Neutrophil-to-lymphocyte ratio as a predictor of all-cause and cardiovascular mortality in coronary heart disease and hypertensive patients: a retrospective cohort study

Abstract

Background: To date, no studies have investigated the correlation between the neutrophil-to-lymphocyte ratio (NLR) and the long-term risk of mortality in individuals with both coronary heart disease (CHD) and hypertension. This study aims to evaluate the association between NLR and all-cause and cardiovascular mortality among this patient population.

Methods: National Death Index (NDI) and National Health and Nutrition Examination Survey (NHANES 2001-2018) were the data sources. A nonlinear association between the NLR and mortality risk was shown by restricted cubic spline (RCS) analysis. Using a weighted Cox proportional hazards model, we quantitatively evaluated the effect of NLR on mortality risk.The capacity of NLR to forecast survival was assessed by evaluating time-dependent receiver operating characteristic (ROC) curves. A mediating influence analysis was conducted to assess the influence of NLR on mortality through eGFR as a mediator.

Results: The study involved a total of 2136 individuals. During the median follow-up interval of 76.0 months, 801 deaths were recorded. The RCS analysis showed NLR and mortality risk to have a nonlinear relationship. Two groups were established based on the participants' NLR levels: a group with high NLR (NLR > 2.65) and a group with low NLR (NLR < 2.65). After adjusting for potential confounding factors, the Cox proportional hazards model revealed that participants with an increased NLR faced a significantly higher risk of cardiovascular mortality. (HR 1.58, 95% CI 1.33-1.82, p < 0.0001) and all-cause mortality (HR 1.46, 95% CI 1.30-1.62, p < 0.0001). An analysis of interactions and data stratification corroborated the validity of our findings. eGFR was identified as a partial mediator in the association between NLR and mortality rates, contributing 12.17% and 9.66% of the variance in all-cause and cardiovascular mortality, respectively. The predictive performance for cardiovascular mortality was quantified using ROC curves, with respective AUC values of 0.67, 0.65, and 0.64 for predictions over 3, 5, and 10 years. The AUC values for all-cause mortality were 0.66, 0.64, and 0.63 for the same time frames.

Conclusion: For patients with CHD and hypertension, an elevated NLR serves as an independent prognostic indicator for both all-cause and cardiovascular mortality.

Keywords: NHANES (national health and nutrition examination survey); coronary heart disease; hypertension; mortality; neutrophil lymphocyte ratio.

Figure 1

The association of NLR with all-cause (A) and cardiovascular mortality (B). Hazard ratios were adjusted for age, sex, race, heart failure, cancer, education, smoking conditions, BMI, HDL, albumin, TC, eGFR.

Figure 2

Kaplan-Meier curves of the survival rate with higher (> 3.5) and lower (≤ 3.5) NLR values. (A) All-cause mortality; (B) cardiovascular mortality.

Figure 3

Time-dependent ROC curves and time-dependent AUC values (with 95% confidence band) of the NLR for predicting all-cause mortality (A, B) and cardiovascular mortality (C, D).

Figure 4

The mediating effect of eGFR on the relationship between NLR and survival [(A) all-cause death; (B) cardiovascular death]. Adjusted for age, sex, race, heart failure, cancer, education, smoking conditions, BMI, HDL, albumin, TC, eGFR.