Hemographic indices are associated with mortality in acute heart failure

Prognostic Value of Neutrophil-to-Lymphocyte Ratio in Patients with Acute Decompensated Heart Failure: A Meta-Analysis

Background: Inflammation plays a pivotal role in the pathogenesis of both acute and chronic heart failure. Recent studies showed that the neutrophil-to-lymphocyte ratio (NLR) could be related to adverse outcomes in patients with cardiovascular diseases. We sought to evaluate whether NLR could predict mortality in patients with acute heart failure by means of a meta-analysis. Methods: A comprehensive literature search was performed in PubMed, Embase, and Cochrane databases through January 2023 for studies evaluating the association of NLR with mortality in patients with acute heart failure. Primary outcomes were in-hospital mortality and long-term all-cause mortality. Endpoints were pooled using a random-effects DerSimonian-and-Laird model and were expressed as a hazard ratio (HR) or mean difference (MD) with their corresponding 95% confidence intervals. Results: A total of 15 studies with 15,995 patients with acute heart failure were included in the final study. Stratifying patients based on a cut-off NLR, we found that high NLR was associated with a significantly higher in-hospital mortality [HR 1.54, 95% CI (1.18-2.00), p < 0.001] and long-term all-cause mortality [HR 1.61, 95% CI (1.40-1.86), p < 0.001] compared to the low-NLR group. Comparing the highest against the lowest NLR quartile, it was shown that patients in the highest NLR quartile has a significantly heightened risk of long-term all-cause mortality [HR 1.77, 95% CI (1.38-2.26), p < 0.001] compared to that of lowest NLR quartile. However, the risks of in-hospital mortality were compared between both quartiles of patients [HR 1.78, 95% CI (0.91-3.47), p = 0.09]. Lastly, NLR values were significantly elevated among non-survivors compared to survivors during index hospitalization [MD 5.07, 95% CI (3.34-6.80), p < 0.001] and during the follow-up period [MD 1.06, 95% CI (0.54-1.57), p < 0.001]. Conclusions: Elevated NLR was associated with an increased risk of short- and long-term mortality and could be a useful tool or incorporated in the risk stratification in patients with acute heart failure.

The impact of platelet-to-lymphocyte ratio on clinical outcomes in heart failure: a systematic review and meta-analysis

BACKGROUND

Inflammation has been suggested to play a role in heart failure (HF) pathogenesis. However, the role of platelet-to-lymphocyte ratio (PLR), as a novel biomarker, to assess HF prognosis needs to be investigated. We sought to evaluate the impact of PLR on HF clinical outcomes.

METHODS

English-published records in PubMed/Medline, Scopus, and Web-of-science databases were screened until December 2023. Relevant articles evaluated PLR with clinical outcomes (including mortality, rehospitalization, HF worsening, and HF detection) were recruited, with PLR difference analysis based on death/survival status in total and HF with reduced ejection fraction (HFrEF) patients.

RESULTS

In total, 21 articles (n = 13,924) were selected. The total mean age was 70.36 ± 12.88 years (males: 61.72%). Mean PLR was 165.54 [95% confidence interval (CI): 154.69-176.38]. In total, 18 articles (n = 10,084) reported mortality [either follow-up (PLR: 162.55, 95% CI: 149.35-175.75) or in-hospital (PLR: 192.83, 95% CI: 150.06-235.61) death rate] and the mean PLR was 166.68 (95% CI: 154.87-178.50). Further analysis revealed PLR was significantly lower in survived HF patients rather than deceased group (152.34, 95% CI: 134.01-170.68 versus 194.73, 95% CI: 175.60-213.85, standard mean difference: -0.592, 95% CI: -0.857 to -0.326, p < 0.001). A similar trend was observed for HFrEF patients. PLR failed to show any association with mortality risk (hazard ratio: 1.02, 95% CI: 0.99-1.05, p = 0.289). Analysis of other aforementioned outcomes was not possible due to the presence of few studies of interest.

CONCLUSION

PLR should be used with caution for prognosis assessment in HF sufferers and other studies are necessary to explore the exact association.

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.

Advance directive screening among veterans with incident heart failure: Comparisons among people aging with and without HIV

BACKGROUND

Heart failure (HF) is common among people aging with HIV (PWH) and without HIV (PWoH). Despite the poor prognosis for HF, advance directives (AD) completion is low but has not been compared among PWH and PWoH.

OBJECTIVES

Determine the prevalence and predictors of AD screening among PWH and PWoH with incident HF.

METHODS

We included Veterans with an incident HF diagnosis code from 2013-2018 in the Veterans Aging Cohort Study (VACS) without prior AD screening. Health records were reviewed for AD screening note titles within -30 days to 1-year post-HF diagnosis. Analyses were stratified by HIV status. Trends in annual AD screening were evaluated with the Cochran-Mantel-Haenszel test. The associations of AD screening with demographics, disease severity (Charlson Comorbidity Index, VACS 2.0 Index), and healthcare encounters (cardiology, palliative care, hospitalization) were evaluated with Cox proportional hazards regression.

RESULTS

HF was diagnosed in 4516 Veterans (28.2% PWH, 71.8% PWoH). Annual AD screening rates increased in both groups (Ptrend<0.0001) and aggregate rates were higher among PWH than PWoH (53.5% vs. 48.2%, p=.001). In both groups, the likelihood of AD screening increased with greater disease severity, palliative care contact, and hospitalization (HR range=1.04-3.32, all p≤.02) but not with cardiology contact (p≥.53).

CONCLUSIONS

AD screening rates after incident HF remain suboptimal but increased over time and were higher in PWH. Future quality improvement and implementation efforts should aim for universal AD screening with incident HF diagnosis, initiated by providers skilled in discussing AD, including in the cardiology subspecialty setting.

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.

Absolute lymphocyte count as a predictor of mortality and readmission in heart failure hospitalization

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Lymphopenia (<1500/mm³) was associated with 82% higher mortality in heart failure patients irrespective of ejection fraction.

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Lymphopenia was a good predictor of all-cause readmission in heart failure patients with reduced ejection fraction.

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Due to cost-effectiveness, easy availability, and ability to predict outcomes in the short-term and medium-term, lymphopenia can be a valuable tool in the mortality, readmission prediction model of heart failure.

Background

There is renewed interest in pursuing frugal and readily available laboratory markers to predict mortality and readmission in heart failure. We aim to determine the relationship between absolute lymphocyte count (ALC) and clinical outcomes in patients with heart failure hospitalization.

Methods

This was a retrospective cohort study of patients with heart failure. Patients were divided into two groups based on ALC, less than or equal to 1500 cells/mm3 and > 1500 cells/ mm3. The primary outcome was all-cause mortality. We did subgroup analysis based on ejection fraction and studied the association between ALC categories and clinical outcomes. Both ALC groups are matched by propensity score, outcomes were analyzed by Cox regression, and estimates are presented in hazard ratios (HR) and 95% confidence intervals (CI).

Results

We included 1029 patients in the pre-matched cohort and 766 patients in the propensity-score matched cohort. The median age was 64 years (IQR, 54–75), and 60.78% were male. In the matched cohort, ALC less than or equal to 1500 cells/mm3 had a higher risk of mortality compared with ALC > 1500 cells/mm3 (HR 1.51, 95% CI: 1.17–1.95; P = 0.002). These results were reproducible in subgroups of heart failure. When ALC was divided into four groups based on their levels, the lowest group of ALC had the highest risk of mortality.

Conclusions

In patients with heart failure and both subgroups, ALC less than or equal to 1500 cells/mm3 had a higher risk of mortality. Patients in lower groups of the ALC categories had a higher risk of mortality.

The association between platelet-to-lymphocyte ratio with mortality among patients suffering from acute decompensated heart failure

Background

Platelet-to-lymphocyte ratio (PLR) is an inflammation index suggested to have the prognostic capability in heart failure (HF). We sought to investigate the association of PLR with cardiovascular disease (CVD) mortality and creatinine (Cr) rise among Iranian individuals suffering from acute decompensated HF (ADHF).

Methods

This retrospective cohort study was in the context of the Persian Registry Of cardioVascular diseasE/Heart Failure (PROVE/HF) study. 405 individuals with ADHF admitted to the emergency department were recruited from April 2019 to March 2020. PLR was calculated by division of platelet to absolute lymphocyte counts and categorized based on quartiles. We utilized the Kaplan–Meier curve to show the difference in mortality based on PLR quartiles. Cr rise was defined as the increment of at least 0.3 mg/dl from baseline. Cox proportional hazard ratio (HR) was used to investigate the association of PLR with CVDs mortality.

Results

Mean age of participants was 65.9 ± 13.49 years (males: 67.7%). The mean follow-up duration was 4.26 ± 2.2 months. CVDs mortality or re-hospitalization was not significantly associated with PLR status. Multivariate analysis of PLR quartiles showed a minimally reduced likelihood of CVDs death in 2nd quartile versus the first one (HR 0.40, 95% confidence interval (CI) 0.16–1.01, P = 0.054). Cr rise had no remarkable relation with PLR status in neither model.

Conclusion

PLR could not be used as an independent prognostic factor among ADHF patients. Several studies are required clarifying the exact utility of this index.

Leucocyte count predicts cardiovascular risk in heart failure with preserved ejection fraction: insights from TOPCAT Americas

AIMS

Prior evidence has implicated leucocyte expansion in several cardiovascular disorders, including heart failure (HF) with reduced ejection fraction (rEF). However, the prognostic importance of leucocyte count in HF with preserved EF (HFpEF) remains largely unexplored.

METHODS AND RESULTS

The Americas cohort of the treatment of preserved cardiac function heart failure with an aldosterone antagonist (TOPCAT-Americas) was used to evaluate the association between total leucocyte count and clinical outcomes in HFpEF. The primary outcome was a composite of aborted cardiac arrest, cardiovascular mortality, or hospitalization for HF. Secondary outcomes were hospitalization for HF, aborted cardiac arrest, stroke, non-fatal myocardial infarction (MI), cardiovascular mortality, non-cardiovascular mortality, and all-cause mortality. Survival models were used to identify the risk of the primary and secondary outcomes in those with leucocyte count above the median (7100 cells/μL), as compared to those with leucocyte count below the median, during the follow-up period. A total of 1746 (out of 1767; 99%) patients from TOPCAT-Americas were available for the analyses with a median follow up of 2.4 (25th to 75th percentile 1.4-3.9) years. Patients with leucocyte count >7100 cells/μL were 36% more likely to experience the primary endpoint compared to those with ≤7100 cells/μL (hazard ratio: 1.36, 95% confidence interval: 1.14-1.61). This association remained significant after extensive adjustment for potential confounders (hazard ratio: 1.27, 95% confidence interval: 1.06-1.52). We also observed a greater incidence of HF hospitalization and non-fatal MI in patients with higher leucocyte count. These associations remained robust on sensitivity analyses, suggesting a low probability of confounding. Exploratory analyses suggested that both higher leucocyte count (integrating the combined influence of both myeloid and lymphoid immune cells) and augmented platelet count (as a surrogate for myeloid immune cell expansion) in the same model were associated with the primary outcome (both P < 0.05).

CONCLUSIONS

Leucocyte count >7100 cells/μL was independently associated with adverse clinical outcomes in HFpEF patients from TOPCAT-Americas. These results were primarily driven by the HF hospitalization outcome but were also accompanied by an excess of non-fatal MI. Further research is needed to define the mechanisms underlying our findings and their prognostic implications.

Pre-operative neutrophil-lymphocyte ratio predicts low cardiac output in children after cardiac surgery

Neutrophil-lymphocyte ratio has been associated with clinical outcomes in several groups of cardiac patients, including patients with coronary artery disease, cardiac failure, and cardiac transplant recipients. We hypothesised that pre- and/or post-operative haematological cell counts are associated with clinical outcomes in children undergoing cardiac surgery for CHD. We performed a post hoc analysis of data collected as part of a prospective observational cohort study (n = 83, data available n = 47) of children evaluated for glucocorticoid receptor levels after cardiac surgery (July 2015-January 2016). The association of neutrophil-lymphocyte ratio with low cardiac output syndrome, time to inotrope free, and vasoactive-inotropic score was examined using proportional odds analysis, cox regression, and linear regression models, respectively. A majority (80%) of patients were infants (median/interquartile range 4.1/0.2-7.6 months) with conotruncal (36%) and left-sided obstructed lesions (28%). Two patients required mechanical circulatory support and three died. Higher pre-operative neutrophil-lymphocyte ratio was associated with higher cumulative odds of severe/moderate versus mild low cardiac output on post-operative day 1 (odds ratio 2.86; 95% confidence interval 1.18-6.93; p = 0.02). Pre-operative neutrophil-lymphocyte ratio was not significantly associated with time to inotrope free or vasoactive-inotrope score. Post-operative neutrophil-lymphocyte ratio was also not associated with outcomes. In children after congenital heart surgery, higher pre-operative neutrophil-lymphocyte ratio was associated with a higher chance of low cardiac output in the early post-operative period. Pre-operative neutrophil-lymphocyte ratio maybe a useful prognostic marker in children undergoing congenital heart surgery.

Value of Neutrophil to Lymphocyte Ratio and Its Trajectory in Patients Hospitalized With Acute Heart Failure and Preserved Ejection Fraction

The neutrophil to lymphocyte ratio (NLR) has been proposed as a simple and routinely obtained marker of inflammation. This study sought to determine whether the NLR on admission as well as NLR trajectory would be complementary to the Get with the Guidelines Heart Failure (GWTG-HF) risk score in patients hospitalized with acute heart failure with preserved ejection fraction (HFpEF).Using the Stanford Translational Research Database, we identified 443 patients between January 2002 and December 2013 hospitalized with acute HFpEF and with complete data of NLR both on admission and at discharge. The primary endpoint was all-cause mortality. Mean age was 77 ± 16 years, 58% were female, with a high prevalence of diabetes mellitus (35.4%), coronary artery disease (58.2%), systemic hypertension (96.6%) and history of atrial fibrillation (57.5%). Over a median follow-up of 2.2 years, 121 (27.3%) patients died. The median NLR on admission was 6.5 (IQR 3.6 - 11.1); a majority of patients decreased their NLR during the course of hospitalization. On multivariable Cox modeling, both NLR on admission (HR 1.18 95% CI (1.00 - .38), p = 0.04) and absolute NLR trajectory (HR 1.26 95% CI (1.10 - 1.45), p = 0.001) were shown to be incremental to GWTG-HF risk score (p < 0.05) for outcome prediction. Adding the NLR or absolute NLR trajectory to the GWTG-HF risk score significantly improved the area under the operator-receiver curve and the reclassification up to 3 years after admission.This simple, readily available marker of inflammation may be useful when stratifying the risk of patients hospitalized with HFpEF.

Primary graft dysfunction after heart transplantation: a thorn amongst the roses

Primary graft dysfunction (PGD) remains the leading cause of early mortality post-heart transplantation. Despite improvements in mechanical circulatory support and critical care measures, the rate of PGD remains significant. A recent consensus statement by the International Society of Heart and Lung Transplantation (ISHLT) has formulated a definition for PGD. Five years on, we look at current concepts and future directions of PGD in the current era of transplantation.

The Role of Norepinephrine and α-Adrenergic Receptors in Acute Stress-Induced Changes in Granulocytes and Monocytes

OBJECTIVE

Acute stress induces redistribution of circulating leucocytes in humans. Although effects on lymphocytes as adaptive immune cells are well understood, the mechanisms underlying stress effects on granulocytes and monocytes as innate immune blood cells are still elusive. We investigated whether the stress hormone norepinephrine (NE) and α-adrenergic receptors (α-ADRs) may play a mediating role.

METHODS

In a stress study, we cross-sectionally tested 44 healthy men for associations between stress-induced NE increases and simultaneous granulocyte and monocyte cell count increases, as measured immediately before and several times after the Trier Social Stress Test. In a subsequent infusion study, 21 healthy men participated in three different experimental trials with sequential infusions of 1- and 15-minute duration with varying substances (saline as placebo, the nonspecific α-ADR blocker phentolamine [2.5 mg/min], and NE [5 μg/min]): trial 1 = saline+saline, trial 2 = saline+NE, trial 3 = phentolamine+NE. Granulocyte and monocyte cell numbers were assessed before, immediately after, 10 minutes, and 30 minutes after infusion procedures.

RESULTS

In the stress study, higher NE related to higher neutrophil stress changes (β = .31, p = .045, R change = .09), but not epinephrine stress changes. In the infusion study, saline+NE induced significant increases in neutrophil (F(3/60) = 43.50, p < .001, η = .69) and monocyte (F(3/60) = 18.56, p < .001, η = .48) numbers compared with saline+saline. With phentolamine+NE, neutrophil (F(3/60) = 14.41, p < .001, η = .42) and monocyte counts (F(2.23/44.6) = 4.32, p = .016, η = .18) remained increased compared with saline+saline but were lower compared with saline+NE (neutrophils: F(3/60) = 19.55, p < .001, η = .494, monocytes: F(3/60) = 2.54, p = .065, η = .11) indicating partial mediation by α-ADRs. Trials did not differ in eosinophil and basophil count reactivity.

CONCLUSIONS

Our findings suggest that NE-induced immediate increases in neutrophil and monocyte numbers resemble psychosocial stress effects and can be reduced by blockade of α-ADRs.

Is Heart Failure Associated With Risk of Suicide?

BACKGROUND

The high prevalence of heart failure (HF) in developed countries imposes a substantial burden on health care resources. Depression is widely recognized as a risk factor associated with HF. This study examined the relationship between suicide and HF after controlling for depression and other comorbidities.

METHODS AND RESULTS

The population comprised 52,749 adult patients who died from suicide from 2000 to 2012 and 210,996 living control subjects matched by age, sex, and residence area. Data were obtained from the Health and Welfare Data Science Center, Taiwan. Multivariable models were constructed to evaluate the relationship between HF and suicide. In the case and control groups 1624 (3.08%) and 4053 (1.92%) patients had HF, respectively, indicating that HF was associated with an increased risk of suicide (odds ratio [OR] 1.68, 95% confidence interval [CI] 1.59-1.79). The risk of suicide was highest during the initial 6 months after HF (adjusted OR 7.04, 95% CI 5.37-9.22) and subsequently declined gradually. Among psychiatric disorders, mood disorders (adjusted OR 7.42, 95% CI 7.06-7.79) yielded the highest odds of suicide.

CONCLUSIONS

The risk of suicide is higher for patients with HF than for healthy individuals without HF. This risk is particularly high during the first 6 months after HF diagnosis. This study provides strong evidence that depression is a negative prognostic factor for patients with HF and increases the risk of suicide. The results suggest that early screening and treatment for depression and suicide risk should be conducted for patients with HF.