Neutrophil-Lymphocyte Ratio (NLR) as A Predictor for Non-ST Elevation Myocardial Infarction (NSTEMI) in the Emergency Room

Lutfi Hafiz Zunardi, Setyasih Anjarwani, Indra Prasetya, Budi Satrijo, Anna Fuji Rahimah

Abstract


Abstract

Background: The usefulness of the NLR as an approach to identifying cases of acute coronary syndrome (ACS) needs to be improved.

Objective: This research was designed to determine the effectiveness of the NLR in identifying individuals who presented to the emergency room complaining of anginal due to ACS.

Methods: The single-center cross-sectional study was performed at Saiful Anwar General Hospital in Malang, East Java, Indonesia, from July 2020 to December 2023. Patients were involved in this study with complaints of angina suspected of ACS. During further observation in the emergency room, based on the findings of the troponin I analysis, individuals were divided into unstable angina pectoris (UAP) and NSTEMI.

Results: Study results were collected from 282 individuals diagnosed with Non-ST Elevation Acute Coronary Syndrome (NSTEACS), with 75.9% male and a mean age of 58.39 ± 10.27 years. The NLR threshold was 4.5 (AUC: 0.78, 95% CI: 0.765–0.867, P <.001) assessed during admission, which showed a sensitivity of 79% and a specificity of 78% in accurately predicting the probability of subsequent troponin positivity. Multivariate analysis revealed that the NLR at hospitalization remained an essential marker of troponin positivity during follow-up.

Conclusions: In the end, NLR could be considered an initial test in emergency services to predict the diagnosis of NSTEMI in people experiencing angina.

 


Keywords


Marker Inflammation; NLR; NSTEMI; Troponin I.

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References


Byrne RA, Rossello X, Coughlan JJ, et al. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J. 2023;44(38):3720-3826. doi:10.1093/eurheartj/ehad191

Collet JP, Thiele H, Barbato E, et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2021;42(14):1289-1367. doi:10.1093/eurheartj/ehaa575

Buonacera A, Stancanelli B, Colaci M, Malatino L. Neutrophil to Lymphocyte Ratio: An Emerging Marker of the Relationships between the Immune System and Diseases. Int J Mol Sci. 2022;23(7). doi:10.3390/ijms23073636

Li Y, Wang W, Yang F, Xu Y, Feng C, Zhao Y. The regulatory roles of neutrophils in adaptive immunity. Cell Commun Signal. 2019;17(1):1-11. doi:10.1186/s12964-019-0471-y

Karakas MS, Korucuk N, Tosun V, et al. Red cell distribution width and neutrophil-to-lymphocyte ratio predict left ventricular dysfunction in acute anterior ST-segment elevation myocardial infarction. J Saudi Hear Assoc. 2016;28(3):152-158. doi:10.1016/j.jsha.2015.07.001

Arbel Y, Finkelstein A, Halkin A, et al. Neutrophil/lymphocyte ratio is related to the severity of coronary artery disease and clinical outcome in patients undergoing angiography. Atherosclerosis. 2012;225(2):456-460. doi:10.1016/j.atherosclerosis.2012.09.009

Honda T, Uehara T, Matsumoto G, Arai S, Sugano M. Neutrophil left shift and white blood cell count as markers of bacterial infection. Clin Chim Acta. 2016;457:46-53. doi:10.1016/j.cca.2016.03.017

Korkmaz A, Yildiz A, Gunes H, Duyuler S, Tuncez A. Utility of neutrophil-lymphocyte ratio in predicting troponin elevation in the emergency department setting. Clin Appl Thromb. 2015;21(7):667-671. doi:10.1177/1076029613519850

Kourilovitch M, Galarza–Maldonado C. Could a simple biomarker as neutrophil-to-lymphocyte ratio reflect complex processes orchestrated by neutrophils? J Transl Autoimmun. 2023;6(June 2022):100159. doi:10.1016/j.jtauto.2022.100159

Dentali F, Nigro O, Squizzato A, et al. Impact of neutrophils to lymphocytes ratio on major clinical outcomes in patients with acute coronary syndromes: A systematic review and meta-analysis of the literature. Int J Cardiol. 2018;266:31-37. doi:10.1016/j.ijcard.2018.02.116

Dong CH, Wang ZM, Chen SY. Neutrophil to lymphocyte ratio predict mortality and major adverse cardiac events in acute coronary syndrome: A systematic review and meta-analysis. Clin Biochem. 2018;52(September 2017):131-136. doi:10.1016/j.clinbiochem.2017.11.008

Lam B, Li J (Junyi), Mukarram M, Nemnom MJ, Booth RA, Thiruganasambandamoorthy V. Validation of the Ottawa Troponin Pathway. Australas Emerg Care. 2022;25(1):37-40. doi:10.1016/j.auec.2021.04.004

Thiruganasambandamoorthy V, Stiell IG, Chaudry H, et al. Use of conventional cardiac troponin assay for diagnosis of non-ST-elevation myocardial infarction: “The Ottawa Troponin Pathway.” PLoS One. 2020;15(1):1-15. doi:10.1371/journal.pone.0226892

Wang Z, Wang J, Cao D, Han L. Correlation of neutrophil-to-lymphocyte ratio with the prognosis of non-ST-segment elevation in patients with acute coronary syndrome undergoing selective percutaneous coronary intervention. J Int Med Res. 2020;48(10). doi:10.1177/0300060520959510

Wang J, Tan GJ, Han LN, Bai YY, He M, Liu H Bin. Novel biomarkers for cardiovascular risk prediction. J Geriatr Cardiol. 2017;14(2):135-150. doi:10.11909/j.issn.1671-5411.2017.02.008

Swirski FK, Nahrendorf M. Leukocyte behavior in atherosclerosis, myocardial infarction, and heart failure. Science (80- ). 2013;339(6116):161-166. doi:10.1126/science.1230719

Dharma S, Hapsari R, Siswanto BB, Van Der Laarse A, Jukema JW. Blood leukocyte count on admission predicts cardiovascular events in patients with acute non-st elevation myocardial infarction. Int J Angiol. 2014;24(2):127-131. doi:10.1055/s-0035-1544178

Shah N, Parikh V, Patel 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. Int J Cardiol. 2014;171(3):390-397. doi:10.1016/j.ijcard.2013.12.019

Akpek M, Kaya MG, Lam YY, 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):621-627. doi:10.1016/j.amjcard.2012.04.041

Tamhane UU, Aneja S, Montgomery D, Rogers EK, Eagle KA, Gurm HS. Association Between Admission Neutrophil to Lymphocyte Ratio and Outcomes in Patients With Acute Coronary Syndrome. Am J Cardiol. 2008;102(6):653-657. doi:10.1016/j.amjcard.2008.05.006

Azab B, Camacho-Rivera M, Taioli E. Average values and racial differences of neutrophil lymphocyte ratio among a nationally representative sample of United States subjects. PLoS One. 2014;9(11). doi:10.1371/journal.pone.0112361

Thygesen K, Alpert JS, Jaffe AS, et al. Fourth Universal Definition of Myocardial Infarction (2018). J Am Coll Cardiol. 2018;72(18):2231-2264. doi:10.1016/j.jacc.2018.08.1038

Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2018;39(2):119-177. doi:10.1093/eurheartj/ehx393

Aydin S, Ugur K, Aydin S, Sahin İ, Yardim M. Biomarkers in acute myocardial infarction: Current perspectives. Vasc Health Risk Manag. 2019;15:1-10. doi:10.2147/VHRM.S166157

Germany GH, Germany AK, Lenzen MJ, Denmark EP, Vranckx P. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST -segment elevation The Task Force for the management of acute myocardial infarction. Published online 2018:119-177. doi:10.1093/eurheartj/ehx393

Damman FAP, Appelman BZY, Vos MVA De, et al. 2020 ESC Guidelines on acute coronary syndrome without ST-segment elevation Recommendations and critical appraisal from the Dutch ACS and Interventional Cardiology working groups. Published online 2021:557-565. doi:10.1007/s12471-021-01593-4

Brunetti ND, Troccoli R, Correale M, Pellegrino P luigi, Di Biase M. C-reactive protein in patients with acute coronary syndrome: Correlation with diagnosis, myocardial damage, ejection fraction and angiographic findings. Int J Cardiol. 2006;109(2):248-256. doi:10.1016/j.ijcard.2005.06.021

Correia LCL, Esteves PJ. C-reactive protein and outcomes in acute coronary syndromes: A systematic review and meta-analysis. Arq Bras Cardiol. 2011;97(1).

Duman H, Çinier G, Bakırcı EM, et al. Relationship Between C-Reactive Protein to Albumin Ratio and Thrombus Burden in Patients With Acute Coronary Syndrome. Clin Appl Thromb. 2019;25. doi:10.1177/1076029618824418

Ma Y, Yang X, Villalba N, et al. Circulating lymphocyte trafficking to the bone marrow contributes to lymphopenia in myocardial infarction. Am J Physiol Heart Circ Physiol. 2022;322(4):H622-H635. doi:10.1152/ajpheart.00003.2022

Muhmmed Suliman MAR, Bahnacy Juma AA, Ali Almadhani AA, Pathare AV, Alkindi SSA, Uwe Werner F. Predictive Value of Neutrophil to Lymphocyte Ratio in Outcomes of Patients with Acute Coronary Syndrome. Arch Med Res. 2010;41(8):618-622. doi:10.1016/j.arcmed.2010.11.006

Tahto E, Jadric R, Pojskic L, Kicic E. Neutrophil-to-lymphocyte Ratio and Its Relation with Markers of Inflammation and Myocardial Necrosis in Patients with Acute Coronary Syndrome. Med Arch (Sarajevo, Bosnia Herzegovina). 2017;71(5):312-315. doi:10.5455/medarh.2017.71.312-315

Chmielewski PP, Strzelec B. Elevated leukocyte count as a harbinger of systemic inflammation, disease progression, and poor prognosis: A review. Folia Morphol. 2018;77(2):171-178. doi:10.5603/FM.a2017.0101

Timmer JR, Van Der Horst ICC, Ottervanger JP, et al. Prognostic value of admission glucose in non-diabetic patients with myocardial infarction. Am Heart J. 2004;148(3):399-404. doi:10.1016/j.ahj.2004.04.007

Monteiro S, Monteiro P, Gonçalves F, Freitas M, Providência LA. Hyperglycaemia at admission in acute coronary syndrome patients: Prognostic value in diabetics and non-diabetics. Eur J Cardiovasc Prev Rehabil. 2010;17(2):155-159. doi:10.1097/HJR.0b013e32832e19a3

Gencer B, Rigamonti F, Nanchen D, et al. Prognostic values of fasting hyperglycaemia in non-diabetic patients with acute coronary syndrome: A prospective cohort study. Eur Hear J Acute Cardiovasc Care. 2020;9(6):589-598. doi:10.1177/2048872618777819




DOI: https://doi.org/10.21776/ub/hsj.2024.005.03.7

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