EC Cardiology

Introduction: Inflammatory response is one of the main mechanisms in the pathogenesis of atherosclerosis and its progression. The neutrophil-lymphocyte ratio (NLR) has been proposed as an inflammatory biomarker and potential risk and prognosis predictor in cardiovascular disease (CVD).

Objective: To evaluate the association between the NLR and the severity of coronary artery disease (CAD).

Methods: An observational and retrospective study was carried out, including 56 patients aged ≥ 18 years (41 men and 15 women) who underwent diagnostic and/or therapeutic coronary angiography from 2014 to 2019 at Sagrada Esperança Clinic, Luanda, Angola. Demographic data, risk factors and comorbidities, biochemical tests and full blood count were collected from the patients’ medical reports. The NLR was calculated as the ratio between the total neutrophil and lymphocyte counts from the patients‘ full blood count. For the statistical analysis purposes, the sample was divided into two groups according to the median of NLR (median: 2.02): patients with NLR ≤median and patients with NLR> median. The statistical significance was set at 5%.

Results: The group of patients with CAD was relatively older than the group without CAD, although without any significant difference (58.49 ± 8.76 vs. 54.74 ± 8.7, p = 0.137). Likewise, the age was similar between groups considering the level of NLR (57.89 ± 8.60 vs. 56.54 ± 9.12, p = 0.571). The risk of having CAD and it being obstructive was twice as high in the group with NLR above the median (NLR > 2.02) compared to the group with a lower NLR (OR: 2.25, CI: 0.722 - 1.012 and 2.17, CI: 0.717 - 6.550, respectively). However, in general, our data suggested that there was no association between the neutrophil-lymphocyte ratio and the presence of CAD, nor with its severity (Χ² = 1.991, p = 0.259 and Χ² = 0.760, p = 0.562, respectively).

Conclusion: The risk of CAD occurrence, as well as the occurrence of obstructive CAD was twice higher in the group with higher neutrophil-lymphocyte ratio.

Keywords: Cardiovascular Diseases; Inflammation; Neutrophil-Lymphocyte Ratio; Biomarkers; Atherosclerosis; Coronary Artery Disease

1. Angkananard T., et al. “Neutrophil Lymphocyte Ratio and Cardiovascular Disease Risk: A Systematic Review and Meta-Analysis”. BioMed Research International (2018): 2703518.
2. World Health Organization. Top 10 Causes of Death (2021).
3. Paquissi FC. “The role of inflammation in cardiovascular diseases: The predictive value of neutrophil-lymphocyte ratio as a marker in peripheral arterial disease”. Therapeutics and Clinical Risk Management 12 (2016): 851-860.
4. Hansson GK. “Inflammation, atherosclerosis, and coronary artery disease”. The New England Journal of Medicine16 (2005): 1685-1695.
5. Criqui MH., et al. “Biomarkers in peripheral arterial disease patients and near- and longer-term mortality”. Journal of Vascular Surgery1 (2010): 85-90.
6. Van Wijk DF., et al. “C - reactive protein, fatal and nonfatal coronary artery disease, stroke, and peripheral artery disease in the prospective EPIC-norfolk cohort study”. Arteriosclerosis, Thrombosis, and Vascular Biology12 (2013): 2888-2894.
7. Kaptoge S., et al. “C-reactive protein concentration and risk of coronary heart disease, stroke, and mortality: an individual participant meta-analysis”. Lancet9709 (2010): 132-140.
8. McDermott MM., et al. “Relation of interleukin-6 and vascular cellular adhesion molecule-1 levels to functional decline in patients with lower extremity peripheral arterial disease”. The American Journal of Cardiology9 (2011): 1392-1398.
9. Danesh J., et al. “C-reactive protein and other circulating markers of inflammation in the prediction of coronary heart disease”. The New England Journal of Medicine14 (2004): 1387-1397.
10. Shah N., et al. “Neutrophil lymphocyte ratio significantly improves the Framingham risk score in prediction of coronary heart disease mortality: insights from the National Health and Nutrition Examination Survey-III”. International Journal of Cardiology3 (2014): 390-397.
11. Papa A., et al. “Predictive value of elevated neutrophil-lymphocyte ratio on cardiac mortality in patients with stable coronary artery disease”. Clinica Chimica Acta1-2 (2008): 27-31.
12. Akpek M., 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”. The American Journal of Cardiology5 (2012): 621-627.
13. Baetta R and Corsini A. “Role of polymorphonuclear neutrophils in atherosclerosis: current state and future perspectives”. Atherosclerosis1 (2010): 1-13.
14. Balta S., et al. “The Relation Between Atherosclerosis and the Neutrophil-Lymphocyte Ratio”. Clinical and Applied Thrombosis/Hemostasis - SAGE Journals5 (2015): 405-411.
15. Liu X., et al. “Blood neutrophil to lymphocyte ratio as a predictor of hypertension”. American Journal of Hypertension11 (2015): 1339-1346.
16. Arbel Y., et al. “Neutrophil/lymphocyte ratio is related to the severity of coronary artery disease and clinical outcome in patients undergoing angiography”. Atherosclerosis2 (2012): 456-460.
17. Azab B., et al. “Average values and racial differences of neutrophil lymphocyte ratio among a nationally representative sample of United States subjects”. PLoS One11 (2014): e112361.
18. Azab B., et al. “Usefulness of neutrophil to lymphocyte ratio in predicting short-and long-term mortality after NonST-elevation myocardial infarction”. The American Journal of Cardiology4 (2010): 470-476.
19. Arbel Y., et al. “Higher Neutrophil/Lymphocyte Ratio Is Related to Lower Ejection Fraction and Higher Long-term All-Cause Mortality in ST-Elevation Myocardial Infarction Patients”. The Canadian Journal of Cardiology10 (2014): 1177-1182.
20. Tamhane UU., et al. “Association between admission neutrophil to lymphocyte ratio and outcomes in patients with acute coronary syndrome”. The American Journal of Cardiology6 (2008): 653-657.
21. Turak O., et al. “Usefulness of the neutrophil-to-lymphocyte ratio to predict bare-metal stent restenosis”. The American Journal of Cardiology10 (2012): 1405-1410.
22. Tasoglu I., et al. “Preoperative neutrophil-lymphocyte ratio and saphenous vein graft patency after coronary artery bypass grafting”. Clinical and Applied Thrombosis/Hemostasis8 (2014): 819-824.
23. Gibson PH., et al. “Preoperative neutrophil-lymphocyte ratio and outcome from coronary artery bypass grafting”. American Heart Journal5 (2007): 995-1002.
24. Ryan TJ., et al. “Guidelines for percutaneous transluminal coronary angioplasty. A report of the American College of Cardiology/American Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Subcommittee on Percutaneous Transluminal Coronary Angioplasty)”. Circulation2 (1998): 486-502.
25. Gensini GG. “A more meaningful scoring system for determining the severity of coronary heart disease”. The American Journal of Cardiology3 (1983): 606.
26. Wang X., et al. “Neutrophil to lymphocyte ratio in relation to risk of all-cause mortality and cardiovascular events among patients undergoing angiography or cardiac revascularization: A meta-analysis of observational studies”. Atherosclerosis1 (2014): 206-213.
27. Kaya H., et al. “Association between neutrophil to lymphocyte ratio and severity of coronary artery disease”. Clinical and Applied Thrombosis/Hemostasis1 (2014): 50-54.
28. Escobar E. “Hypertension and coronary heart disease”. Journal of Human Hypertension 16 (2002): S61-S63.
29. Sharma KK., et al. “Epidemiology of cardioprotective pharmacological agent use in stable coronary heart disease”. Indian Heart Journal3 (2013): 250-255.