Prognostic value of RDW-to-platelet ratio for short- and long-term mortality after cardiac surgery: dual-center MIMIC-IV and external validation

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Cardiac surgery (n=11349). Intervention: Highest tertile of RDW-to-platelet ratio (RPR >= 0.11) vs. Middle tertile of RDW-to-platelet ratio (RPR 0.082-0.11). Primary outcome: 28-day all-cause mortality (fully adjusted Model III in MIMIC-IV cohort) (HR 2.168, 95% CI 1.300-3.614, p=0.003).

Q: What does this research mean for the field?

Preoperative red blood cell distribution width-to-platelet ratio of 0.11 or higher independently predicts increased 28-day and 365-day mortality following cardiac surgery with a nonlinear U-shaped relationship. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Qiannan Guo; Yuehang Yang; Hanshen Luo; Chuli Shi; Jiawei Shi

doi:10.1038/s41598-026-76834-w

October 21, 2026Scientific ReportsOpen Access

Prognostic value of RDW-to-platelet ratio for short- and long-term mortality after cardiac surgery: dual-center MIMIC-IV and external validation

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Key result

High preoperative RPR linked to ~2.2-fold higher 28-day mortality after cardiac surgery.

HR 2.168
95% CI 1.300-3.614
P=0.003
n=11,349

Why the study?

The prognostic value of the red cell distribution width to platelet ratio (RPR) in patients undergoing cardiac surgery remained unclear.

Does a high or low preoperative red cell distribution width to platelet ratio (RPR) predict 28-day and 365-day all-cause mortality in adult patients undergoing cardiac surgery?

Key Points

To assess the prognostic value of the red cell distribution width-to-platelet ratio (RPR) for 28-day and 365-day mortality in patients undergoing cardiac surgery.
Retrospective dual-center cohort analysis of 8,619 cardiac surgery patients from the MIMIC-IV database and an external validation cohort of 2,730 patients.
Preoperative RPR was categorized into tertiles (MIMIC-IV: T1 ≤ 0.082, T2 0.082–0.11, T3 ≥ 0.11; external cohort: T1 ≤ 0.087, T2 0.087–0.12, T3 ≥ 0.12).
Multivariable Cox proportional hazards modeling and restricted cubic spline analyses evaluated short-term (28-day) and long-term (365-day) all-cause mortality.
In the MIMIC-IV cohort, patients in the highest RPR tertile (T3) had significantly higher mortality than T2 in fully adjusted models for 28-day mortality (HR 2.168, 95% CI 1.300–3.614, P < 0.001) and 365-day mortality (HR 1.575, 95% CI 1.111–2.233, P < 0.001).
Restricted cubic spline analyses demonstrated a nonlinear U-shaped association between RPR and mortality in both the MIMIC-IV cohort (28-day P for nonlinear < 0.001; 365-day P = 0.001) and the external validation cohort (28-day P for nonlinear = 0.001; 365-day P = 0.003).
In sensitivity analysis applying MIMIC-IV cutoffs to the external cohort, RPR ≥ 0.11 remained independently associated with 28-day mortality (HR 1.867, 95% CI 1.072–3.251, P = 0.027) and 365-day mortality (HR 1.513, 95% CI 1.040–2.201, P = 0.030).

Study Design

Type

Cohort (n=11,349)

Multicenter

Yes

Structured PICO

Does a high or low preoperative red cell distribution width to platelet ratio (RPR) predict 28-day and 365-day all-cause mortality in adult patients undergoing cardiac surgery?

P

Population

11,349 adult cardiac surgery ICU patients (8,619 in the MIMIC-IV derivation cohort [median age 69 years, 27.7% female] and 2,730 in an external Chinese validation cohort [median age 59 years, 38.8% female]), with ICU stay >= 24 hours, followed for 365 days.

E

Exposure

Preoperative red cell distribution width to platelet ratio (RPR = RDW [%] / PLT [×10⁹/L]) recorded at ICU admission, evaluated continuously and stratified into tertiles: in MIMIC-IV, T1 (≤0.082) and T3 (≥0.11); in the external validation cohort, T1 (≤0.087) and T3 (≥0.12).

C

Comparator

Middle tertile (T2) of RPR as the reference group (0.082–0.11 in MIMIC-IV; 0.087–0.12 in the external validation cohort).

O

Outcome

Short-term (28-day) and long-term (365-day) all-cause mortality following cardiac surgery.hard clinical

Main Result

Hazard Ratio: 2.168 (95% CI 1.3–3.614)

Absolute Event Rate: 2.12% vs 0.84%

p-value: p=0.003

Preoperative red cell distribution width to platelet ratio (RPR) is independently and nonlinearly associated with both 28-day and 365-day all-cause mortality following cardiac surgery, providing a readily available biomarker for perioperative risk stratification.

Limitations

Retrospective observational design precludes causal inference and leaves potential residual confounding from unmeasured variables (e.g., frailty, nutritional status, cardiopulmonary bypass use/duration, perioperative transfusions).
RPR was measured only at ICU admission from preoperative blood samples, without assessing dynamic postoperative changes.
Generalizability may be limited as each cohort originated from a single tertiary center within its respective country.
Lack of data on specific causes of death prevented analysis of cause-specific mortality.
Subgroup analyses were exploratory and subject to multiple comparisons.
The external validation cohort lacked complete data on several comorbidities (hyperlipidemia, liver cirrhosis, chronic kidney disease, cancer, and coronary artery disease), restricting full model adjustment.

Implication

RPR ≥0.11 was associated with higher mortality after cardiac surgery; hypothesis-generating for risk stratification, needs prospective validation.

Abstract

The prognostic value of red cell distribution width to platelet ratio (RPR) in cardiac surgery remains unclear. This retrospective study included 8,619 patients from MIMIC-IV and 2,730 from an external cohort. RPR tertiles were used to assess associations with 28‑ and 365‑day mortality using Cox and restricted cubic spline (RCS) analyses. In MIMIC-IV, the highest RPR tertile (T3, ≥ 0.11) was associated with significantly increased mortality risk compared to the middle tertile. Fully adjusted hazard ratios for T3 were 2.168 (95% CI 1.300–3.614) for 28-day mortality and 1.575 (95% CI 1.111–2.233) for 365-day mortality. RCS revealed a nonlinear U-shaped relationship (P for nonlinear < 0.001 and = 0.001, respectively). Subgroup effects were more pronounced in females, hypertensive patients, and those without diabetes, heart failure, or COPD (P for interaction < 0.05). These findings were validated in the external cohort, which showed similar effect magnitudes and nonlinear patterns (P for nonlinear = 0.001 for 28-day; = 0.003 for 365-day mortality). Kaplan–Meier analysis confirmed significant mortality differences across RPR tertiles in both cohorts. RPR is independently and nonlinearly associated with increased short- and long-term mortality after cardiac surgery, suggesting its utility in perioperative risk stratification.

Discussion

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Cite This Study

Guo et al. (2026) conducted a cohort in Cardiac surgery (n=11,349). Highest tertile of RDW-to-platelet ratio (RPR >= 0.11) vs. Middle tertile of RDW-to-platelet ratio (RPR 0.082-0.11) was evaluated on 28-day all-cause mortality (fully adjusted Model III in MIMIC-IV cohort) (HR 2.168, 95% CI 1.300-3.614, p=0.003). Preoperative RDW-to-platelet ratio >=0.11 independently predicted higher 28-day (HR 2.168, 95% CI 1.300-3.614) and 365-day (HR 1.575, 95% CI 1.111-2.233) mortality after cardiac surgery.

synapsesocial.com/papers/6ad9e562f67b53d094565a32 https://doi.org/10.1038/s41598-026-76834-w

Topics

HFrEF treatment

Heart failure

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Prognostic value of RDW-to-platelet ratio for short- and long-term mortality after cardiac surgery: dual-center MIMIC-IV and external validation

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

Topics

Prognostic value of RDW-to-platelet ratio for short- and long-term mortality after cardiac surgery: dual-center MIMIC-IV and external validation

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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