Neutrophil-to-lymphocyte ratio did not improve NSTEMI diagnostic accuracy over hs-cTn alone (17% NSTEMI prevalence), but provided incremental prognostic value for mortality and MACE at 1285 days.
Observational (n=3,926)
Yes
Does the neutrophil-to-lymphocyte ratio (NLR) improve diagnostic and prognostic accuracy in patients presenting to the emergency department with acute chest pain?
NLR provides incremental prognostic value for long-term mortality and MACE in patients with acute chest pain, though it does not improve the diagnostic accuracy of high-sensitivity troponin for NSTEMI.
Abstract Background Neutrophil-to-lymphocyte ratio (NLR) is a marker easily obtainable by dividing two routinely assessable laboratory values – the neutrophil and lymphocyte count, thus reflecting the ratio in between acute and chronic inflammatory stress. Being increased as a part of the physiological stress response to acute myocardial infarction (AMI), the NLR might be helpful in its early diagnosis. Purpose To assess the diagnostic and prognostic value of the NLR in patients presenting to the emergency department with acute chest pain as a symptom suggestive for AMI. Methods NLR, high-sensitivity cardic toponin (hs-cTn) T and hs-cTnI were measured in consecutive patients presenting to the emergency department (ED) with acute chest discomfort enrolled in a large international study. The primary diagnostic endpoint was the index non-ST-segment elevation myocardial infarction (NSTEMI) being assessed by computing the receiver operational characteristic curves (ROC) of hs-cTnT/hs-cTnI and NLR and comparing the area uder the curve (AUC). The co-primary prognostic endpoint was the all-cause mortality (ACM) as well as major adverse cardiovascular event (MACE) defined as a composite outcome of AMI, cardiovascular mortality (CVM), stroke and hospitalization due to heart failure, excluding the index event and within 1285 days from ED presentation. The association between NLR and each prognostic endpoint has been modelled using multivariable Cox proportional hazard regression fitting restricted cubic splines to continuous variables. The magnitude of the effect of each NLR unit change on multivariable-adjusted models was assessed graphically using dose-response plots. To compute a hazard ratio (HR) for the dose-response plots, we chose NLR value of 3, described previously as a possible reference value. For the restricted cubic splines three knots were used. Results Among 3926 eligible patients, NSTEMI was the final diagnosis in 668 (17%) of them. Diagnostic accuracy quantified using AUC for the combination of NLR with hs-cTnT/hs-cTnI was very high, but showed no statistically significant difference to the AUC of hs-cTnT/hs-cTnI alone (Figure 1). Regarding the prognostic outcomes, NLR levels, after adjustment for the covariates of age, sex, diabetes mellitus, kidney function, BMI, hypercholesterolemia, hypertension, cancer and active smoking status, showed to be associated with an increased hazard of all-cause mortality as well as the composite outcome of MACE at 1825 days (Figure 2). Conclusion Our results showed that whereas not improving the diagnostic accuracy in combination with hs-cTnT/hs-cTnI, the NLR provides an incremental prognostic value for the outcomes of ACM and MACE at 1285 days.Figure 1 Figure 2
Okamura et al. (Sat,) conducted a observational in acute chest pain (n=3,926). Neutrophil-to-lymphocyte ratio (NLR) vs. hs-cTnT/hs-cTnI alone was evaluated on Index NSTEMI (diagnostic) and all-cause mortality or MACE (prognostic). Neutrophil-to-lymphocyte ratio did not improve NSTEMI diagnostic accuracy over hs-cTn alone (17% NSTEMI prevalence), but provided incremental prognostic value for mortality and MACE at 1285 days.