Elsevier

Atherosclerosis

Volume 225, Issue 2, December 2012, Pages 456-460
Atherosclerosis

Neutrophil/lymphocyte ratio is related to the severity of coronary artery disease and clinical outcome in patients undergoing angiography

https://doi.org/10.1016/j.atherosclerosis.2012.09.009Get rights and content

Abstract

Background

White blood cell count is an independent predictor of cardiovascular events and mortality. Neutrophil/lymphocyte ratio (NLR) is a biomarker that can single out individuals at risk for vascular events.

Objective

To evaluate whether NLR adds additional information beyond that provided by conventional risk factors and biomarkers for coronary artery disease (CAD) severity and adverse outcome, in a large cohort of consecutive patients referred for coronary angiography.

Materials and methods

NLR was computed from the absolute values of neutrophils and lymphocytes from the complete blood count of 3005 consecutive patients undergoing coronary angiography for various indications. CAD severity was determined by an interventional cardiologist unaware of the study aims. The association between NLR and CAD severity was assessed by logistic regression and the association between NLR and 3-years outcome were analyzed using Cox regression models, adjusting for potential clinical, metabolic, and inflammatory confounders.

Results

The cohort was divided into 3 groups according to the NLR value (<2, 2–3, and >3). NLR was independently associated with CAD severity and it contributed significantly to the regression models. Patients with NLR >3 had more advanced obstructive CAD (OR = 2.45, CI 95% 1.76–3.42, p < 0.001) and worse prognosis, with a higher rate of major CVD events during up to 3 years of follow-up (HR = 1.55, CI 95% 1.09–2.2, p = 0.01).

Conclusion

Neutrophil/lymphocyte ratio is independently associated with CAD severity and 3-years outcome. NLR value appears additive to conventional risk factors and commonly used biomarkers.

Highlights

► In a large unselected heterogeneous cohort undergoing coronary angiography. ► High NLR value (above 3) is an independent predictor of CAD severity. ► High NLR value (above 3) is a predictor of worse clinical outcome. ► NLR is a readily available biomarker that can single out individuals at risk for future events.

Introduction

White blood cell (WBC) count is an independent predictor of cardiovascular (CVD) events and all-cause mortality, and may recognize high-risk individuals who are not currently being identified by traditional CVD risk factors [1]. In the GRACE registry, the admission leukocyte count in 8269 patients was associated with hospital death (adjusted odds ratio [OR] 2.8, 95% CI 2.1–3.6) and heart failure (OR 2.7, 95% CI 2.2–3.4) among patients presenting with acute coronary syndrome (ACS) [2]. Leukocytes and especially neutrophils play a central role in atherogenesis and atherothrombosis [3]. Low lymphocyte counts have been shown in ACS patients and associated with complications [4]. Therefore, the ratio between the absolute number of neutrophils to the number of lymphocytes (Neutrophil/lymphocyte ratio ((NLR)) has recently emerged as a potential new biomarker which singles out individuals at risk for future CVD events [5], [6], [7], [8], [9], [10]. It has been suggested that NLR is a better predictor of CVD events compared to the WBC count or Neutrophil count, even after controlling for various known risk factors [11].

While WBC count has been shown to correlate with the severity of coronary artery disease (CAD) [12], no correlation between the NLR and CAD severity has ever been demonstrated. Prior studies have looked at homogenous patient populations, such as those with heart failure [10] and ST-elevation myocardial infarction (MI) [5], and those who are after vascular surgery [9] and non-ST elevation MI [11].

The aim of the present study was to evaluate whether NLR adds additional information above and beyond that provided by conventional risk factors and biomarkers for CAD severity and adverse outcome in a large and heterogeneous cohort of consecutive patients referred for coronary angiography for various reasons.

Section snippets

Study design and patient selection

The data in this study were collected from the Tel Aviv Prospective Angiographic Survey (TAPAS) database. The TAPAS is a prospective, single-center registry which enrolls all patients undergoing cardiac catheterization at the Tel Aviv Medical Center [13], [14], [15]. The study cohort consisted of 3005 consecutive patients referred for coronary angiography in our institution for various clinical presentations. All the enrollees signed a written informed consent for participation in the study,

Results

A total of 3005 consecutive patients referred for coronary angiography at the Tel Aviv Medical Center were included in the final analysis. The mean age was 66.6 ± 11.9 (range: 18–97 years), and 71% were males. Their baseline clinical characteristics are presented in Table 1. As can be seen, approximately half of the cohort underwent angiography due to acute coronary syndrome while the other half were stable at presentation. Coronary angiography revealed normal or non-obstructive CAD in 22% of

Discussion

Neutrophil/lymphocyte ratio (NLR) has recently emerged as a potential new biomarker which singles out individuals at risk for future CVD events. In the present study, we demonstrate that high NLR value (above 3) is an independent predictor of CAD severity and a predictor of worse clinical outcome in a large unselected heterogeneous cohort undergoing coronary angiography.

NLR provided supplementary information on CAD severity and CVD outcome after controlling for all the currently accepted risk

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