (HCA) identified a unique CD4⁺CD57⁺ T-cell population in PPCI patients that reflected acute proliferation in the CD4⁺ T-cell compartment. CD4⁺CCR7⁺ T cells were specifically depleted from peripheral blood during the first 30 min of myocardial reperfusion after PPCI, suggesting a potential role for the chemokine receptor CCR7 in T-cell redistribution to either peripheral tissues or migration to the infarcted heart during ischemia/reperfusion following PPCI.

Conclusions

High-throughput polychromatic flow cytometry and HCA are capable of objective, time and cost efficient assessment of the individual T-cell immune profile in different stages of coronary heart disease and have broad applications in clinical trials.

Relation of neutrophil/lymphocyte ratio to coronary flow to in-hospital major adverse cardiac events in patients with ST-elevated myocardial infarction undergoing primary coronary intervention

With the growing understanding of the role of inflammation in patients with atherosclerotic disease, studies have focused on high-sensitivity C-reactive protein (hs-CRP) and other inflammatory markers in their association with outcomes in ST-segment elevation myocardial infarction. The goal of this study was to investigate the association of the neutrophil/lymphocyte (N/L) ratio and in-hospital major adverse cardiac events (MACEs) in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention (PCI). The association of hs-CRP and N/L ratio on admission with Thrombolysis In Myocardial Infarction (TIMI) flow grade after PCI was assessed in 418 consecutive primary patients with PCI. The N/L ratio was significantly higher in the no-reflow group (TIMI grade 0/1/2 flow, n = 158) compared to that of the normal-flow group (TIMI grade 3 flow, n = 260, 4.6 ± 1.7 vs 3.1 ± 1.9, p <0.001). In-hospital MACEs were significantly higher in patients with no reflow (23% vs 7%, p <0.001). There was a significant and positive correlation between hs-CRP and N/L ratio (r = 0.657, p <0.001). In receiver operating characteristic analysis, N/L ratio >3.3 predicted no reflow with 74% sensitivity and 83% specificity. In a multivariate regression model, N/L ratio remained an independent correlate of no reflow (odds ratio [OR] 1.54, 95% confidence interval [CI] 1.34 to 1.76, p <0.001) and in-hospital MACEs (OR 1.14, 95% CI 0.98 to 1.32, p = 0.043). The N/L ratio, an inexpensive and easily measurable laboratory variable, is independently associated with the development of no reflow and in-hospital MACEs in patients with ST-segment elevation myocardial infarction undergoing primary PCI.

Usefulness of C-reactive protein as a marker of early post-infarct left ventricular systolic dysfunction

Objective

To assess the usefulness of in-hospital measurement of C-reactive protein (CRP) concentration in comparison to well-established risk factors as a marker of post-infarct left ventricular systolic dysfunction (LVSD) at discharge.

Materials and methods

Two hundred and four consecutive patients with ST-segment-elevation myocardial infarction (STEMI) were prospectively enrolled into the study. CRP plasma concentrations were measured before reperfusion, 24 h after admission and at discharge with an ultra-sensitive latex immunoassay.

Results

CRP concentration increased significantly during the first 24 h of hospitalization (2.4 ± 1.9 vs. 15.7 ± 17.0 mg/L; p < 0.001) and persisted elevated at discharge (14.7 ± 14.7 mg/L), mainly in 57 patients with LVSD (2.4 ± 1.8 vs. 25.0 ± 23.4 mg/L; p < 0.001; CRP at discharge 21.9 ± 18.6 mg/L). The prevalence of LVSD was significantly increased across increasing tertiles of CRP concentration both at 24 h after admission (13.2 vs. 19.1 vs. 51.5 %; p < 0.0001) and at discharge (14.7 vs. 23.5 vs. 45.6 %; p < 0.0001). Multivariate analysis demonstrated CRP concentration at discharge to be an independent marker of early LVSD (odds ratio of 1.38 for a 10 mg/L increase, 95 % confidence interval 1.01–1.87; p < 0.04).

Conclusion

Measurement of CRP plasma concentration at discharge may be useful as a marker of early LVSD in patients after a first STEMI.

Neutrophils and clinical outcomes in patients with acute coronary syndromes and/or cardiac revascularisation. A systematic review on more than 34,000 subjects

Some studies have suggested that high levels of total white blood cell (WBC) count and C-reactive protein (CRP) may be considered as independent prognostic factors in patients with acute coronary syndromes (ACS) and/or after cardiac revascularisation by percutaneous coronary intervention or coronary artery bypass grafting surgery. Evidence on the role of neutrophils in cardiovascular disease is less compelling. Therefore, we conducted a systematic review of the literature with the aim of identifying all the available evidence to clarify the role of neutrophils (absolute or relative count, neutrophil/lymphocyte ratio) as a prognostic risk factor in patients with ACS and/or cardiac revascularisation. All published studies evaluating the role of neutrophils as a risk factor for clinical outcomes were assessed using the MEDLINE and EMBASE databases. Study selection, data extraction and validity assessment was performed independently by two reviewers. Twenty-one studies (17 of which had positive results) for a total of more than 34,000 patients were included. Ten of 13 studies in ACS patients found that neutrophils measured on-admission are related to mortality rate and/or to major adverse clinical events. A predictive value of neutrophils after cardiac revascularisation procedures was reported in seven out of eight studies. Most of the studies showed that neutrophils were independent predictors of cardiovascular outcomes when analysed concomitantly with other markers of inflammation (WBC, CRP). The findings of our systematic review highlight the potential application of this inexpensive and readily available inflammatory marker for risk stratification in patients with ACS and/or cardiac revascularisation.

Myocardial infarction induces early increased remote ADAM8 expression of rat hearts after cardiac arrest

BACKGROUND

A disintegrin and metalloproteinase-8 (ADAM8) is a potential surrogate of inflammation which has recently been associated with myocardial infarction. We evaluated in a rat cardiac transplantation model whether ischemia-reperfusion injury alone (IRI) or with early regional myocardial infarction (MI) would suffice to induce inflammatory myocardial remodeling and ADAM8 expression.

MATERIAL AND METHODS

Isogenic heterotopic cardiac transplantation after cardiac arrest was performed to 48 Fischer 344 rats to induce ischemia-reperfusion injury (IRI), of which 27 rats also underwent ligation of the left anterior coronary artery (LAD) of the heart to yield MI. Histology was performed at 0.5, 24 and 48 h after transplantation. ADAM8 was evaluated by qRT-PCR after graft harvesting.

RESULTS

After 0.5 and 48 h respectively, edematous intramyocardial artery nuclei and periadventitial inflammation were more prominent in MI after transplantation, as compared with IRI alone and Controls (57.0 vs 40.0 and 5.0; 1.9 vs 1.1 and 0.9, point score units, p < 0.05, respectively). The expression of ADAM-8 was increased in MI as compared with Controls (1.9 vs 1.0, 1.9 fold increase) at 48 h. In grafts with MI, ADAM8 was localized using immunohistochemistry to the vicinity of the area corresponding to the developing infarction as well as in intramyocardial arteries remote to the infarction area.

CONCLUSIONS

Remote histopathological changes of ischemic cardiac grafts are associated with increased expression of ADAM8 thus emphasizing a global myocardial impact of MI.

Association between circulating monocytes and coronary plaque progression in patients with acute myocardial infarction

BACKGROUND

Monocytes and macrophages have been shown to play major roles in the progression of atherosclerosis. This study examined whether the circulating monocyte count can be used to predict coronary plaque progression of non-culprit intermediate lesions in acute myocardial infarction (AMI).

METHODS AND RESULTS

Intravascular ultrasound findings of non-culprit intermediate plaque in 90 patients were analyzed in the acute phase and at a 7-month follow up. A higher peak monocyte count after AMI was associated with a greater plaque volume change (r=0.32, P=0.002). Multivariate analysis showed that a peak monocyte count of > or =800 /mm(3) was an independent predictor of plaque progression (odds ratio 5.02, P=0.005). High monocyte (> or =800 /mm(3)) at baseline had a higher monocyte count at 7-month follow up than did those with a lower count (368+/-109 vs 263+/-64 /mm(3), P<0.0001). Moreover, the monocyte count at the 7-month follow up was also associated with plaque volume change (r=0.29, P=0.006).

CONCLUSIONS

The results suggest that circulating monocytes play an important role in the progression of coronary plaque in AMI and that the peak monocyte count during hospitalization might be a predictor of plaque progression.

Enhanced expression of the S100A8/A9 complex in acute myocardial infarction patients

BACKGROUND

S100A8/A9 complex (S100A8/A9) is expressed in activated human neutrophils and macrophages. Enhanced expression of S100A8/A9 in atherosclerotic plaque of patients with unstable angina pectoris (UAP) has been demonstrated, but its profile in acute myocardial infarction (AMI) has not been clarified.

METHODS AND RESULTS

Serum S100A8/A9 levels were serially measured in patients with AMI (n=55) and UAP (n=16) during the acute period. The expression of S100A8/A9 was examined immunohistochemically in the infarcted myocardium of 7 autopsied patients with AMI. Serum S100A8/A9 levels on the 1st day were 1,118+/-115 (SE) ng/ml in AMI patients as compared with 787+/-147 ng/ml in UAP patients. On days 3-5, serum S100A8/A9 levels in AMI patients reached a peak value and were significantly higher than the values in UAP patients (1,690+/-144 ng/ml vs 844+/-100 ng/ml; P<0.0001). In AMI patients, peak S100A8/A9 levels positively correlated with peak white blood cell and neutrophil counts, and peak creatine kinase-MB and peak C-reactive protein levels. Double immunostaining revealed that S100A8/A9 was specifically expressed in neutrophils and macrophages infiltrating the infarcted myocardium.

CONCLUSIONS

S100A8/A9 is implicated in the pathophysiology of AMI and may be an additional biomarker of the local inflammatory response following AMI.

Expression of ADAM-15 in rat myocardial infarction

A disintegrin and metalloprotease-15 (ADAM-15) is a potential novel regulator of inflammatory response and tissue remodelling, which is thought to have the ability to attenuate the cardiac function resulting from myocardial infarction (MI). Therefore, the aim of our study was to investigate the expression of ADAM-15 in rat MI. Wistar rats were subjected to MI by ligation of the left anterior descending coronary artery. Euthanasia was performed at 1, 3, 7 and 14 days following MI. The mRNA and protein expression levels of ADAM-15 were detected respectively by reverse transcription-polymerase chain reaction (RT-PCR) and Western blot. The localization of ADAM-15 protein was observed by immunohistochemistry. Compared with sham-MI, the expression of ADAM-15 in MI increased at day 1, reached to maximum at day 3, decreased at day 7 and day 14 gradually. In addition, we also found that the localization of ADAM-15 was mainly at cardiac myocytes in the border area of MI and some macrophages in the border and infarcted areas. This study revealed a significant difference of ADAM-15 expression in rat MI and indicated that ADAM-15 maybe one of the important factors involved in inflammatory response and cardiac remodelling of rat MI.

High ratio of myeloid dendritic cells to plasmacytoid dendritic cells in blood of patients with acute coronary syndrome

BACKGROUND

Dendritic cells (DCs) stimulate T-cells to participate in the inflammatory processes that promote the destruction of vulnerable plaques. The relationship between circulating levels of myeloid DCs (mDCs) and plasmacytoid DCs (pDCs) in patients with acute coronary syndrome (ACS) was evaluated.

METHODS AND RESULTS

Blood samples were obtained from 39 patients with ACS, 41 patients with stable angina pectoris (SAP) and 43 controls. The proportion of mDCs tended to be lower in the ACS group than in the SAP group and controls. Interleukin-12 levels associated with mDCs were significantly higher in the ACS group than in control group. The proportion of pDCs was significantly lower in the ACS groups than in the other two groups. Interferon-alpha levels secreted by pDCs, however, were not significantly different among the 3 groups. The ratio of mDCs to pDCs >or=4 is an important value for distinguishing ACS from SAP patients and control patients through receiver operating characteristic analysis (sensitivity; 85.0%, specificity; 83.4%).

CONCLUSIONS

The ratio of mDCs to pDCs may be a useful marker for detecting ACS and the existence of vulnerable plaques.

Immune system and atherosclerotic disease: heterogeneity of leukocyte subsets participating in the pathogenesis of atherosclerosis

Atherosclerosis is an inflammatory disease in which a systemic inflammatory reaction is combined with an accumulation of immune cells, such as monocytes/macrophages, dendritic cells (DCs), and numerous lymphocytes, in atherosclerotic plaques. The immune system, comprising innate immunity and adaptive immunity, has been implicated in all stages of atherosclerosis, from initiation through progression and in atherothrombotic complications. It is clear that different subpopulations of leukocytes are involved in the pathogenesis of atherosclerosis and plaque instability. Recent studies have also demonstrated that each heterogeneity of immune-associated cells contributes to the atherogenic and atheroprotective axis. This review highlights recent advances in research and explores the role of the complex heterogeneity of leukocyte subsets, especially monocytes/macrophages (inflammatory monocytes, resident monocytes, M1, and M2), DCs (myeloid DCs, plasmacytoid DCs, pre DCs, conventional DCs, inflammatory DCs), and CD4(+) cells (T-helper 1, T-helper 2, regulatory T, and T-helper 17 cells), in the initiation and development of atherosclerotic disease and its complications.

Prognostic value of albuminuria on 1-month mortality in acute myocardial infarction

RATIONALE

An increase in albuminuria occurs in the early days after acute myocardial infarction. The aim of this study was to assess the relation between albuminuria and 30-day mortality, as well as its incremental predictive value, on top of established prognostic parameters.

METHODS AND RESULTS

Demographic, clinical, and biological characteristics at admission, as well as in-hospital treatments and 1-month survival, were recorded in 1,211 consecutive patients admitted for acute myocardial infarction. Albuminuria was assessed from an 8-hour overnight urine collection within the first 2 days using immunonephelemetry. The population was categorized into 3 groups according to albuminuria levels (<20, 20-200, and >200 microg/min). Among survivors on day 2, 52% (625/1,211) of patients had an albuminuria level <20 microg/min, 39% (477) between 20 and 200 microg/min, and 9% (109) >200 microg/min. High levels of albuminuria were associated with older age, peripheral vessel disease, systolic blood pressure, glucose, creatinine, troponin, B-type natriuretic peptide, and high-sensitivity C reactive protein levels, as well as use of angiography, angiotensin-converting enzyme inhibitors, and beta blockers. At 1 month, there was a significantly higher mortality rate in groups with higher albuminuria. After adjustment for baseline characteristics, patients with albuminuria level of >20 microg/min had a 2.7-fold higher 30-day mortality, and those with >200 microg/min had an almost 4-fold higher 30-day mortality compared to those with albuminuria level of <20 microg/min. The addition of albuminuria information improved the discrimination capacity of the model and the global risk prediction.

CONCLUSIONS

Albuminuria level, taken as a quantitative or categorical variable, is an independent and powerful predictor of mortality after acute myocardial infarction.

Significant association between neutrophil aggregation in aspirated thrombus and myocardial damage in patients with ST-segment elevation acute myocardial infarction

BACKGROUND

This study was designed to clarify the relationship between myocardial damage and platelet-neutrophil aggregation in patients with acute myocardial infarction (AMI).

METHODS AND RESULTS

The study group comprised 107 patients with ST-segment elevation AMI, in whom aspiration catheter was used during emergency percutaneous coronary intervention. Patients were divided into 2 groups according to the cellular density of neutrophils in the aspirated sample: group L (n=53), <or=100 neutrophils/0.025 mm(2) thrombus; group H (n=54), >100 neutrophils/0.025 mm(2) thrombus. Myocardial blush grade (MBG) <or=1 and ST-segment resolution (STR) <50% were more frequently found in group H than in group L. Peak creatine kinase level tended to be higher and left ventricular ejection fraction (LVEF) at 6 months after onset was lower in group H than in group L. Multivariate analysis showed that high neutrophil density in aspirated thrombus was an independent predictor of MBG <or=1, STR <50%, and low LVEF at 6 months after onset.

CONCLUSIONS

Platelet-neutrophil aggregates retrieved from ruptured plaque may be associated with impaired coronary microcirculation and resultant myocardial necrosis/dysfunction. These findings underscore the clinical importance of the interaction between thrombosis and inflammation in the pathogenesis of AMI.

Epithelial neutrophil-activating peptide (ENA-78), acute coronary syndrome prognosis, and modulatory effect of statins

Endothelial inflammation with chemokine involvement contributes to acute coronary syndromes (ACS). We tested the hypothesis that variation in the chemokine gene CXCL5, which encodes epithelial neutrophil-activating peptide (ENA-78), is associated with ACS prognosis. We also investigated whether statin use, a potent modulator of inflammation, modifies CXCL5's association with outcomes and characterized the in vitro effect of atorvastatin on endothelial ENA-78 production. Using a prospective cohort of ACS patients (n = 704) the association of the CXCL5 −156 G>C polymorphism (rs352046) with 3-year all-cause mortality was estimated with hazard ratios (HR). Models were stratified by genotype and race. To characterize the influence of statins on this association, a statin*genotype interaction was tested. To validate ENA-78 as a statin target in inflammation typical of ACS, endothelial cells (HUVECs) were treated with IL-1β and atorvastatin with subsequent quantification of CXCL5 expression and ENA-78 protein concentrations. C/C genotype was associated with a 2.7-fold increase in 3-year all-cause mortality compared to G/G+G/C (95%CI 1.19–5.87; p = 0.017). Statins significantly reduced mortality in G/G individuals only (58% relative risk reduction; p = 0.0009). In HUVECs, atorvastatin dose-dependently decreased IL-1β-stimulated ENA-78 concentrations (p<0.0001). Drug effects persisted over 48 hours (p<0.01). CXCL5 genotype is associated with outcomes after ACS with potential statin modification of this effect. Atorvastatin lowered endothelial ENA-78 production during inflammation typical of ACS. These findings implicate CXCL5/ENA-78 in ACS and the statin response.