The Relationship Between the Neutrophil Percentage-to-Albumin Ratio and Rates of 28-Day Mortality in Atrial Fibrillation Patients 80 Years of Age or Older

Figures & data

Figure 1 Flowchart of patient selection.

Table 1 Baseline Characteristics of Patients

Variables	Total	Neutrophil Percentage-to-Albumin Ratio			P-value
		T1	T2	T3
		(≤16.4)	(16.4–20.3)	(>20.3)
N	1141	380	380	381
Age, y	84.7 ± 3.9	83.9 ± 3.6	84.6 ± 3.7	85.6 ± 4.3	<0.001
Male, n (%)	528 (46.3)	164 (43.2)	182 (47.9)	182 (47.8)	0.328
SBP, mmHg	133.7 ± 18.7	136.1 ± 19.1	133.4 ± 17.7	131.6 ± 19.0	0.004
DBP, mmHg	76.3 ± 10.8	76.8 ± 10.7	76.5 ± 10.5	75.5 ± 11.2	0.216
Smoking habits, n (%)	135 (12.3)	46 (12.4)	45 (12.3)	44 (12.2)	0.995
Drinking habits, n (%)	60 (5.5)	21 (5.7)	23 (6.3)	16 (4.4)	0.535
Paroxysmal AF, n (%)	344 (30.1)	133 (35.0)	112 (29.5)	99 (26.0)	0.024
New-onset AF, n (%)	97 (8.5)	21 (5.5)	34 (8.9)	42 (11.0)	0.023
HAS-BLED score	2.4 ± 1.0	2.3 ± 0.9	2.4 ± 0.9	2.4 ± 1.1	0.306
CHA2DS2-VASc score	4.4 ± 1.2	4.4 ± 1.2	4.3 ± 1.1	4.4 ± 1.3	0.384
Comorbidities, n (%)
Hypertension	794 (69.6)	274 (72.1)	276 (72.6)	244 (64.0)	0.015
Diabetes	304 (26.6)	104 (27.4)	88 (23.2)	112 (29.4)	0.139
Coronary heart disease	477 (41.8)	162 (42.6)	166 (43.7)	149 (39.1)	0.407
Chronic heart failure	534 (46.8)	158 (41.6)	162 (42.6)	214 (56.2)	<0.001
COPD	122 (10.7)	31 (8.2)	34 (8.9)	57 (15.0)	0.004
History of cancer	146 (12.8)	44 (11.6)	47 (12.4)	55 (14.4)	0.476
Heart valvular disorders	55 (4.8)	16 (4.2)	17 (4.5)	22 (5.8)	0.559
Prior stroke	376 (33.0)	116 (30.5)	127 (33.4)	133 (34.9)	0.425
Primary reason of hospital admission, n (%)					<0.001
Atrial fibrillation	416 (36.5)	198 (52.1)	136 (35.8)	82 (21.5)
Acute heart failure	151 (13.2)	41 (10.8)	58 (15.3)	52 (13.6)
ACS	110 (9.6)	25 (6.6)	43 (11.3)	42 (11.0)
Other	464 (40.7)	116 (30.5)	143 (37.6)	205 (53.8)
Hematological and biochemical variables
WBC, 10^9/L	7.1 ± 3.4	5.6 ± 1.6	6.7 ± 2.5	9.1 ± 4.5	<0.001
Neutrophil percentage, %	68.8 ± 11.5	57.6 ± 7.6	68.9 ± 6.4	79.7 ± 7.5	<0.001
Lymphocyte, 10^9/L	1.4 ± 0.6	1.7 ± 0.6	1.4 ± 0.5	1.0 ± 0.5	<0.001
Hemoglobin, g/L	119.9 ± 21.0	125.5 ± 17.8	120.7 ± 20.1	113.5 ± 22.9	<0.001
Platelet, 10^9/L	178.9 ± 65.3	171.6 ± 52.6	180.2 ± 60.7	185.0 ± 79.2	0.016
CRP, mg/L	8.7 (3.3, 27.7)	4.5 (1.7, 8.9)	7.3 (3.2, 19.9)	29.4 (10.1, 66.3)	<0.001
Blood urea, mmol/L	7.3 (5.4, 9.6)	6.4 (5.2, 8.3)	7.0 (5.4, 9.0)	8.8 (6.1, 12.4)	<0.001
Blood creatine, umol/L	90.9 (73.3, 116.4)	87.7 (71.7, 105.6)	92.0 (76.1, 118.2)	95.5 (71.6, 135.5)	<0.001
eGFR, mL/min/1.73m^2	56.6 ± 20.6	60.7 ± 16.7	55.9 ± 19.1	53.4 ± 24.7	<0.001
Albumin, g/dL	3.7± 0.5	4.1 ± 0.4	3.8 ± 0.3	3.3 ± 0.4	<0.001
Total cholesterol, mmol/L	3.9 ± 1.0	4.1 ± 1.0	3.9 ± 0.9	3.6 ± 1.0	<0.001
BNP, pg/mL	332.0 (172.0, 516.0)	248.5 (126.2, 442.2)	320.5 (163.8, 494.0)	473.0 (224.0, 860.0)	<0.001
Echocardiography
LVEF, %	58.7 ± 7.8	60.1 ± 6.6	58.8 ± 6.9	57.2 ± 9.2	<0.001
LA, mm	44.3 ± 6.7	45.1 ± 6.7	44.4 ± 7.2	43.4 ± 6.2	0.002
LVIDd, mm	46.9 ± 6.2	47.0 ± 5.8	46.9 ± 5.5	46.9 ± 7.1	0.989
LVIDs, mm	32.0 ± 6.2	31.7 ± 5.5	31.9 ± 5.5	32.5 ± 7.4	0.175
LVSV, mL	55.3 ± 17.1	57.5 ± 16.0	55.4 ± 16.3	53.0 ± 18.8	0.001
LVEDV, mL	96.2 ± 34.9	97.5 ± 33.1	95.5 ± 30.7	95.5 ± 40.4	0.670
Medication, n (%)
Statin	66 (5.8)	19 (5.0)	20 (5.3)	27 (7.1)	0.406
Beta blocker	132 (11.6)	41 (10.8)	39 (10.3)	52 (13.6)	0.291
RAS inhibitors	248 (21.7)	78 (20.5)	91 (23.9)	79 (20.7)	0.440
Antiplatelet	163 (14.3)	55 (14.5)	49 (12.9)	59 (15.5)	0.589
Anticoagulation	63 (5.5)	18 (4.7)	28 (7.4)	17 (4.5)	0.153
Cardiovascular mortality, n (%)	38 (3.3)	1 (0.3)	7 (1.8)	30 (7.9)	<0.001
All-cause mortality, n (%)	99 (8.7)	3 (0.8)	18 (4.7)	78 (20.5)	<0.001

Notes: Mean ± SD for normally distributed continuous variables, median [Q1, Q3] for non-normally distributed continuous variables: P-value was calculated by one-way ANOVAs. Number () for categorical variables: P-value was calculated by chi-square test. eGFR was defined by the Chronic Kidney Disease Epidemiology Collaboration equation. Heart valvular diseases was defined as the presence of moderate-to-severe mitral stenosis or a mechanical heart valve. ACS included STEMI, non-STEMI and unstable angina.

Abbreviations: AF, atrial fibrillation; NPAR, neutrophil percentage-to-albumin ratio; CHA₂DS₂-VASc, Cardiac failure or dysfunction, Hypertension, Age ≥ 75 years (doubled), Diabetes, Stroke (doubled), Vascular disease, Age 65–74 years and sex category (Female); HAS-BLED score, Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio (INR), Elderly (65 years), Drugs/alcohol concomitantly. COPD, chronic obstructive pulmonary disease; SBP, systolic blood pressure; DBP, diastolic blood pressure; ACS, acute coronary syndrome; CRP, C reactive protein; eGFR, estimated glomerular filtration rate; WBC, white blood cell; BNP, brain natriuretic peptide; LVEF, left ventricular ejection fraction; LA, left atrial diameter; LVIDd, left ventricular interior diameter at end-diastole, LVIDs, left ventricular interior diameter at end-systolic, LVSV, left ventricular stroke volume, LVEDV, left ventricular end diastolic volume.

Table 2 Associations Between NPAR and All-Cause Mortality by Cox Analysis

	The Number of Events (Deaths), n (%)	Unadjusted HR (95 CI, P)	Minimally Adjusted, HR (95 CI, P)	Fully Adjusted, HR (95 CI, P)
NPAR	99 (8.7)	1.15 (1.13, 1.17) <0.001	1.15 (1.12, 1.17) <0.001	1.13 (1.09, 1.16) <0.001
NPAR (tertiles)
T1	3 (0.8)	Ref	Ref	Ref
T2	18 (4.7)	6.08 (1.79, 20.64) 0.004	5.62 (1.65, 19.08) 0.006	4.43 (1.30, 15.18) 0.016
T3	78 (20.5)	28.89 (9.12, 91.52) <0.001	24.23 (7.61, 77.12) <0.001	13.52 (4.14, 44.21) <0.001
P for trend	--	<0.001	<0.001	<0.001

Notes: Minimally adjusted HR controls for age, sex, SBP. Fully adjusted HR controls for age, sex, SBP, AF type, history of cancer, primary reason of hospital admission, LVEF, CRP, total cholesterol, hemoglobin, eGFR, urea, BNP and HAS-BLED score.

Abbreviations: AF, atrial fibrillation; NPAR, neutrophil percentage-to-albumin ratio; SBP, systolic pressure; CRP, C reactive protein; eGFR, estimated glomerular filtration rate; WBC, white blood cell; BNP, brain natriuretic peptide; LVEF, left ventricular ejection fraction.

Table 3 The Predictive Values of NPAR, Neutrophil Percentage or Albumin for All-Cause Mortality

	HR (95% CI)	P-value	AUC	95% CI
NPAR	1.13 (1.09, 1.16)	<0.001	0.81	(0.77, 0.85)
Neutrophil percentage,	1.08 (1.05, 1.10)	<0.001	0.77	(0.72, 0.82)
Albumin, g/dL	0.34 (0.22, 0.53)	<0.001	0.71	(0.66, 0.76)

Note: The Cox proportional model adjusted HR controls for age, sex, SBP, AF type, history of cancer, primary reason of hospital admission, LVEF, CRP, total cholesterol, hemoglobin, eGFR, urea, BNP and HAS-BLED score.

Abbreviations: AF, atrial fibrillation; NPAR, neutrophil percentage-to-albumin ratio; SBP, systolic pressure; CRP, C reactive protein; eGFR, estimated glomerular filtration rate; WBC, white blood cell; BNP, brain natriuretic peptide; LVEF, left ventricular ejection fraction.

Figure 2 Kaplan–Meier survival curve analysis of all-cause mortality (A) and cardiovascular mortality (B) across the tertiles of the NPAR value (NPAR: ≤ 16.4, 16.4 to 20.3, and > 20.3).