Neutrophil-to-lymphocyte ratio for predictor of in-hospital mortality in ST-segment elevation myocardial infarction: a meta-analysis
BACKGROUND ST-segment elevation myocardial infarction (STEMI) is the most life-threatening condition of acute coronary syndrome that carries a poor prognosis of in-hospital mortality. Multiple scoring systems have been developed to predict in-hospital mortality and other cardiovascular events. Neutrophil-to-lymphocyte ratio (NLR) is hardly used as a predictor of in-hospital mortality. This study was aimed to determine the predictive value of NLR concerning in-hospital mortality in STEMI patients.
METHODS Literature search and pooled analysis related to studies on MEDLINE/PubMed, EBSCO, Science Direct, Cochrane, and ProQuest were retrieved. Inclusion criteria were met if they were cohort studies, the subjects were STEMI patient, contained pretreatment NLR cut-off, and considered in-hospital mortality, which is defined as cardiac or all-cause mortality. Quality assessment was conducted using Newcastle-Ottawa scale. Review Manager version 5.3 (The Nordic Cochrane Centre, Copenhagen) was used for meta-analysis.
RESULTS We found 12 studies with a total of 7,251 STEMI subjects with median NLR cut-off value of 5.6. Elevated NLR on admission carries a high risk of in-hospital mortality (odds ratio [OR] = 3.00, 95% confidence interval [CI] = 2.46–3.67). A slightly higher risk of all-cause mortality (OR = 2.74, 95% CI = 1.99–3.77) was observed compared with cardiac-related mortality (OR = 3.20, 95% CI = 2.47–4.14). No significant heterogeneity was observed between these studies (p = 0.46, I2 = 0%).
CONCLUSIONS Elevated NLR predicts a higher in-hospital mortality rate of STEMI patients.
Sanchis-Gomar F, Perez-Quilis C, Leischik R, Lucia A. Epidemiology of coronary heart disease and acute coronary syndrome. Ann Transl Med. 2016;4(13):256. https://doi.org/10.21037/atm.2016.06.33
Roth GA, Huffman MD, Moran AE, Feigin V, Mensah GA, Naghavi M, et al. Global and regional patterns in cardiovascular mortality from 1990 to 2013. Circulation. 2015;132(17):1667-78. https://doi.org/10.1161/CIRCULATIONAHA.114.008720
Kusuma D. Cardiovascular diseases of multiple ethnic in Indonesia. In: Yuniadi Y, Hermanto DY, Raajoe AU. Textbook of cardiovascular volume 1. 1st ed. Jakarta: Sagung Seto; 2017. p. 3-17. Indonesian.
Hamm CW, Bassand JP, Agewall S, Bax J, Boersma E, Bueno H, et al. ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2011;32(23):2999-3054. https://doi.org/10.1093/eurheartj/ehr236
Wilder J, Sabatine MS, Lilly LS. Acute coronary syndrome. In: Creager MA, Beckman JA, Losclazo J. Vascular medicine - a companion to Braunwald's heart disease. 2nd ed. Philadelphia: Elsevier Saunders; 2013. p. 162-91.
Shahawy S, Libby P. Atherosclerosis. In: Lilly LS. Pathophysiology of heart disease. 6th ed. Philadelphia: Lippincott William & Wilkins; 2016. p. 112-32.
Horne BD, Anderson JL, John JM, Weaver A, Bair TL, Jensen KR, et al. Which white blood cell subtypes predict increased cardiovascular risk? J Am Coll Cardiol. 2005;45(10):1638-43. https://doi.org/10.1016/j.jacc.2005.02.054
Cho KH, Jeong MH, Ahmed K, Hachinohe D, Choi HS, Chang SY, et al. Value of early risk stratification using hemoglobin level and neutrophil-to-lymphocyte ratio in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention. Am J Cardiol. 2011;107(6):849-56. https://doi.org/10.1016/j.amjcard.2010.10.067
Núñez J, Núñez E, Bodí V, Sanchis J, Mainar L, Miñana G, et al. Low lymphocyte count in acute phase of ST-segment elevation myocardial infarction predicts long-term recurrent myocardial infarction. Coron Artery Dis. 2010;21(1):1-7.
Sawant AC, Adhikari P, Narra SR, Srivatsa SS, Mills PK, Srivatsa SS. Neutrophil to lymphocyte ratio predicts short- and long-term mortality following revascularization therapy for ST elevation myocardial infarction. Cardiol J. 2014;21(5):500-8. https://doi.org/10.5603/CJ.a2013.0148
Akpek M, Kaya MG, Lam YY, Sahin O, Elcik D, Celik T, et al. 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. Am J Cardiol. 2012;110(5):621-7. https://doi.org/10.1016/j.amjcard.2012.04.041
Kaya MG, Akpek M, Lam YY, Yarlioglues M, Celik T, Gunebakmaz O, et al. Prognostic value of neutrophil/lymphocyte ratio in patients with ST-elevated myocardial infarction undergoing primary coronary intervention: a prospective, multicenter study. Int J Cardiol. 2013;168(2):1154-9. https://doi.org/10.1016/j.ijcard.2012.11.074
Shen XH, Chen Q, Shi Y, Li HW. Association of neutrophil/lymphocyte ratio with long-term mortality after ST elevation myocardial infarction treated with primary percutaneous coronary intervention. Chin Med J (Engl). 2010;123(23):3438-43. https://doi.org/10.3760/cma.j.issn.0366-6999.2010.23.012
Gazi E, Bayram B, Gazi S, Temiz A, Kirilmaz B, Altun B, et al. Prognostic value of the neutrophil-lymphocyte ratio in patients with ST-elevated acute myocardial infarction. Clin Appl Thromb Hemost. 2012;21(2):155-9. https://doi.org/10.1177/1076029613492011
Han YC, Yang TH, Kim DI, Jin HY, Chung SR, Seo JS, et al. Neutrophil to lymphocyte ratio predicts long-term clinical outcomes in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention. Korean Circ J. 2013;43(2):93-9. https://doi.org/10.4070/kcj.2013.43.2.93
Park JJ, Jang HJ, Oh IY, Yoon CH, Suh JW, Cho YS, et al. Prognostic value of neutrophil to lymphocyte ratio in patients presenting with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention. Am J Cardiol. 2013;111(5):636-42. https://doi.org/10.1016/j.amjcard.2012.11.012
Sen N, Afsar B, Ozcan F, Buyukkaya E, Isleyen A, Akcay AB, et al. The neutrophil to lymphocyte ratio was associated with impaired myocardial perfusion and long term adverse outcome in patients with ST-elevated myocardial infarction undergoing primary coronary intervention. Atherosclerosis. 2013;228(1):203-10. https://doi.org/10.1016/j.atherosclerosis.2013.02.017
Ergelen M, Uyarel H, Altay S, Kul S, Ayhan E, Isik T, et al. Predictive value of elevated neutrophil to lymphocyte ratio in patients undergoing primary angioplasty for ST-segment elevation myocardial infarction. Clin Appl Thromb Hemost. 2014;20(4):427-32. https://doi.org/10.1177/1076029612473516
He J, Li J, Wang Y, Hao P, Hua Q. Neutrophil-to-lymphocyte ratio (NLR) predicts mortality and adverse-outcomes after ST-segment elevation myocardial infarction in Chinese people. Int J Clin Exp Pathol. 2014;7(7):4045-56.
Hartopo AB, Puspitawati I, Setianto BY. On-admission high neutrophil to lymphocyte ratio as predictor of in-hospital adverse cardiac event in st-elevation myocardial infarction. Acta Med Indones. 2015;47(1):3-10.
Pan W, Zhao D, Zhang C, Li W, Yu J, Wang S, et al. Application of neutrophil/lymphocyte ratio in predicting coronary blood flow and mortality in patients with ST-elevation myocardial infarction undergoing percutaneous coronary intervention. J Cardiol. 2015;66(1):9-14. https://doi.org/10.1016/j.jjcc.2014.10.014
Gul U, kayani AM, Munir R, Hussain S. Neutrophil lymphocyte ratio: a prognostic marker in acute st elevation myocardial infarction. J Coll Physicians Surg Pak. 2017;27(1):4-7.
Dharma S, Andriantoro H, Purnawan I, Dakota I, Basalamah F, Hartono B, et al. Characteristics, treatment and in-hospital outcomes of patients with STEMI in a metropolitan area of a developing country: an initial report of the extended Jakarta Acute Coronary Syndrome registry. BMJ Open. 2016;6(8):e012193. https://doi.org/10.1136/bmjopen-2016-012193corr1
Miyachi H, Takagi A, Miyauchi K, Yamasaki M, Tanaka H, Yoshikawa M, et al. Current characteristics and management of ST elevation and non-ST elevation myocardial infarction in the Tokyo metropolitan area: from the Tokyo CCU network registered cohort. Heart Vessels. 2016;31(11):1740-51. https://doi.org/10.1007/s00380-015-0791-9
Fox KA, Eagle KA, Gore JM, Steg PG, Anderson FA, GRACE and GRACE2 Investigators. The Global Registry of Acute Coronary Events, 1999 to 2009 - GRACE. Heart. 2010;96(14):1095-101. https://doi.org/10.1136/hrt.2009.190827
Demirer Z, Uslu AU. Predictive value of neutrophil-lymphocyte ratio in non-muscle-invasive bladder cancer. Urol Oncol. 2016;34(1):1-2. https://doi.org/10.1016/j.urolonc.2015.09.006
Cho Y, Kim WH, Yoon HI, Lee CG, Keum KC, Lee IJ. The prognostic significance of neutrophil-to-lymphocyte ratio in head and neck cancer patients treated with radiotherapy. J Clin Med. 2018;7(12):512. https://doi.org/10.3390/jcm7120512
Deng M, Ma X, Liang C, Zhu C, Wang M. Are pretreatment neutrophil-lymphocyte ratio and platelet-lymphocyte ratio useful in predicting the outcomes of patients with small-cell lung cancer? Oncotarget. 2017;8(23):37200-7. https://doi.org/10.18632/oncotarget.16553
Li L, Xia Y, Chen C, Cheng P, Peng C. Neutrophil-lymphocyte ratio in systemic lupus erythematosus disease: a retrospective study. Int J Clin Exp Med. 2015;8(7):11026-31.
Martins EC, da Fe Silveira L, Viegas K, Beck AD, Júnior GF, Cremonese RV, et al. Neutrophil-lymphocyte ratio in the early diagnosis of sepsis in an intensive care unit: a case control study. Rev Bras Ter Intensiva. 2019;31(1):63–70.
Uslu AU, Küçük A, Şahin A, Ugan Y, Yilmaz R, Güngör T, et al. Two new inflammatory markers associated with Disease Activity Score-28 in patients with rheumatoid arthritis: neutrophil-lymphocyte ratio and platelet-lymphocyte ratio. Int J Rheum Dis. 2015;18(7):731–5.
Zhang J, Ren Q, Song Y, He M, Zeng Y, Liu Z, et al Prognostic role of neutrophil-lymphocyte ratio in patients with acute ischemic stroke. Medicine (Baltimore). 2017;96(45);e8624. https://doi.org/10.1097/MD.0000000000008624
Angkananard T, Anothaisintawee T, Mc Evoy M, Attia J, Thakkinistian A. Neutrophil lymphocyte ratio and cardiovascular disease risk: a systematic review and meta-analysis. Biomed Res Int. 2018;2018:2703518. https://doi.org/10.1155/2018/2703518
Börekçi A, Gür M, Türkoğlu C, Baykan AO, Şeker T, Şahin DY, et al. Neutrophil to lymphocyte ratio predicts left ventricular remodeling in patients with ST elevation myocardial infarction after primary percutaneous coronary intervention. Korean Circ J. 2016;46(1):15–22.
Morrow DA, Antman EM, Charlesworth A, Cairns R, Murphy SA, de Lemos JA, et al. TIMI risk score for ST-elevation myocardial infarction: a conventient, bedside, clinical score for risk assessment at presentation: an intravenous nPA for treatment of infarcting myocardium early II trial substudy. Circulation. 2000;102(17):2031-7. https://doi.org/10.1161/01.CIR.102.17.2031
Acet H, Ertaş F, Bilik MZ, Akıl MA, Özyurtlu F, Aydın M, et al. The relationship between neutrophil to lymphocyte ratio, platelet to lymphocyte ratio and thrombolysis in myocardial infarction risk score in patients with ST elevation acute myocardial infarction before primary coronary intervention. Postepy Kardiol Interwecyjnej. 2015;11(2):126–35.
Ginanjar E, Yamin M, Wijaya IP, Harimurti K. Predictors of 30-day mortaliy in ST-elevation myocardial infarction (STEMI) patients. Acta Med Indones. 2019;51(3):238-43.
Meeuwsen JA, Wesseling M, Hoefer IE, de Jager SC. Prognostic value of circulating inflammatory cells in patients with stable and acute coronary artery disease. Front Cardiovasc Med. 2017;4:44. https://doi.org/10.3389/fcvm.2017.00044
Widmer A, Linka AZ, Attenhofer Jost CH, Buergi B, Brunner-La Rocca HP, Salomon F, et al. Mechanical complications after myocardial infarction reliably predicted using C-reactive protein levels and lymphocytopenia. Cardiology. 2003;99(1):25-31. https://doi.org/10.1159/000068448
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