Value of Neutrophil to Lymphocyte Ratio and Its Trajectory in Patients Hospitalized With Acute Heart Failure and Preserved Ejection Fraction

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The neutrophil to lymphocyte ratio (NLR) has been proposed as a simple and routinely obtained marker of inflammation. This study sought to determine whether the NLR on admission as well as NLR trajectory would be complementary to the Get with the Guidelines Heart Failure (GWTG-HF) risk score in patients hospitalized with acute heart failure with preserved ejection fraction (HFpEF).Using the Stanford Translational Research Database, we identified 443 patients between January 2002 and December 2013 hospitalized with acute HFpEF and with complete data of NLR both on admission and at discharge. The primary endpoint was all-cause mortality. Mean age was 77 ± 16 years, 58% were female, with a high prevalence of diabetes mellitus (35.4%), coronary artery disease (58.2%), systemic hypertension (96.6%) and history of atrial fibrillation (57.5%). Over a median follow-up of 2.2 years, 121 (27.3%) patients died. The median NLR on admission was 6.5 (IQR 3.6 – 11.1); a majority of patients decreased their NLR during the course of hospitalization. On multivariable Cox modeling, both NLR on admission (HR 1.18 95% CI (1.00 – .38), p = 0.04) and absolute NLR trajectory (HR 1.26 95% CI (1.10 – 1.45), p = 0.001) were shown to be incremental to GWTG-HF risk score (p < 0.05) for outcome prediction. Adding the NLR or absolute NLR trajectory to the GWTG-HF risk score significantly improved the area under the operator-receiver curve and the reclassification up to 3 years after admission.This simple, readily available marker of inflammation may be useful when stratifying the risk of patients hospitalized with HFpEF.

Section snippets

Methods

Using Stanford Translational Research Integrated Database Environment (STRIDE),11 we identified 3,847 adult patients with a diagnostic code of “HFpEF” (ICD-9 code 428.3) between January 2002 and December 2013, in whom CBC data were available on both admission and discharge. HFpEF was diagnosed clinically in the presence of an elevated NT-proBNP level >300 pg/mL or evidence of heart failure with a LVEF >50%. Evidence of heart failure was based on the presence of pulmonary edema on chest X-ray,

Results

Clinical and biological characteristics on admission of the 443 patients included are presented in Tables 1 and 2. Mean age was 77 ± 16 years; 59% were women and the median duration of hospitalization was 5 (3 to 9) days. The GWTG-HF risk score was normally distributed as illustrated in Figure 2 and had a mean value of 41.4 ± 8.3. The median NT-proBNP, available in 271 patients (58.8%), was 2,262 (1,071 to 5,243) pg/mL.

The NLR on admission was skewed to the right with a median value of 6.5 (3.6

Discussion

The main finding of our study is that NLR on admission and absolute NLR trajectory are associated with all-cause mortality in patients with acute HFpEF beyond the well-validated GWTG-HF risk score.

The importance of the NLR in patients with cardiovascular disease was first recognized in patients with ischemic heart disease and myocardial infarction.14,15 Recently, the prognostic value of NLR in patients with heart failure has further been investigated; however, majority of the previously

Disclosures

Dr. Horne is an inventor of complete blood count-based risk scores that Intermountain Healthcare has licensed to CareCentra, and is PI of research grants funded by Intermountain Healthcare's Foundry innovation program, the Intermountain Research and Medical Foundation, CareCentra, GlaxoSmithKline, and AstraZeneca for the development and/or clinical implementation of complete blood count-based clinical decision tools. We also would like to acknowledge the Srinivasan research fund.

Acknowledgment

This work was supported by the Intermountain-Stanford Collaboration Initiative and the Philips Royal Research Grant of Heart Failure with Preserved Ejection Fraction.

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    Funding: This work was supported by the Intermountain-Stanford Collaboration Initiative and the Philips Royal Research grant of heart failure with preserved ejection fraction.

    1

    KAB and YK contributed equally to this study.

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