中性粒细胞与淋巴细胞比值对急性心肌梗死合并多支血管病变患者远期预后的预测价值

Predictive value of neutrophil to lymphocyte ratio on long-term outcomes of acute myocardial infarction patients with multivessel disease

目的探讨中性粒细胞与淋巴细胞比值(NLR)对于急性心肌梗死(AMI)合并多支血管病变(MVD)患者远期预后的预测价值。方法该研究为前瞻性观察研究,连续纳入2013年1至12月于阜外医院行经皮冠状动脉介入治疗(PCI)的AMI合并MVD的患者1433例。根据受试者工作特征(ROC)曲线确定NLR预测2年全因死亡的最佳临界值,分为高NLR组和低NLR组。主要临床终点为2年全因死亡,次要终点是2年主要不良心脑血管事件(MACCE)的复合终点。结果ROC曲线结果显示NLR预测2年全因死亡临界值是3.39(曲线下面积是0.765,敏感度71%,特异度73%)。纳入的1433例患者中,396例(27.6%)NLR≥3.39,归为高NLR组,1037例NLR<3.39,归为低NLR组。高NLR组患者中既往心肌梗死、PCI、主动脉内球囊反搏(IABP)发生的比例均明显高于低NLR组(P均<0.01)。与低NLR组相比,高NLR组患者年龄较大、中性粒细胞计数较多、高敏C反应蛋白(hs-CRP)水平较高(P均<0.001),而淋巴细胞计数较少、左心室射血分数较低、估测的肾小球滤过率较低(P均<0.001)。2年随访结果显示,高NLR组患者2年全因死亡率[5.1%(20/396)比0.8%(8/1037),P<0.001],MACCE发生率[21.7%(86/396)比12.6%(131/1037),P<0.001)],心原性死亡率[4.0%(16/396)比0.7%(7/1037),P<0.001]均明显高于低NLR组,支架内血栓和血运重建发生率均高于低NLR组(P均<0.05),两组患者心肌梗死、卒中和出血发生率差异均无统计学意义(P均>0.05)。Cox多因素回归分析结果显示,NLR≥3.39是AMI合并MVD患者全因死亡(HR=3.23,95%CI1.38~7.54,P=0.007)和MACCE(HR=1.58,95%CI1.19~2.10,P=0.002)的独立预测因子。NLR与hs-CRP相关性分析显示二者水平呈显著正相关(r=0.241,P<0.001)。结论NLR是AMI合并MVD患者远期全因死亡和MACCE的独立预测因子,具有很强的预测价值。

Objective Patients with acute coronary syndrome due to multivessel disease (MVD) were at the highest risk of adverse cardiovascular events. Neutrophil to lymphocyte ratio (NLR) was proposed as a marker of cardiovascular risk. Present study evaluated the independent predictive value of NLR for acute myocardial infarction (AMI) patients with MVD. Methods AMI patients with MVD (n=1 433) underwent percutaneous coronary intervention (PCI) between January 2013 and December 2013 were followed up for 2 years. Patients were divided into 2 sub-groups based on an optimal cut off value of NLR to predict 2-year all-cause mortality. The primary endpoint was all-cause death. The secondary endpoint was long-term major adverse cardiovascular and cerebrovascular events (MACCE). Results By receiver operating characteristics curve analysis, the optimal cut-off value of admission NLR to predict 2-year all-cause mortality was 3.39 (area under the curve 0.765, sensitivity 71%, specificity 73%). The high NLR group(n=396) had higher prevalence of prior myocardial infarction, prior PCI and intra-aortic balloon pump use (IABP)(P<0.01). Compared to the low NLR group (n=1 037), patients in the high NLR group were older, had higher level of neutrophil count and high-sensitivity C-reactive protein (hs-CRP) (P<0.001), but lower level of lymphocyte count, estimated glomerular filtration rate (eGFR) and ejection fraction (P<0.001). During the follow-up period, rate of long-term all-cause death was significantly higher in the high NLR group than in the low NLR group (5.1% (20/396) vs. 0.8% (8/1 037), P<0.001). Cardiac death (4.0% (16/396) vs. 0.7% (7/1 037), P<0.001) and MACCE (21.7% (86/396) vs. 12.6% (131/1 037), P<0.001) were also significantly higher in the high NLR group than in the low NLR group. Multivariate Cox analysis showed that NLR ≥ 3.39 was determined as an independent predictor of 2-year all-cause mortality (HR=3.23, 95%CI 1.38-7.54, P=0.007) and MACCE (HR=1.58, 95%CI 1.19-2.10, P=0.002) in this patient cohort after adjusting for other risk factors. Correlation analysis showed that the NLR was positively correlated with hs-CRP levels (r=0.241, P<0.001). Conclusion Our study demonstrates that admission NLR ≥ 3.39 is an independent predictor of long term all cause death and MACCE in AMI patients with MVD post PCI.