Response to: Akhtar MS, Bhat T, Teli S et al. Neutrophil to lymphocyte ratio and cardiovascular diseases: a review. Expert Rev. Cardiovasc. Ther. 11(1), 55–59 (2013).
We read the article ‘Neutrophil to lymphocyte ratio (NLR) and cardiovascular diseases: a review’ by MS. Akhtar et al. with great interest Citation[1]. In this well-presented review, the authors discussed the association of N/L ratio with various cardiovascular diseases and its possibility of emerging as a cheap, reliable and independent prognostic marker of cardiovascular disease.
Some studies have indicated that NLR is a novel inflammatory marker in various diseases. In this particular review of M. Akhtar that he made reference to in our publication, the authors evaluated the relationship between NLR and the various cardiovascular diseases and their outcomes. White blood cell count is one of the useful inflammatory biomarkers in clinical practice. However, the sub-types, particularly the neutrophils and lymphocytes, and subsequent calculation of NLR are relatively more stable than individual leukocytic parameters. This ratio is significantly altered by many conditions (e.g., dehydration, over-hydration, diluted blood specimens, in-vitro blood specimen handling). As highlighted by this article Citation[1], the authors provided a very concise review of NLR and its association with heart failure, coronary artery bypass surgery and various cardiac rhythm abnormalities Citation[1].
Based on this particular review, we designed our research to assess the presence of left atrial thrombus in patients with non-valvular atrial fibrillation (AF). A total of 309 (70.1 ± 9.8 years, 49% males) patients with nonvalvular AF underwent transesophageal echocardiography to assess the presence of left atrium (LA) thrombus. Baseline NLR was measured by dividing neutrophil count to lymphocyte count. Left atrial thrombus was detected in 32 (10.3%) of 309 patients. Mean NLR (2.2 ± 1.0 vs 2.7 ± 1.1, p = 0.026) was significantly higher among patients with LA thrombus compared to patients without LA thrombus. On multivariate analysis, NLR (odds ratio 1.59; 95% CI: 0.87–4.18; p < 0.02) was an independent risk factor for the presence of LA thrombus in patients with non-valvular AF. We concluded that NLR, an emerging marker of inflammation, was independently associated with the presence of LA thrombus in patients with non-valvular AF Citation[2]. I have also developed an association between NLR and anti-hypertensive therapy Citation[3], NLR and its association with metabolic syndrome Citation[4] as well as NLR association with carotid artery thickness in patients with slow coronary flow Citation[5]. In all these studies, M. Akhtar’s review Citation[1] provided with greater guidance at each level of research.
Recent evidence has extensively indicated that the NLR is a significant predictor of subclinical atherosclerosis. Atherosclerosis plays an important role in the pathogenesis of coronary artery ectasia. We also showed that the NLR was significantly higher in patients with coronary artery ectasia compared to controls Citation[6] in another study that took a lot of guidance from M. Akhtar’s review Citation[1].
As a conclusion, the role of inflammatory markers in cardiovascular diseases has been reviewed extensively, and a consistent relationship between various inflammatory markers and cardiovascular diseases has been established in the past. In addition to NLR, high-sensitivity C-reactive protein, red cell distribution width, γ-glutamyl transferase and uric acid are also used as assessment tools in patients and clinical practice Citation[7]. NLR together with other serum inflammatory markers is proving as a significant clinical tool as an inflammatory marker and prediction of stress in human body Citation[8]. M. Akhtar’s review, in this scenario, provided us with a deeper understanding about NLR and I have consulted the review on numerous occasions during our subsequent research.
Financial & competing interests disclosure
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.
No writing assistance was utilized in the production of this manuscript.
References
- Akhtar MS, Bhat T, Teli S, et al. Neutrophil to lymphocyte ratio and cardiovascular diseases: a review. Expert Rev Cardiovasc Ther 2013;11(1):55-9
- Yalcin M, Aparci M, Uz O, et al. Neutrophil-Lymphocyte Ratio May Predict Left Atrial Thrombus in Patients With Nonvalvular Atrial Fibrillation. Clin Appl Thromb Hemost 2013. [Epub ahead of print]
- Karaman M, Balta S, Ay SA, et al. The Comparative Effects of Valsartan and Amlodipine on vWf Levels and N/L Ratio in Patients with Newly Diagnosed Hypertension. Clin Exp Hypertens 2013;35(7):516-22
- Balta S, Cakar M, Demirkol S, et al. Higher neutrophil to lymhocyte ratio in patients with metabolic syndrome. Clin Appl Thromb Hemost 2013. [Epub ahead of print]
- Cingoz F, Iyisoy A, Demirkol S, et al. Carotid ıntima-media thickness in patients with slow coronary flow and its association with neutrophil-to-lymphocyte ratio: a preliminary report. Clin Appl Thromb Hemost 2013. [Epub ahead of print]
- Balta S, Demirkol S, Celik T, et al. Association Between Coronary Artery Ectasia and Neutrophil-Lymphocyte Ratio. Angiology 2013. [Epub ahead of print]
- Demirkol S, Balta S, Unlu M, et al. Neutrophils/lymphocytes ratio in patients with cardiac syndrome x and its association with carotid ıntima-media thickness. Clin Appl Thromb Hemost 2012. [Epub ahead of print]
- Balta S, Demirkol S, Cakar M, et al. Other inflammatory markers should not be forgotten when assessing the neutrophil-to-lymphocyte ratio. Clin Appl Thromb Hemost 2013. [Epub ahead of print]