Published: 2018-03-21

Association between neutrophil to lymphocyte ratio and severity of coronary artery disease

Jagadish H. R., Divyaprakash M., Manjunath R., Girish P. G.


Background: Atherosclerosis is a chronic systemic inflammatory disease. Neutrophil-to-lymphocyte ratio (NLR) is systemic inflammatory marker that is correlated with poor cardiovascular outcome. The aim of this study was to investigate the association between neutrophil to lymphocyte ratio (NLR) and severity of coronary atherosclerosis.

Methods: A total of 324 patients undergoing coronary angiography were included in the study. All the patients were included in study were divided into two groups based on the result of coronary angiography report. While 226 patients had abnormal coronary angiography (case) (78 female, mean age: 60.6±12.6 years), 98 patients had normal coronary angiography (control) (60 female, mean age: 57.2±10.9 years). NLR was calculated as the ratio of neutrophil count to lymphocyte count.

Results: Although age distribution was similar between the two groups

(p = 0.073), female gender was significantly higher in the normal coronary angiography group (p < 0.001). Smoking history has shown a significant higher in cases compared to the normal coronary angiography (p=0.001). Patients with abnormal coronary angiography had significantly higher NLR when compared to patients with normal coronary angiography (p<0.001). NLR was significantly correlated with Gensini score. In logistic regression analyses, NLR was an independent predictor of CAD. An NLR of 2.34 or higher predicted the CAD with a sensitivity of 66% and specificity of 70%.

Conclusions: There is significant association between severity of coronary artery disease and neutrophils to lymphocyte ratio. This study suggests that the NLR is an independent predictor of coronary heart disease that may be useful for cardiac risk stratification in patients with coronary artery disease.


Coronary artery disease, Coronary angiography, Gensini Score, Neutrophil-lymphocyte ratio

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Ross R. Atherosclerosis-an inflammatory disease. N Engl J Med. 1999;340(2):115-26.

Hansson GK. Inflammation, atherosclerosis, and coronary artery disease. N Engl J Med. 2005;352(16):1685-95.

Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Lancet. 2006;367(9524):1747-57.

Onat A, Yazici M, Sari İ, Türkmen S, Uzunlar B, Uyarel H, et al. The risk factor survey of 2003 in western Turkey indicates trend to declining coronary mortality and urban overall mortality. Archives Turkish Society Cardiology. 2003;31(12):762-9.

Gurm HS, Bhatt DL, Lincoff AM, Tcheng JE, Kereiakes DJ, Kleiman NS, et al. Impact of preprocedural white blood cell count on long term mortality after percutaneous coronary intervention: insights from the EPIC, EPILOG, and EPISTENT trials. Heart. 2003;89(10):1200-4.

Horne BD, Anderson JL, John JM, Weaver A, Bair TL, Jensen KR, et al. Which white blood cell subtypes predict increased cardiovascular risk?. J Ame Coll Cardiol. 2005;45(10):1638-43.

Gibson PH, Cuthbertson BH, Croal BL, Rae D, El-Shafei H, Gibson G, et al. Usefulness of neutrophil/lymphocyte ratio as predictor of new-onset atrial fibrillation after coronary artery bypass grafting. Ame J Cardiol. 2010;105(2):186-91.

Papa A, Emdin M, Passino C, Michelassi C, Battaglia D, Cocci F. Predictive value of elevated neutrophil-lymphocyte ratio on cardiac mortality in patients with stable coronary artery disease. Clin Chim Acta. 2008;395(1-2):27-31.

Duffy BK, Gurm HS, Rajagopal V, Gupta R, Ellis SG, Bhatt DL. Usefulness of an elevated neutrophil to lymphocyte ratio in predicting long-term mortality after percutaneous coronary intervention. American J Cardiology. 2006;97(7):993-6.

Gibson PH, Croal BL, Cuthbertson BH, Small GR, Ifezulike AI, Gibson G, et al. Preoperative neutrophil-lymphocyte ratio and outcome from coronary artery bypass grafting. American heart J. 2007;154(5):995-1002.

Ryan TJ, Faxon DP, Gunnar RM, Kennedy JW, King SB, Loop FD, et al. You have accessGuidelines 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). Circulation. 1988;78(2):486-502.

Gensini GG. A more meaningful scoring system for determining the severity of coronary heart disease.Am J Cardiol. 1983;51(3):606.

Libby P, Ridker PM, Hansson GK. Inflammation in atherosclerosis: from pathophysiology to practice. J Am Coll Cardiol. 2009;54:2129-38.

Okyay GU, İnal S, Öneç K, Er RE, Paşaoğlu Ö, Paşaoğlu H, et al. Neutrophil to lymphocyte ratio in evaluation of inflammation in patients with chronic kidney disease. Renal failure. 2013;35(1):29-36.

Sunbul M, Gerin F, Durmus E, Kivrak T, Sari I, Tigen K, Cincin A. Neutrophil to lymphocyte and platelet to lymphocyte ratio in patients with dipper versus non-dipper hypertension. Clinical Experimental Hypertension. 2014;36(4):217-21.

Lee S, Choe JW, Kim HK, Sung J. High-sensitivity C-reactive protein and cancer. J Epidemiol. 2011;21(3):161-8.

Pitsavos C, Tampourlou M, Panagiotakos DB, Skoumas Y, Chrysohoou C, Nomikos T, et al. Association between low-grade systemic inflammation and type 2 diabetes mellitus among men and women from the ATTICA study. The review of diabetic studies: RDS. 2007;4(2):98.

Sunbul M, Gerin F, Durmus E, Kivrak T, Sari I, Tigen K, et al. Neutrophil to lymphocyte and platelet to lymphocyte ratio in patients with dipper versus non-dipper hypertension. Clinical and Experimental Hypertension. 2014;36(4):217-21.

Suliman MA, Juma AA, Almadhani AA, Pathare AV, Alkindi SS, et al. Predictive value of neutrophil to lymphocyte ratio in outcomes of patients with acute coronary syndrome. Archives Med Res. 2010;41(8):618-22.

Cho KH, Jeong MH, Ahmed K, Hachinohe D, Choi HS, Chang SY, et al. Value of early risk stratification using hemoglobin level and neutrophil-to-lymphocyte ratio in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention. Ame J Cardiol. 2011;107(6):849-56.

Doğan M, Akyel A, Çimen T, Öksüz F, Çelik İE, Aytürk M, et al. Relationship between neutrophil-to-lymphocyte ratio and saphenous vein graft disease in patients with coronary bypass. Clinical and Applied Thrombosis/Hemostasis. 2015;21(1):25-9.

Uthamalingam S, Patvardhan EA, Subramanian S, Ahmed W, Martin W, Daley M, et al. Utility of the neutrophil to lymphocyte ratio in predicting long-term outcomes in acute decompensated heart failure. Ame J Cardiol. 2011;107(3):433-8.

Açar G, Kalkan ME, Avci A, Alizade E, Tabakci MM, Toprak C, et al. The relation of platelet–lymphocyte ratio and coronary collateral circulation in patients with stable angina pectoris and chronic total occlusion. Clin App Thrombosis/Hemostasis. 2015;21(5):462-8.

Gary T, Pichler M, Belaj K, Hafner F, Gerger A, Froehlich H, et al. Platelet-to-lymphocyte ratio: a novel marker for critical limb ischemia in peripheral arterial occlusive disease patients. PLoS One. 2013;8(7):e67688.

Yüksel M, Yıldız A, Oylumlu M, Akyüz A, Aydın M, Kaya H, et al. The association between platelet/lymphocyte ratio and coronary artery disease severity. Anatolian J cardiology. 2015;15(8):640-7.