Predictive value of the monocyte-to-high-density lipoprotein cholesterol ratio in atrial fibrillation: a meta-analysis

Background The monocyte-to-high-density lipoprotein cholesterol ratio (MHR) has emerged as a novel biomarker for cardiovascular outcomes. However, its role in atrial fibrillation (AF) remains unclear. This meta-analysis aimed to evaluate the diagnostic efficacy of MHR in predicting AF risk. Methods We systematically searched PubMed, Embase, and Web of Science up to March 20, 2025. The primary outcome was to assess the diagnostic accuracy of MHR for predicting AF using summary receiver operating characteristic (SROC) curve analysis. The secondary outcome was to explore the relationship between MHR and AF risk. Pooled odds ratio (OR), sensitivity, specificity, and area under the curve (AUC) were calculated. Results A total of 13 studies comprising 5,499 participants were included. Elevated MHR was independently associated with an increased AF risk (OR = 1.21; 95% CI, 1.11–1.31; P < 0.001). The pooled sensitivity and specificity were 0.85 (95% CI, 0.71–0.93) and 0.68 (95% CI, 0.60–0.75), yielding an area under the SROC curve of 0.80 (95% CI, 0.76–0.83). Subgroup analyses revealed significant diagnostic performance variations by AF phenotype: MHR had the highest sensitivity (0.91; 95% CI 0.74–1.00) and AUC (0.94; 95% CI 0.91–0.96) in non-procedural AF, followed by post-ablation recurrence (sensitivity = 0.86, AUC = 0.83) and new-onset AF (sensitivity = 0.80, AUC = 0.83). Large-sample studies (>600) showed lower sensitivity (0.71 vs. 0.90) but higher specificity (0.78 vs. 0.60) than small-sample studies (≤600). No significant publication bias was detected ( p = 0.45). Conclusions MHR demonstrates moderate diagnostic accuracy for AF risk prediction and is better suited as a screening or complementary biomarker than a standalone diagnostic tool. Its diagnostic performance varies significantly by AF phenotype and clinical context. Given the limited number of studies, significant heterogeneity, and unstandardized MHR cut-offs, large-scale prospective studies with standardized protocols are warranted to validate these findings and facilitate targeted clinical application. Systematic Review Registration https://www.crd.york.ac.uk/prospero/ , identifier CRD420251030225.