Neutrophil to Lymphocyte Ratio and Long-Term Cardiovascular Outcomes in Coronary Artery Disease Patients with Low High-Sensitivity C-Reactive Protein Level

Association between neutrophil to lymphocyte ratio and all-cause mortality in critical patients with coronary artery disease - a study based on the MIMIC-IV database

Background

Neutrophil-to-lymphocyte ratio (NLR) has been presented as a possible indicator associated with the outcomes of growing patients and an available predictor of inflammation. Nevertheless, just a handful of researches shed light on the association between NLR and the consequences of critical patients with coronary artery disease (CAD). The study aimed to investigate the correlation between NLR and all-cause mortality of short-term and long-term in patients with CAD.

Methods

We obtained objective data from the Medical Information Mart for Intensive Care (MIMIC)-IV version 2.2, a comprehensive and large-scale single-center database. NLR was calculated separately. Patients were categorized by quartiles of NLR: Q1 group (NLR < 3.56), Q2 (NLR 3.56-5.54), Q3 group (NLR 5.54-9.05), Q4 group (NLR > 9.05). Kaplan-Meier survival curves based on NLR quartiles were created to compare all-cause mortality rates, and the log-rank test evaluated the differences between groups. The hazard ratio (HR) of NLR as a risk factor for outcome events was assessed using the Cox proportional risk model with the Q1 group serving as the reference group and restricted cubic spline (RCS) with the infection points of 5.54.

Results

A total of 3,692 patients were included in this study. The 30-day mortality rate among the patients was 8.85%, while the 365-day mortality rate was 16.98%. High NLR (NLR > 5.54) was significantly associated with 30-day mortality [HR, 3.99,95% confident interval (CI), (3.03-5.24); P < 0.001] and 365-day mortality [HR, 5.72, 95% CI (3.83-8.54); P < 0.001] in patients with critical CAD in the completely adjusted Cox proportional risk model. RCS analysis revealed a U-shaped relationship between NLR and outcome events.

Conclusion

In patients diagnosed with critical CAD, a significant correlation was observed between NLR and all-cause mortality, particularly among individuals exhibiting elevated NLR levels. These findings suggest that NLR may serve as a valuable prognostic marker for evaluating both short-term and long-term mortality risk in this patient population.

Role of a new inflammation predictor in predicting recurrence of atrial fibrillation after radiofrequency catheter ablation

BACKGROUND

Radiofrequency catheter ablation (RFCA) has become an important strategy for treating atrial fibrillation (AF), and postoperative recurrence represents a significant and actively discussed clinical concern. The recurrence after RFCA is considered closely related to inflammation. Systemic immune inflammation index (SII) is a novel inflammation predictor based on neutrophils, platelets, and lymphocytes, and is considered a biomarker that comprehensively reflects the immune inflammatory status of the body.

AIM

To explore the predictive effect of the SII on AF recurrence after RFCA and its predictive value in combination with the existing APPLE score for AF recurrence after RFCA in patients with non-valvular AF (NVAF).

METHODS

We retrospectively included 457 patients with NVAF first receiving RFCA and classified them into the recurrent or non-recurrent group. We also investigated the predictive role of SII on AF recurrence following RFCA. Finally, we explored and compared the additional predictive value of the SII after combining with the APPLE score.

RESULTS

After 12 months of follow-up, 113 (24.7%) patients experienced recurrence. High SII has been demonstrated to be an independent predictor for postoperative AF recurrence. Receiver operating characteristic and decision curve analysis (DCA), as well as net reclassification improvement (NRI) and integrated discrimination improvement (IDI) results, showed that SII combined with the APPLE score had higher predictive efficiency than using the SII or APPLE score alone. The area under the curve of the combined model (0.662, 95% confidence interval: 0.602-0.722) significantly increased compared with that of the SII and APPLE scores alone (P < 0.001). The combined model resulted in an NRI of 29.6% and 34.1% and IDI of 4.9% and 3.5% in predicting AF recurrence compared with the SII and APPLE scores alone, respectively (all P < 0.001). The SII, APPLE score, and their combination demonstrated greater clinical utility than did the treat-all and treat-none strategies over the 20-80% risk threshold according to the DCA.

CONCLUSION

The SII was a predictor of recurrence after RFCA of AF. Moreover, the SII enhanced the predictability of the APPLE score for post-RFCA AF recurrence, providing valuable insights for physicians to optimise patient selection and develop personalised treatment plans.

Association of NLR with all-cause and cardiovascular mortality in adults with coronary heart disease: 1999-2018 NHANES data analysis

The neutrophil-to-lymphocyte ratio (NLR) is an important inflammatory marker. However, the relationship between NLR and the prognosis of patients with coronary heart disease (CHD) remains unclear. The purpose of this study is to explore the relationship between NLR and all-cause mortality and cardiovascular mortality in CHD patients. This study analyzed data from 1625 CHD patients who participated in the National Health and Nutrition Examination Survey from 1999 to 2018. Multivariate Cox regression analysis was used to explore the relationship between mortality risk and NLR. The optimal NLR cutoff value related to survival outcomes was determined using the maximum selected rank method. Restricted cubic spline analysis was performed to investigate the correlation between NLR and mortality risk in CHD patients. Moreover, subgroup analyses were conducted to assess the relationship between NLR and all-cause and cardiovascular mortality in different populations. Additionally, time-dependent receiver operating characteristic curves were used to evaluate the accuracy of NLR in predicting survival outcomes. During a median follow-up of 88 months, a total of 475 patients experienced all-cause mortality, and 278 patients experienced cardiovascular mortality. After adjusting for confounding factors, compared with CHD patients with higher NLR, those with lower NLR had a 43% reduced risk of all-cause mortality (hazard ratio: 0.57, 95% CI: 0.41-0.8) and a 51% reduced risk of cardiovascular mortality (hazard ratio: 0.49, 95% CI: 0.3-0.78). Kaplan-Meier analysis showed that the survival rate in the high NLR group was significantly lower in terms of all-cause and cardiovascular mortality rates than in the low NLR group (P < .0001). The results of the restricted cubic spline analysis indicated a nonlinear relationship between NLR and all-cause mortality as well as cardiovascular mortality in CHD patients. In addition, receiver operating characteristic analysis showed that the area under the curve for all-cause mortality at 3 years, 5 years, and 10 years were 0.596, 0.591, and 0.604, while the area under the curve for cardiovascular mortality were 0.623, 0.617, and 0.623, in CHD patients. Elevated NLR is associated with increased risk of cardiovascular and all-cause mortality in CHD patients, and NLR can independently predict the prognosis of CHD 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.

Prediction of Osteoporotic Hip Fracture Outcome: Comparative Accuracy of 27 Immune-Inflammatory-Metabolic Markers and Related Conceptual Issues

Objectives: This study, based on the concept of immuno-inflammatory-metabolic (IIM) dysregulation, investigated and compared the prognostic impact of 27 indices at admission for prediction of postoperative myocardial injury (PMI) and/or hospital death in hip fracture (HF) patients. Methods: In consecutive HF patient (n = 1273, mean age 82.9 ± 8.7 years, 73.5% females) demographics, medical history, laboratory parameters, and outcomes were recorded prospectively. Multiple logistic regression and receiver-operating characteristic analyses (the area under the curve, AUC) were used to establish the predictive role for each biomarker. Results: Among 27 IIM biomarkers, 10 indices were significantly associated with development of PMI and 16 were indicative of a fatal outcome; in the subset of patients aged >80 years with ischaemic heart disease (IHD, the highest risk group: 90.2% of all deaths), the corresponding figures were 26 and 20. In the latter group, the five strongest preoperative predictors for PMI were anaemia (AUC 0.7879), monocyte/eosinophil ratio > 13.0 (AUC 0.7814), neutrophil/lymphocyte ratio > 7.5 (AUC 0.7784), eosinophil count < 1.1 × 109/L (AUC 0.7780), and neutrophil/albumin × 10 > 2.4 (AUC 0.7732); additionally, sensitivity was 83.1-75.4% and specificity was 82.1-75.0%. The highest predictors of in-hospital death were platelet/lymphocyte ratio > 280.0 (AUC 0.8390), lymphocyte/monocyte ratio < 1.1 (AUC 0.8375), albumin < 33 g/L (AUC 0.7889), red cell distribution width > 14.5% (AUC 0.7739), and anaemia (AUC 0.7604), sensitivity 88.2% and above, and specificity 85.1-79.3%. Internal validation confirmed the predictive value of the models. Conclusions: Comparison of 27 IIM indices in HF patients identified several simple, widely available, and inexpensive parameters highly predictive for PMI and/or in-hospital death. The applicability of IIM biomarkers to diagnose and predict risks for chronic diseases, including OP/OF, in the preclinical stages is discussed.

Discordance Between Neutrophil to Lymphocyte Ratio and High Sensitivity C-Reactive Protein to Predict Clinical Events in Patients with Stable Coronary Artery Disease: A Large-Scale Cohort Study

PURPOSE

Neutrophil to lymphocyte ratio (NLR), a novel inflammatory biomarker, has been shown to positively predict prognosis independent of high-sensitivity C-reactive protein (hsCRP) in patients with coronary artery disease (CAD). This study aimed to use discordance analysis to evaluate the effectiveness of NLR and hsCRP to predict adverse events in patients with stable CAD.

PATIENTS AND METHODS

This observational cohort study included 7827 consecutive CAD patients at Fuwai Hospital from March 2011 to April 2017. Discordant NLR with hsCRP was defined by the highest quartiles and medians. The primary endpoint was major adverse cardiovascular and cerebrovascular events (MACCEs), including cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, and unplanned revascularization.

RESULTS

During a median 36-month follow-up, 624 (8.0%) MACCEs occurred. Compared with the lowest NLR quartile, a significantly higher risk of MACCEs was observed in the highest NLR quartile after adjusting for confounding factors (hazard ratio [HR], 1.36; 95% confidence interval [CI], 1.09-1.71). High NLR and low hsCRP discordance were also associated with an increased risk of MACCEs in the fully adjusted model (HR, 1.39; 95% CI, 1.05-1.84).

CONCLUSION

This study demonstrated that discordantly elevated NLR levels were associated with a greater risk of adverse clinical events in patients with stable CAD, suggesting the potential clinical significance of NLR as a goal of inflammatory risk management.

Prognostic significance of inflammation in patients with coronary artery disease at low residual inflammatory risk

Patients with coronary artery disease (CAD) at low residual inflammatory risk are often overlooked in research and practice. This study examined the associations between fourteen inflammatory indicators and all-cause mortality in 5,339 CAD patients with baseline high-sensitivity C-reactive protein (hsCRP) <2 mg/L who received percutaneous coronary intervention and statin and aspirin therapy. The median follow-up time was 2.1 years. Neutrophil-derived systemic inflammatory response index (SIRI) yielded the strongest and most robust association with all-cause mortality among all indicators. Lower hsCRP remained to be associated with a lower risk of all-cause mortality. A newly developed comprehensive inflammation score (CIS) showed better predictive performance than other indicators, which was validated by an independent external cohort. In conclusion, neutrophil-derived indicators, particularly SIRI, strongly predicted all-cause mortality independent of hsCRP in CAD patients at low residual inflammatory risk. CIS may help identify individuals with inflammation burdens that cannot be explained by hsCRP alone.

Door to Balloon Time of Non-ST Elevation Myocardial Infarction May be Reconsidered According to Systemic Immune-Inflammation Index

Aim    Early diagnosis and treatment is very important in acute coronary syndromes (ACS). Previous studies showed that not all non-ST elevation myocardial infarction (NSTEMI) patients should be considered and treated in the same way. The systemic immune-inflammation index (SII), which is an easily accessible, rapidly computed, and cost-effective parameter, was evaluated in this study to determine the optimal intervention time for NSTEMI.Material and methods    469 patients diagnosed with ACS were included to the study. STEMI and NSTEMI patients were compared according to their SII. Univariate and binary logistic regression analysis were performed to determine which parameters have a significant effect on the discrimination of types of myocardial infarction.Results    The mean age of the patients was 61.43±11.52 yrs, and 348 (74.2 %) were male. NSTEMI patients with an SII value higher than 768×109 / l may be assumed to be STEMI (p<0.001). Univariate analysis and binary logistic regression showed that only SII and hypertension had statistically impact on differentiation of STEMI and NSTEMI. In addition, SII value of 1105×109 / l was the cut-off point for discrimination of cardiovascular survival (p<0.001, AUC =0.741). This study was performed to find out which NSTEMI patients should be treated percutaneously immediately after first medical contact according to SII. It was found that, SII value of higher than 768×109 / l is related with STEMI.Conclusion    In conclusion, NSTEMI patients with a SII value higher than 768×109 / l may be considered as STEMI and treated with in 120 min after first contact. In addition, SII was found to be a cardiovascular mortality predictor after myocardial infarction, and this may be used for identifying high-risk patients after percutaneous coronary intervention.

Comparison of Different Systemic Inflammatory Markers in Predicting Clinical Outcomes with Syntax Score in Patients with Non-ST Segment Elevation Myocardial Infarction: A Retrospective Study

Background

The clinical value of the Syntax score in patients with non-ST segment elevation myocardial infarction (NSTEMI) has been well established. The neutrophil-lymphocyte ratio (NLR), the platelet-lymphocyte ratio (PLR), the high sensitivity C-reactive protein (hsCRP)-albumin ratio (hsCAR), and systemic immune-inflammatory (SII) index are promising systemic inflammation (SI) biomarkers in coronary artery diseases. However, studies which compare the predicting value of these SI indicators with the Syntax score in NSTEMI patients are limited.

Material and Methods

NSTEMI patients who underwent coronary angiography (CAG) in our department were retrospectively enrolled. Both univariable and multivariable logistic regression analyses were performed to evaluate the clinical value between SI biomarkers and Syntax score in these patients. The area under the receiver operating characteristic curve (ROC) was used to compare the clinical values of these parameters in predicting 6-month major cardiovascular events (MACE) and over-all mortality.

Results

A total of 429 NSTEMI patients were finally enrolled in this study. The level of NLR, PLR, as well as hsCAR, and SII in patients with high Syntax scores, are significantly higher than patients with the low Syntax score. Multivariable logistic regression analysis demonstrated that all of the SI indicators but not the Syntax score were the independent risk factors of 6-month MACE in NSTEMI patients. ROC showed that all of the SI indicators had better predictive value than the Syntax score in these patients (0.637, 0.592, 0.631, 0.590, 0.559, respectively) in predicting MACE and similar predictive value in over-all mortality (0.530, 0.524, 0.761, 0.553, 0.620, respectively).

Conclusion

Novel SI biomarkers including NLR, PLR, hsCAR, and SII have better predictive value in MACE and similar predictive value in over-all mortality compared with Syntax score in NSTEMI patients.

Lower omega-3 status associated with higher erythrocyte distribution width and neutrophil-lymphocyte ratio in UK Biobank cohort

High red blood distribution width (RDW) is associated with decreased red blood cell deformability, and high neutrophil-lymphocyte ratio (NLR) is a biomarker of systemic inflammation and innate-adaptive immune system imbalance. Both RDW and NLR are predictors of chronic disease risk and mortality. Omega-3 index (O3I) values have previously been shown to be inversely associated with RDW and NLR levels. Our objective was to determine if total plasma long chain omega-3 fatty acids (Omega3%) measured in the UK Biobank cohort were associated with RDW and NLR values. RDW- and NLR- relationships with Omega3% were characterized in 109,191 adults (58.4% female). RDW- and NLR-Omega3% relationships were inversely associated with Omega3% (both p < 0.0001). These cross-sectional associations confirm previous findings that increasing RDW and NLR values are associated with low O3I. The hypothesis that RDW and/or NLR values can be reduced in individuals with less-than optimal long chain omega 3 values need to be tested in randomized controlled intervention trials using EPA and/or DHA.

Cepharanthine action in preventing obesity and hyperlipidemia in rats on a high-fat high sucrose diet

Background

It was demonstrated that cepharanthine (CEP), derived from Stephania cepharantha hayata, is a potent inhibitor of the ABCC10 transmembrane protein. It is approved to be a natural product or remedy. The present study focuses on investigating whether cepharanthine effectively reduces hyperlipidemia and obesity in an experimental hyperlipidemic rat model.

Method

Four groups of Wistar rats were assigned randomly to the following groups: a high-fat high sucrose diet (HFHS), normal-fat diet (NFD), HFHS plus cepraranthine (10 mg/kg) (HFHS-C), and a HFHS diet with atorvastatin (HFHS-A). The responses of rats were observed on the basis of serum and hepatic biochemical parameters, food intake, and body weight after CEP treatment, and assessing the histopathological modifications by the optical microscope in the liver and its cells.

Results

Significant improvement in the serum total cholesterol (TC), serum triglycerides (TG), and serum low-density lipoprotein (LDL) levels were observed following CEP treatment. We have also observed significant improvement in the structure of liver tissue and reduced-fat droplets in the cytoplasm. Moreover, CEP had a significant effect in preventing the gain in body weight of animals, and food intake was not significantly affected.

Conclusion

Our research results revealed that CEP significantly improved dyslipidemia and prevented the accumulation of fatty deposits in the rats' liver tissue fed an HFHS diet. In addition, CEP exerted an anti-obesity effect.

The Core Role of Neutrophil–Lymphocyte Ratio to Predict All-Cause and Cardiovascular Mortality: A Research of the 2005–2014 National Health and Nutrition Examination Survey

Objective

To further supplement the previous research on the relationship between neutrophil–lymphocyte ratio (NLR) and all-cause and cardiovascular mortality, and construct clinical models to predict mortality.

Methods

A total number of 2,827 observers were included from the National Health and Nutrition Examination Survey (NHANES) database in our research. NLR was calculated from complete blood count. According to the quartile of baseline NLR, those observers were divided into four groups. A multivariate weighted Cox regression model was used to analyze the association of NLR with mortality. We constructed simple clinical prognosis models by nomograms. Kaplan–Meier survival curves were used to depict cause-specific mortality. Restricted cubic spline regression was used to make explicit relationships between NLR and mortality.

Results

This study recruited 2,827 subjects aged ≥ 18 years from 2005 to 2014. The average age of these observers was 51.55 ± 17.62, and 57.69% were male. NLR is still an independent predictor, adjusted for age, gender, race, drinking, smoking, dyslipidemia, and other laboratory covariates. The area under the receiver operating characteristic curves (AUCs) of NLR for predicting all-cause mortality and cardiovascular mortality were 0.632(95% CI [0599, 0.664]) and 0.653(95% CI [0.581, 0.725]), respectively, which were superior to C-reactive protein (AUCs: 0.609 and 0.533) and WBC (AUCs: 0.522 and 0.513). The calibration and discrimination of the nomograms were validated by calibration plots and concordance index (C-index), and the C-indexes (95% CIs) of nomograms for all-cause and cardiovascular mortality were 0.839[0.819,0.859] and 0.877[0.844,0.910], respectively. The restricted cubic spline showed a non-linear relationship between NLR and mortality. NLR > 2.053 might be a risk factor for mortality.

Conclusion

There is a non-linear relationship between NLR and mortality. NLR is an independent factor related to mortality, and NLR > 2.053 will be a risk factor for prognosis. NLR and nomogram should be promoted to medical use for practicality and convenience.

Dysbiosis of Gut Microbiota and Metabolite Phenylacetylglutamine in Coronary Artery Disease Patients With Stent Stenosis

Introduction

Dysbiotic gut microbiota (GM) plays a regulatory role during the pathogenesis of several cardiovascular diseases, including atherosclerosis. GM-derived metabolite phenylacetylglutamine (PAGln) enhances platelet responsiveness and thrombosis potential, thereby inducing major adverse cardiovascular events. However, the role of GM and microbial metabolite PAGln in the pathogenesis of in-stent stenosis remains unknown.

Methods

16S rRNA sequencing was performed on fecal samples in 103 coronary artery disease (CAD) patients, including 35 individuals with in-stent patency (control), 32 individuals with in-stent hyperplasia (ISH), and 36 subjects with in-stent stenosis (ISS), and the levels of plasma PAGln were evaluated by enzyme-linked immunosorbent assay.

Results

The results revealed significantly enhanced microbial diversity and disrupted composition, such as enrichment of Roseburia, Blautia, and Ruminococcus, were observed in CAD patients with in-stent stenosis. The imbalance of microbial function related to PAGln synthesis and elevated plasma GM-derived metabolite PAGln levels was detected in CAD patients with in-stent stenosis. The GM-dependent diagnostic model could identify CAD patients with in-stent stenosis.

Conclusion

The current study revealed the disordered signature, altered functions, and potential diagnostic ability of GM in CAD patients with in-stent hyperplasia and stenosis. Enhanced microbiota-derived PAGln synthesis-related functions and elevated plasma PAGln levels were associated with in-stent stenosis and hyperplasia in CAD patients. Thus, an intervention targeting gut microbes may be a promising strategy to prevent stent stenosis in patients with CAD.

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

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

The omega-3 index is inversely associated with the neutrophil-lymphocyte ratio in adults'

The neutrophil-lymphocyte ratio (NLR) is a biomarker of systemic inflammation and measures innate-adaptive immune system balance. The omega-3-index (O3I) measures the amount of EPA+DHA in blood. Both a low O3I and an elevated NLR are associated with increased risk for chronic disease and mortality, including cardiovascular diseases and cancer. Hypothesizing that low O3I may partly contribute to systemic chronic inflammation, we asked if a relationship existed between O3I and NLR in healthy adults (≥18 y, n = 28,871, 51% female) without inflammation [C-reactive protein (CRP) <3 mg/mL)] who underwent a routine clinical assessment. NLR was inversely associated with O3I before (p < 0.0001) and after adjusting for age, sex, BMI, and CRP (p < 0.0001). Pearson correlations of other variables with NLR were r = 0.06 (CRP), r = 0.14 (age), and r = 0.01(BMI). In this healthy population, an O3I < 6.6% was associated with increasing NLR whereas NLR remained relatively constant (low) when O3I > 6.6%, suggestive of a quiescent, balanced immune system.

ADS Score as a Novel Predictor of Outcomes in Patients Who Underwent Percutaneous Coronary Intervention

Objectives: A novel AFR– albumin-derived neutrophil to lymphocyte ratio (dNLR) score (ADS) were reported to associate with clinical outcome in various malignancies, However, the relation between the ADS score and outcomes in coronary artery disease (CAD) patients after percutaneous coronary intervention (PCI) has not been investigated.

Methods: Three thousand five hundred and sixty-one patients were divided into two groups according to ADS score: low group (ADS score <2; n = 2,682) and high group (ADS score ≥ 2; n = 879). Overall, there were 133 all-cause mortality (ACM) during the following up. The incidence of ACM in the low group is 2.7% (72/2,682) and high group is 6.9% (61/879). The ACM incidence was significantly higher in high group compared to that in the low group (P < 0.001). Cardiac mortality (CM) occurred in 82 patients: 44(1.6%) in the low group and 38 (4.3%) in the high group. There was significant difference in the CM incidence between the low group and high group (P < 0.001). Major adverse cardiac and cerebrovascular events (MACCE) occurred in 520 patients: 366 (13.6%) in the low group and 154 (17.5%) in the high group. There was significant difference in the MACCE incidence between the low group and high group (P = 0.005). Major adverse cardiac and events (MACE) occurred in 395 patients: 281(10.5%) in the low group and 114 (13.0%) in the high group. There was significant difference in the MACE incidence between the low group and high group (P = 0.041). The multivariate Cox proportional hazards model showed that ADS score was independently correlated with the ACM [adjusted HR = 2.031 (1.357–3.039), P = 0.001]; CM [adjusted HR = 1.883 (1.127–3.147), P = 0.016]; MACCE [adjusted HR = 1.352 (1.096–1.668), P = 0.005], and MACE [adjusted HR = 1.260 (0.987–1.608), P = 0.063].

Conclusion: The present study indicated that the ADS score was associated with long-term mortality, the MACCE, and the MACE in CAD patients underwent PCI.

Association between neutrophil-to-lymphocyte ratio and major postoperative complications after carotid endarterectomy: A retrospective cohort study

BACKGROUND

Carotid artery cross-clamping during carotid endarterectomy (CEA) may damage local cerebral perfusion and induce cerebral ischemia–reperfusion injury to activate local inflammatory responses. Neutrophil-to-lymphocyte ratio (NLR) is an indicator that reflects systemic inflammation. However, the correlation between NLR and complications after CEA remains unclear.

AIM

To investigate the association between NLR and major complications after surgery in patients undergoing CEA.

METHODS

This retrospective cohort study included patients who received CEA between January 2016 and July 2018 at Beijing Tiantan Hospital. Neutrophil and lymphocyte counts in whole blood within 24 h after CEA were collected. The primary outcome was the composite of major postoperative complications including neurological, pulmonary, cardiovascular and acute kidney injuries. The secondary outcomes included infections, fever, deep venous thrombosis, length of hospitalization and cost of hospitalization. Statistical analyses were performed using EmpowerStats software and R software.

RESULTS

A total of 224 patients who received CEA were screened for review and 206 were included in the statistical analyses; of whom, 40 (19.42%) developed major postoperative complications. NLR within 24 h after CEA was significantly correlated with major postoperative complications (P = 0.026). After confounding factors were adjusted, the odds ratio was 1.15 (95%CI: 1.03–1.29, P = 0.014). The incidence of major postoperative complications in the high NLR group was 8.47 times that in the low NLR group (P = 0.002).

CONCLUSION

NLR is associated with major postoperative complications in patients undergoing CEA.

Vitamin K: A vital micronutrient with the cardioprotective potential against diabetes-associated complications

Cardiovascular disease (CVD) remains the leading cause of mortality in patients with type 2 diabetes (T2D). The conventional therapies seem to offer minimal long-term cardioprotection against diabetes-related complications in patients living with T2D. There is a growing interest in understanding the therapeutic effects of food-derived bioactive compounds in protecting or managing these metabolic diseases. This includes uncovering the therapeutic potential of fat-soluble micronutrients such as vitamin K, which are abundantly found in green leafy vegetables. We searched the major electronic databases including PubMed, Web of Sciences, Scopus, Google Scholar and Science direct. The search retrieved randomized clinical trials and preclinical studies, reporting on the impact of vitamin K on CVD-related complications in T2D. The current review updates clinical evidence on the therapeutic benefits of vitamin K by attenuating CVD-risk factors such as blood lipid profiles, blood pressure, as well as markers of oxidative stress and inflammation in patients with T2D. Importantly, the summarized preclinical evidence provides a unique perspective into the pathophysiological mechanisms that could be targeted by vitamin K in the primary prevention of T2D-related complications. Lastly, this review further explores the controversies related to the cardioprotective effects of vitamin K, and also provides the basic information such as the source and bioavailability profile of this micronutrient is covered to highlight its therapeutic potential.

High-Sensitivity C-Reactive Protein to HDL-C Ratio

Inflammation and lipid signaling are involved in the pathogenesis and progression of coronary artery disease (CAD). We proposed that high-sensitivity C-reactive proteins, as a marker of the pro-inflammatory state, and high-density lipoprotein cholesterol (HDL-C), as an anti-atherosclerosis component, should be integrated into a single novel biomarker. Our work was conducted to discuss and compare the predictive ability of the high-sensitivity C-reactive protein to high-density lipoprotein cholesterol ratio (CHR) with other existing indices, for example, neutrophil high-density lipoprotein ratio (NHR) and neutrophil lymphocyte ratio (NLR), in the severity of CAD patients.Based on the results of coronary angiography, patients were divided into the CAD⁺ group, CAD^- group, and control group. The relationship between various serum markers and the severity of coronary artery disease was examined via Spearman's correlation analysis. Logistic regression analysis was conducted to identify the influencing factors of the coronary artery disease severity.This study included 420 patients. The Gensini score was positively correlated with CHR. Multiple regression analysis revealed that the CHR was significantly associated with CAD. CHR is an independent predictor of CAD. The receiver operating characteristic (ROC) analysis provided a cut-off value of 1.17 for CHR to predict CAD, with a specificity of 86.7%, Yoden index of 0.264, and area under the ROC curve of 0.662 (95% confidence intervals 0.606-0.719, P < 0.001). At the same time, the area under the ROC curve of the NHR was 0.652, and that of the NLR was 0.579. The results of the DeLong test indicated that the area under the ROC curve of the CHR was larger than that of the NLR (P = 0.0306). This suggests that the CHR as a predictor of CAD has better diagnostic performance than the NLR.CHR was not only closely related to the presence and severity of CAD but also an independent predictor of severe CAD.

Neutrophil-to-Lymphocyte Ratio and Erythropoietin Resistance among Maintenance Hemodialysis Patients

INTRODUCTION

Neutrophil lymphocyte ratio (NLR) and platelet lymphocyte ratio (PLR) are recent prognostic biomarkers associated with inflammation. Increased erythropoiesis resistance index (ERI) may predict the risk of all-cause and cardiovascular mortality in hemodialysis (HD) patients. However, the roles of NLR and PLR in erythropoietin (EPO) responsiveness remain unclear in HD patients. This study aims to investigate the relationship between NLR and PLR and EPO responsiveness in maintenance HD patients.

METHODS

A total of 299 HD patients were included in this survey. Laboratory data and demographic details were collected. EPO responsiveness was evaluated by ERI. Pearson correlation analysis and logistic regressions were conducted to evaluate the factors that may be associated with EPO responsiveness.

RESULTS

The EPO responsiveness was positively related to ferritin and negatively related to serum albumin, lymphocytes, and hemoglobin. A multivariate linear regression revealed that only NLR (standardized β = 0.13, p = 0.024) but not PLR (standardized β = 0.107, p = 0.063) was correlated with a higher ERI.

CONCLUSION

A higher NLR level was shown to be a cheaper method to predict worse EPO responsiveness in HD patients.

Association of Derived Neutrophil-To-Lymphocyte Ratio With Prognosis of Coronary Heart Disease After PCI

Aims: The present study aimed to investigate the prognostic role of derived neutrophil-to-lymphocyte ratio (dNLR) in patients with coronary heart disease (CHD) after PCI.

Methods: A total of 3,561 post-PCI patients with CHD were retrospectively enrolled in the CORFCHD-ZZ study from January 2013 to December 2017. The patients (3,462) were divided into three groups according to dNLR tertiles: the first tertile (dNLR < 1.36; n = 1,139), second tertile (1.36 ≥ dNLR < 1.96; n = 1,166), and third tertile(dNLR ≥ 1.96; n = 1,157). The mean follow-up time was 37.59 ± 22.24 months. The primary endpoint was defined as mortality (including all-cause death and cardiac death), and the secondary endpoint was major adverse cardiovascular events (MACEs) and major adverse cardiovascular and cerebrovascular events (MACCEs).

Results: There were 2,644 patients with acute coronary syndrome (ACS) and 838 patients with chronic coronary syndrome (CCS) in the present study. In the total population, the all-cause mortality (ACM) and cardiac mortality (CM) incidence was significantly higher in the third tertile than in the first tertile [hazard risk (HR) = 1.8 (95% CI: 1.2–2.8), p = 0.006 and HR = 2.1 (95% CI: 1.23–3.8), p = 0.009, respectively]. Multivariate Cox regression analyses suggested that compared with the patients in the first tertile than those in the third tertile, the risk of ACM was increased 1.763 times (HR = 1.763, 95% CI: 1.133–2.743, p = 0.012), and the risk of CM was increased 1.763 times (HR = 1.961, 95% CI: 1.083–3.550, p = 0.026) in the higher dNLR group during the long-term follow-up. In both ACS patients and CCS patients, there were significant differences among the three groups in the incidence of ACM in univariate analysis. We also found that the incidence of CM was significantly different among the three groups in CCS patients in both univariate analysis (HR = 3.541, 95% CI: 1.154–10.863, p = 0.027) and multivariate analysis (HR = 3.136, 95% CI: 1.015–9.690, p = 0.047).

Conclusion: The present study suggested that dNLR is an independent and novel predictor of mortality in CHD patients who underwent PCI.

Distribution and reference interval establishment of neutral-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), and platelet-to-lymphocyte ratio (PLR) in Chinese healthy adults

Background

Neutral‐to‐lymphocyte ratio (NLR), lymphocyte‐to‐monocyte ratio (LMR), and platelet‐to‐lymphocyte ratio (PLR) are associated with coronavirus disease 2019 (COVID‐19) and many diseases, but there are few data about the reference interval (RI) of NLR, LMR, and PLR.

Methods

The neutrophil count, lymphocyte count, monocyte count, and platelet count of 404,272 Chinese healthy adults (>18 years old) were measured by Sysmex XE‐2100 automatic hematology analyzer, and NLR, LMR, and PLR were calculated. According to CLSI C28‐A3, the nonparametric 95% percentile interval is defined as the reference interval.

Results

The results of Mann‐Whitney U test showed that NLR (p < .001) in male was significantly higher than that in female; LMR (p < .001) and PLR (p < .001) in male were significantly lower than that in female. Kruskal‐Wallis H test showed that there were significant differences in NLR, LMR, and PLR among different genders and age groups (p < .001). The linear graph showed that the reference upper limit of NLR and PLR increased with age and the reference upper limit of LMR decreases with age in male population. In female population, the reference upper limit of NLR in 50–59 group, LMR in >80 group, and PLR in 70–79 group appeared a trough; the reference upper limit of NLR in >80 group, LMR in 50–59 group, and PLR in 40–49 group appeared peak.

Conclusion

The establishment of RI for NLR, LMR, and PLR in Chinese healthy adults according to gender and age will promote the standardization of clinical application.

Changes in the neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios before and after percutaneous coronary intervention and their impact on the prognosis of patients with acute coronary syndrome

OBJECTIVES

This study aimed to prospectively observe the changes in the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) before and after percutaneous coronary intervention (PCI) and their impact on the prognosis of patients with acute coronary syndrome (ACS).

METHODS

Blood samples from 205 patients with ACS were collected at admission and at 24h and 30 days post-PCI to observe changes in the complete blood count. The Cox multivariate regression model was used to analyze the factors influencing major adverse cardiac events (MACE) after PCI in patients with ACS. A receiver operating characteristic (ROC) curve was used to evaluate the predictive value of inflammation indicators for MACE after PCI.

RESULTS

Following PCI, NLR and PLR first increased postoperatively and then decreased within 30 days after PCI. Cox multivariate regression analysis showed that NLR and PLR at 24h post-PCI and acute ST-segment elevation myocardial infarction were independent influencing factors for the incidence of MACE after PCI. The ROC curve analysis showed that the NLR at 24h post-PCI was a better predictor of the incidence of MACE. The NLR at 24h post-PCI was significantly correlated with the number and length of implanted stents and operation duration.

CONCLUSIONS

After PCI, patients with ACS had an increased neutrophil proportion and NLR. The NLR at 24h post-PCI was a better predictor of the incidence of postoperative MACE.

Right Heart Changes Impact on Clinical Phenotype of Amyloid Cardiac Involvement: A Single Centre Study

Amyloidosis is due to deposition of an excessive amount of protein in many parenchymal tissues, including myocardium. The onset of cardiac Amyloidosis (CA) is an inauspicious prognostic factor, which can lead to sudden death. We retrospectively analyzed 135 patients with systemic amyloidosis, admitted to our ward between 1981 and 2019. Among them, 54 patients (46.30% F/53.70% M, aged 63.95 ± 12.82) presented CA at baseline. In 53 patients, it was associated with a multiorgan involvement, while in one there was a primary myocardial deposition. As a control group, we enrolled 81 patients (49.30% F/50.70% M, aged 58.33 ± 15.65) who did not meet the criteria for CA. In 44/54 of patients CA was associated with AL, 5/54 with AA and 3/54 of patients with ATTR, and in 1/54 AL was related to hemodialysis and in 1/54 to Gel-Amyloidosis. The most common AL type was IgG (28/44); less frequent forms were either IgA (7/44) or IgD (2/44), while seven patients had a λ free light chain form. The 32 AL with complete Ig were 31 λ-chain and just one k-chain. CA patients presented normal BP (SBP 118.0 ± 8.4 mmHg; DBP 73.8 ± 4.9 mmHg), while those with nCA had an increased proteinuria (p = 0.02). TnI and NT-proBNP were significantly increased compared to nCA (p = 0.031 and p = 0.047, respectively). In CA patients we found an increased LDH compared to nCA (p = 0.0011). CA patients were also found to have an increased interventricular septum thickness compared to nCA (p = 0.002), a decreased Ejection Fraction % (p = 0.0018) and Doppler velocity E/e’ ratio (p = 0.0095). Moreover, CA patients had an enhanced right atrium area (p = 0.0179), right ventricle basal diameter (p = 0.0112) and wall thickness (p = 0.0471) compared to nCA, and an increased inferior cava vein diameter (p = 0.0495) as well. TAPSE was the method chosen to evaluate systolic function of the right heart. In CA subjects very poor TAPSE levels were found compared to nCA patients (p = 0.0495). Additionally, we found a significant positive correlation between TAPSE and lymphocyte count (r = 0.47; p = 0.031) as well as Gamma globulins (r = 0.43, p = 0.033), Monoclonal components (r = 0.72; p = 0.047) and IgG values (r = 0.62, p = 0.018). Conversely, a significant negative correlation with LDH (r = −0.57, p = 0.005), IVS (r = −0.51, p = 0.008) and diastolic function evaluated as E/e’ (r = −0.60, p = 0.003) were verified. CA patients had very poor survival rates compared to controls (30 vs. 66 months in CA vs. nCA, respectively, p = 0.15). Mean survival of CA individuals was worse also when stratified according to NT-proBNP levels, using 2500 pg/mL as class boundary (174 vs. 5.5 months, for patients with lower vs. higher values than the median, respectively p = 0.013). In much the same way, a decreased right heart systolic function was correlated with a worse prognosis (18.0 months median survival, not reached in subjects with lower values than 18 mm, p = 0.0186). Finally, our data highlight the potential prognostic and predictive value of right heart alterations characterizing amyloidosis, as a novel clinical parameter correlated to increased LDH and immunoglobulins levels. Overall, we confirm the clinical relevance of cardiac involvement suggests that right heart evaluation may be considered as a new marker for clinical risk stratification in patients with amyloidosis.

Prognostic role of neutrophil-to-lymphocyte ratio in aortic disease: a meta-analysis of observational studies

OBJECTIVE

Recent studies have reported that neutrophil-to-lymphocyte ratio (NLR) is associated with cardiovascular disease. The aim of the present study was to investigate the prognostic value of NLR in aortic disease.

METHODS

We systematically searched electronic databases (Cochrane, PubMed, Elsevier, Medline, and Embase) from their inception to March 2020. Observational studies that evaluated the relationship between NLR and aortic disease were eligible for critical appraisal. Data were extracted from applicable articles, risk ratio (RR), weighted mean differences (MD) and 95% confidence intervals (CI) were calculated by RevMan 5.3, and statistical heterogeneity was assessed by the I² statistic.

RESULTS

Fourteen studies enrolling 4066 individuals were included in the meta-analysis. Compared with the control group, NLR was significantly higher in the aortic disease group (MD 3.44, 95%CI: 0.81-6.07, P = 0.01, I² = 99%). The NLR was also significantly higher in non-survivors with aortic disease, compared to the survivors (MD 4.62, 95%CI: 2.75-6.50, P < 0.00001, I² = 60%). Compared with the aortic disease patients with a low NLR, mortality was significantly higher in those with a high NLR (RR 2.63, 95%CI: 1.79-3.86, P < 0.00001, I² = 67%).

CONCLUSION

Based on current evidence, an elevated NLR was associated with aortic disease and in-hospital mortality. Raised NLR also demonstrated a significantly increased the risk of mortality after surgical repair in aortic disease patients. NLR may be a good prognostic biomarker in aortic disease and deserve further research in this area.