Usefulness of Neutrophil to Lymphocyte Ratio in Predicting Short- and Long-Term Mortality After Non–ST-Elevation Myocardial Infarction

      Neutrophil/lymphocyte ratio (NLR) is the strongest white blood cell predictor of adverse outcomes in stable and unstable coronary artery syndromes. The aim of our study was to explore the utility of NLR in predicting long-term mortality in patients with non–ST-segment elevation myocardial infarction (NSTEMI). Consecutive patients with NSTEMI at Staten Island University Hospital were evaluated for study inclusion. Of the 1,345 patients with NSTEMI admitted from September 2004 to September 2006, 619 qualified for study inclusion. Survival analysis, stratified by NLR tertiles, was used to evaluate the predictive value of average inpatient NLR levels. Four-year vital status was accessed with electronic medical records and Social Security Death Index. Patients in the highest NLR tertile (NLR >4.7) had a higher 4-year mortality rate (29.8% vs 8.4%) compared to those in the lowest tertile (NLR <3, Wilcoxon chi-square 34.64, p <0.0001). After controlling for Global Registry of Acute Coronary Events risk profile scores, average NLR level remained a significant predictor of inpatient and 4-year mortality. Hazard ratios per unit increase of average NLR (log) increased by 1.06 (p = 0.0133) and 1.09 (p = 0.0006), respectively. In conclusion, NLR is an independent predictor of short-term and long-term mortalities in patients with NSTEMI with an average NLR >4.7. We strongly suggest the use of NLR rather than other leukocyte parameters (e.g., total white blood cell count) in risk stratification of the NSTEMI population.
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        • Gurm H.S.
        • Bhatt D.L.
        • Lincoff A.M.
        • Tcheng J.E.
        • Kereiakes D.J.
        • Kleiman N.S.
        • Jia G.
        • Topol E.J.
        Impact of preprocedural white blood cell count on long-term mortality after percutaneous coronary intervention: insights from the EPIC, EPILOG, and EPISTENT trials.
        Heart. 2003; 89: 1200-1204
        • Gibson P.H.
        • Croal B.L.
        • Cuthbertson B.H.
        • Small G.R.
        • Ifezulike A.I.
        • Gibson G.
        • Jeffrey R.R.
        • Buchan K.G.
        • El-Shafei H.
        • Hillis G.S.
        Preoperative neutrophil-lymphocyte ratio and outcome from coronary artery bypass grafting.
        Am Heart J. 2007; 154: 995-1002
        • Duffy B.K.
        • Gurm H.S.
        • Rajagopal V.
        • Gupta R.
        • Ellis S.G.
        • Bhatt D.L.
        Usefulness of an elevated neutrophil to lymphocyte ratio in predicting long-term mortality after percutaneous coronary intervention.
        Am J Cardiol. 2006; 97: 993-996
        • Nunez J.
        • Nunez E.
        • Bodi V.
        • Sanchis J.
        • Minana G.
        • Mainar L.
        • Santas E.
        • Merlos P.
        • Rumiz E.
        • Darmofal H.
        • Heatta A.M.
        • Llacer A.
        Usefulness of the neutrophil to lymphocyte ratio in predicting long-term mortality in ST segment elevation myocardial infarction.
        Am J Cardiol. 2008; 101: 747-752
        • Tamhane U.U.
        • Aneja S.
        • Montgomery D.
        • Rogers E.K.
        • Eagle K.A.
        • Gurm H.S.
        Association between admission neutrophil to lymphocyte ratio and outcomes in patients with acute coronary syndrome.
        Am J Cardiol. 2008; 102: 653-657
        • Papa A.
        • Emdin M.
        • Passino C.
        • Michelassi C.
        • Battaglia D.
        • Cocci F.
        Predictive value of elevated neutrophil-lymphocyte ratio on cardiac mortality in patients with stable coronary artery disease.
        Clin Chim Acta. 2008; 395: 27-31
        • Granger C.B.
        • Goldberg R.J.
        • Dabbous O.
        • Pieper K.S.
        • Eagle K.A.
        • Cannon C.P.
        • Van De Werf F.
        • Avezum A.
        • Goodman S.G.
        • Flather M.D.
        • Fox K.A.
        Predictors of hospital mortality in the global registry of acute coronary events.
        Arch Intern Med. 2003; 163: 2345-2353
        • Tang E.W.
        • Wong C.K.
        • Herbison P.
        Global Registry of Acute Coronary Events (GRACE) hospital discharge risk score accurately predicts long-term mortality post acute coronary syndrome.
        Am Heart J. 2007; 153: 29-35
        • Garrey W.E.
        Variation in white blood cell counts.
        Physiol Rev. 1935; 15: 597-638
        • Benschop R.J.
        • Rodriguez-Feuerhahn M.
        • Schedlowski M.
        Catecholamine-induced leukocytosis: early observations, current research, and future directions.
        Brain Behav Immun. 1996; 10: 77-91
        • Mehta J.
        • Dinerman J.
        • Mehta P.
        • Saldeen T.G.
        • Lawson D.
        • Donnelly W.H.
        • Wallin R.
        Neutrophil function in ischemic heart disease.
        Circulation. 1989; 79: 549-556
        • Baldus S.
        • Heeschen C.
        • Meinertz T.
        • Zeiher A.M.
        • Eiserich J.P.
        • Munzel T.
        • Simoons M.L.
        • Hamm C.W.
        Myeloperoxidase serum levels predict risk in patients with acute coronary syndromes.
        Circulation. 2003; 108: 1440-1445
        • Hansen P.R.
        Role of neutrophils in myocardial ischemia and reperfusion.
        Circulation. 1995; 91: 1872-1885
        • Avanzas P.
        • Quiles J.
        • Lopez de Sa E.
        • Sanchez A.
        • Rubio R.
        • Garcia E.
        • Lopez-Sendon J.L.
        Neutrophil count and infarct size in patients with acute myocardial infarction.
        Int J Cardiol. 2004; 97: 155-156
        • Kirtane A.J.
        • Bui A.
        • Murphy S.A.
        • Barron H.V.
        • Gibson C.M.
        Association of peripheral neutrophilia with adverse angiographic outcomes in ST-elevation myocardial infarction.
        Am J Cardiol. 2004; 93: 532-536
        • Siminiak T.
        • Flores N.A.
        • Sheridan D.J.
        Neutrophil interactions with endothelium and platelets: possible role in the development of cardiovascular injury.
        Eur Heart J. 1995; 16: 160-170
        • Ommen S.R.
        • Gibbons R.J.
        • Hodge D.O.
        • Thomson S.P.
        Usefulness of the lymphocyte concentration as a prognostic marker in coronary artery disease.
        Am J Cardiol. 1997; 79: 812-814
        • Ommen S.R.
        • Hodge D.O.
        • Rodeheffer R.J.
        • McGregor C.G.
        • Thomson S.P.
        • Gibbons R.J.
        Predictive power of the relative lymphocyte concentration in patients with advanced heart failure.
        Circulation. 1998; 97: 19-22
        • Blum A.
        • Sclarovsky S.
        • Rehavia E.
        • Shohat B.
        Levels of T-lymphocyte subpopulations, interleukin-1beta, and soluble interleukin-2 receptor in acute myocardial infarction.
        Am Heart J. 1994; 127: 1226-1230
        • Carpagnano G.E.
        • Spanevello A.
        • Sabato R.
        • Depalo A.
        • Palladino G.P.
        • Bergantino L.
        • Foschino Barbaro M.P.
        Systemic and airway inflammation in sleep apnea and obesity: the role of ICAM-1 and IL-8.
        Transl Res. 2010; 155: 35-43
        • MacNee W.
        • Wiggs B.
        • Belzberg A.S.
        • Hogg J.C.
        The effect of cigarette smoking on neutrophil kinetics in human lungs.
        N Engl J Med. 1989; 321: 924-928
        • Nieman D.C.
        • Henson D.A.
        • Nehlsen-Cannarella S.L.
        • Ekkens M.
        • Utter A.C.
        • Butterworth D.E.
        • Fagoaga O.R.
        Influence of obesity on immune function.
        J Am Diet Assoc. 1999; 99: 294-299
        • Palmerini T.
        • Barozzi C.
        • Tomasi L.
        • Sangiorgi D.
        • Marzocchi A.
        • De Servi S.
        • Ortolani P.
        • Bacchi Reggiani L.
        • Alessi L.
        • Lauria G.
        • Bassi M.
        • Branzi A.
        A randomised study comparing the antiplatelet and antiinflammatory effect of clopidogrel 150 mg/day versus 75 mg/day in patients with ST-segment elevation acute myocardial infarction and poor responsiveness to clopidogrel: results from the DOUBLE study.
        Thromb Res. 2010; 125: 309-314
        • Ridker P.M.
        • Cannon C.P.
        • Morrow D.
        • Rifai N.
        • Rose L.M.
        • McCabe C.H.
        • Pfeffer M.A.
        • Braunwald E.
        C-reactive protein levels and outcomes after statin therapy.
        N Engl J Med. 2005; 352: 20-28
        • Karfis E.A.
        • Papadopoulos G.
        • Matsagas M.
        • Pantazi D.
        • Lekka M.
        • Kitsiouli I.
        • Siminelakis S.
        • Anagnostopoulos C.
        • Drossos G.
        The systemic inflammatory response in coronary artery bypass grafting: what is the role of the very low ejection fraction (EF < or = 30%)?.
        J Cardiovasc Surg. 2008; 49: 801-808
        • Skubitz K.M.
        Neutrophilic leukocytes.
        in: Greer J.P. Foerester J. Rodgers G.M. Paraskevas F. Glader B. Arber D.A. Means Jr, R.T. Wintrobe's Clinical Hematology. Wolters Kluwer/Lippincott Williams & Wilkins Health, Philadelphia2009: 170-193
        • Geaghan S.M.
        Normal Blood Values: Selected References Values for Neonatal, Pediatric and Adult Populations. Elsevier Churchill Livingstone, New York2005
        • Bain B.J.
        Ethnic and sex differences in the total and differential white cell count and platelet count.
        J Clin Pathol. 1996; 49: 664-666
        • Lichtman M.A.
        Cellular deformability during maturation of the myeloblast.
        N Engl J Med. 1970; 283: 943-948
        • Cannon C.P.
        • Braunwald E.
        Unstable angina and non-ST elevation myocardial infarction.
        in: Libby P. Bonow R.O. Mann D.L. Zipes D.P. Braunwald's Heart Disease. Saunders Elsevier, Philadelphia2008: 1319-1351